WELFARE AND INSTITUTIONS CODE
SECTION 14088-14088.25
14088. (a) It is the purpose of this article to ensure that the
Medi-Cal program shall be operated in the most cost-effective and
efficient manner possible with the optimum number of Medi-Cal
providers and shall assure quality of care and known access to
services.
(b) For the purposes of this article, the following definitions
shall apply:
(1) "Primary care provider" means either of the following:
(A) Any internist, general practitioner,
obstetrician/gynecologist, pediatrician or family practice physician
or any primary care clinic, rural health clinic, community clinic or
hospital outpatient clinic currently enrolled in the Medi-Cal
program, which agrees to provide case management to Medi-Cal
beneficiaries.
(B) A county or other political subdivision that employs,
operates, or contracts with, any of the primary care providers listed
in subparagraph (A), and that agrees to use that primary care
provider for the purposes of contracting under this article.
(2) "Primary care case management" means responsibility for the
provision of referral, consultation, ordering of therapy, admission
to hospitals, follow up care, and prepayment approval of referred
services.
(3) "Designation form" or "form" means a form supplied by the
department to be executed by a Medi-Cal beneficiary and a primary
care provider or other entity eligible pursuant to this article who
has entered into a contract with the department pursuant to this
article, setting forth the beneficiary's choice of contractor and an
agreement to be limited by the case management decisions of that
contractor and the contractor's agreement to be responsible for that
beneficiary's case management and medical care, as specified in this
article.
(4) "Emergency services" means health care services rendered by an
eligible Medi-Cal provider to a Medi-Cal beneficiary for those
health services required for alleviation of severe pain or immediate
diagnosis and treatment of unforeseen medical conditions which if not
immediately diagnosed and treated could lead to disability or death.
(5) "Modified primary care case management" means primary care
case management wherein capitated services are limited to primary
care physician office visits only.
(6) "Service area" means an area designated by either a single
federal Postal ZIP Code or by two or more Postal ZIP Codes that are
contiguous.
14088.05. For purposes of this article, "primary care case
management plan" means a primary care provider or other entity who
has contracted with the department pursuant to this article.
14088.2. The primary care provider or other entity eligible
pursuant to this article with whom a contract has been entered into
pursuant to this article shall have responsibility for providing for
case management as defined, pursuant to Section 14088.
14088.4. (a) No reimbursement shall be provided, for any
beneficiary receiving case management services, for any services
covered by the contract entered into pursuant to this article, except
emergency services and dental services, not authorized pursuant to
case management decisions made by the appropriate contractor.
(b) Notwithstanding subdivision (a), a provider shall be
reimbursed for covered services rendered to a beneficiary, when the
department's automated eligibility verification system, developed
pursuant to Section 14042, fails to indicate that the beneficiary is
subject to receiving case management services, provided that claims
for these services meet all other requirements for valid claims under
the program.
14088.5. The beneficiary shall be permitted to disenroll from any
contract entered into pursuant to this article upon request, except
where prohibited under the provisions of any federal waivers obtained
by the department.
14088.6. In order to achieve maximum cost savings, the Legislature
hereby determines that an expedited contract process for contracts
under this article is necessary. Therefore, contracts under this
article may be on a nonbid basis and shall be exempt from the
provisions of Chapter 2 (commencing with Section 10290) of Part 2 of
Division 2 of the Public Contract Code.
14088.7. Primary care providers and other entities with whom a
contract has been entered into pursuant to this article shall be
exempt from Chapter 2.2 (commencing with Section 1340) of Division 2
of the Health and Safety Code for purposes of carrying out the
contracts.
14088.8. (a) The department may establish modified primary care
case management contracts pursuant to this article. This authority
shall be subject to the department seeking and obtaining all
necessary federal waivers to implement this section.
(b) In establishing modified primary care case management
contracts pursuant to this article, the department may enter into
contracts with providers whose application to develop a full primary
care case management contract has been accepted by the department and
who are working with the department to document, develop, and
install the required systems, policies, and procedures. These
contracts may provide for the following:
(1) The modified primary care case management contract would have
effect only until the contractor's full primary care case management
contract is executed.
(2) The scope of services covered and the case management and
utilization control responsibilities of the contractor may be more
limited than under a full primary care case management.
(3) Formal enrollment of Medi-Cal beneficiaries with the
contractor would occur but the contractor could be reimbursed on a
fee-for-service basis for the services the contractor provides to
them. Beneficiaries enrolling under the modified primary care case
management contract would remain enrolled under the full primary care
case management contract entered into by the contractor.
(4) Contractor quality of care requirements could be modified to
reflect the contractor's fee-for-service managed care mode of health
care delivery.
(5) Evaluation by the department of the contractor's efficiency,
case management effectiveness and the calculation of any savings and
savings sharing would reflect the temporary fee-for-service approach
under which the contractor is operating.
(c) Contracts shall not be entered into by the department unless
the waivers or revision to any existing waiver are granted by the
federal government. The provisions for which appropriate federal
waivers cannot be obtained shall not be implemented, but provisions
for which waivers are either obtained or found to be unnecessary
shall be unaffected by the inability to obtain federal waivers for
other provisions.
14088.85. (a) The department may enter into primary care case
management contracts with primary care providers that serve persons
infected with human immunodeficiency virus (HIV). Except as otherwise
provided in this section, contracts made pursuant to this section
shall be subject to all the requirements of this article and
regulations of the department.
(b) Primary care providers contracted with pursuant to this
section may provide services exclusively to Medi-Cal eligible persons
infected with HIV.
(c) Capitation payment rates for primary care providers under this
section shall be calculated based on the equivalent fee-for-service
costs of providing care to HIV infected patients rather than on the
equivalent fee-for-service cost of providing care to all Medi-Cal
patients.
14088.12. Primary care case management contractors shall establish,
maintain, and conduct an active, ongoing outreach and recruitment
effort to add primary care and specialty providers to their networks
to the extent necessary to meet the health care needs of their
enrollees. Contractors shall submit to the department documentation
regarding the participation and availability of primary care and
specialty providers added to their network on or after enactment of
this section. The department may enter into primary care case
management contracts with children's hospitals.
14088.13. The department shall approve those Medi-Cal services for
which the contractor is at risk that shall be provided in any
contract or contracts for services under the primary care provider
case management program. Medi-Cal services provided under any
contract or contracts for services under this article shall be
subject to review and approval by the department.
14088.14. The department may enter into contracts pursuant to this
article with nurse practitioners, acting within the scope of practice
of a nurse practitioner, certified nurse midwives, acting within the
scope of practice of a certified nurse midwife, and, for the purpose
of providing services to populations with special medical problems,
with any physician who has specialized in an area of medicine
relevant to the special population to be served and who is currently
enrolled in the Medi-Cal program.
14088.15. A plan shall not use false advertising or false
statements to induce enrollment. No solicitation of enrollees shall
include the granting or offering of any monetary or other valuable
consideration for enrollment.
14088.16. The department or a county which has contracted for the
provision of services pursuant to this article may, within service
areas designated by the department, enter into contracts with primary
care providers. The contracts shall be on a capitated rate or
risk-sharing basis, or a combination of both. The rate of payment for
services shall not vary solely according to the category of
licensure of the facility in which the services are rendered by
providers within each service area. The rate of payment established
under the contract shall not exceed the total per capita amount which
the department estimates would be payable for all services and
requirements covered under the contract if all such services and
requirements were to be furnished Medi-Cal beneficiaries under the
Medi-Cal fee-for-service program.
Prior to entering into any contract for primary care case
management under this chapter, the department shall provide public
notice of its intent to enter into such a contract. Furthermore, the
department shall develop specific criteria for evaluating potential
contractors which ensure that all types of primary care providers are
given equal consideration in the contractor selection process.
14088.17. (a) The department may contract under this article, on an
exclusive or nonexclusive basis, with an established professional
organization with a membership which consists of physicians who
engage in the types of practices or who provide services in the
locations set forth in subdivision (a) of Section 14088.
(b) (1) A contract under this section shall be implemented in a
manner consistent with any federal waivers which are obtained by the
department to enable such an arrangement.
(2) Where federal waivers permit restrictions on beneficiary
freedom of choice, the contract shall provide covered Medi-Cal
beneficiaries with an initial choice of a primary care physician and
a procedure through which a beneficiary may change primary care
physicians with good cause.
(c) This section shall apply only to the provision of services to
beneficiaries who, for purposes of Medi-Cal eligibility
determination, are residents of Lake County, Mendocino County, or
Sonoma County.
14088.18. (a) In order to increase the number of nonprofit
providers under this article, the department may enter into contracts
each fiscal year under this section with eligible nonprofit
organizations to provide a one-time interest-bearing loan, repayable
at the Pooled Money Investment Account rate, to that eligible
organization.
(b) Contracts entered into pursuant to this section shall be
limited to contracts within those counties where the department does
not have contracts authorized by this article on the effective date
of this section.
(c) Any loan entered into pursuant to this section shall not
exceed one hundred thousand dollars ($100,000).
(d) The department shall adopt standards and procedures for loan
applications and repayment of the loans made pursuant to this
section.
(e) The department shall make no loan pursuant to this section
until the department has made savings payments to contractors who
have entered into contracts under this article on or before the
effective date of this section.
(f) For purposes of this section, "eligible nonprofit organization"
means any organization which meets all of the following
requirements:
(1) The organization is exempt from taxation under Section 501(c)
(3) or 501(c)(25)(C)(iii) of the federal Internal Revenue Code.
(2) The organization is organized to provide health care to the
medically underserved and to provide services in service areas.
14088.19. (a) The department may enter into primary care case
management contracts pursuant to this article with any health care
service plan that is licensed by the Director of the Department of
Managed Health Care pursuant to the Knox-Keene Health Care Service
Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of
Division 2 of the Health and Safety Code).
The terms of the contracts entered into pursuant to this section
shall be exempt from those provisions of Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code that
regulate health care service plan contracts. Nothing in this section
shall preclude the Director of the Department of Managed Health Care
from otherwise regulating a health care service plan subject to the
Knox-Keene Health Service Plan Act of 1975 (Chapter 2.2 (commencing
with Section 1340) of Division 2 of the Health and Safety Code).
(b) When a health care service plan enters into a contract
pursuant to this article and also pursuant to Chapter 8 (commencing
with Section 14200), there shall be no duplication of service areas
between the two contracts without prior written approval by the
department.
14088.22. Sections 14408, 14409, 14410, and 14411 shall apply to
primary care case management plans.
14088.23. (a) The department may apply one or more of the following
sanctions against any contractor for failure to comply with the
requirements of this article, regulations adopted by the department,
the contract between the contractor and the department, or for other
good cause shown. Good cause includes, but is not necessarily limited
to, three repeated and uncorrected findings of serious deficiencies
that have the potential to endanger patient care, as defined by the
department in accordance with this section, identified in the medical
audits conducted by the department:
(1) Terminate the contract.
(2) Suspend enrollment and marketing activities.
(3) Require the contractor to suspend or terminate personnel of
the contractor or to terminate participation by subcontractors
specified by the department.
(4) Impose civil penalties not to exceed ten thousand dollars
($10,000) per violation pursuant to regulations adopted by the
director. Unless imposed in error, penalties shall not be returned to
the plan.
(5) Take other appropriate action as determined necessary by the
department.
(b) The department shall give the contractor and any other persons
who may be directly interested not less than 30 days' notice of its
intention to impose any of the sanctions authorized by this section.
(c) The notice required by subdivision (b) shall be written, and
shall specify each requirement that has not been met, the proposed
effective date of the sanction or sanctions, and the amount and
duration of each proposed sanction.
(d) (1) Within five working days after the receipt of the written
notice required by subdivision (b), the contractor may submit notice
of its intent to comply with the requirements specified in the
written notice.
(2) If the contractor submits the notice of intent authorized by
paragraph (1), the department shall allow the contractor to
demonstrate its compliance with the requirements specified in the
department's written notice. Substantial compliance shall be achieved
within 30 calendar days from the date of the submission of the
notice of intent to comply by the contractor. Within 15 days
following the completion of the 30-day compliance correction period,
the department shall review the corrective actions taken by the
contractor and, if appropriate, approve those actions.
(3) If a contractor subject to notice to apply sanctions under
subdivision (b) does not demonstrate appropriate corrective
compliance within the 30-day corrective action period or does not
submit a notice of intent to comply with the requirements specified
in the notice required by subdivision (b), the department shall
notify the contractor, in writing, of the effective date and terms of
the sanction or sanctions applied pursuant to this section.
(4) The department may make one or more of the following temporary
suspension orders as an immediate sanction: temporarily suspend
enrollment activities, temporarily suspend marketing activities,
require the contractor temporarily to suspend specified personnel of
the contractor, or require the contractor temporarily to suspend
participation by a specified subcontractor. The temporary suspension
orders may be effective beginning on the first day after the
expiration of the 30-day compliance correction period, if the
contractor submitted a notice of intent to comply, but has not
demonstrated appropriate corrective action, or beginning on the first
day after the notice required by subdivision (b) if the contractor
did not submit a notice of intent to comply. All other sanctions
shall be effective no earlier than 20 days after the notice specified
in paragraph (3).
(5) If the department issues a temporary suspension order as an
immediate sanction, it shall notify the contractor of the nature and
effective date of the temporary suspension and at the same time shall
serve the provider with an accusation. Upon receipt of a notice of
defense filed by the contractor, the department shall, within 15
days, set the matter for hearing, which shall be held as soon as
possible, but not later than 30 days after receipt of the notice of
hearing by the contractor. The hearing may be continued at the
request of the contractor if a continuance is necessary to permit
presentation of an adequate defense. The temporary suspension order
shall remain in effect until the hearing is completed and the
department has made a final determination on the merits. However, the
temporary suspension order shall be deemed vacated if the director
fails to make a final determination on the merits within 60 days
after the original hearing has been completed.
(6) A contractor may request a hearing in connection with any
sanctions applied pursuant to this section, other than those
contained in a temporary suspension order, within 15 working days
after the notice of the effective date of the sanctions has been
given pursuant to paragraph (3), by sending a letter so stating to
the address specified in the notice. The department shall stay
implementation of the sanction upon receipt of the request for a
hearing. Implementation of the sanction shall remain stayed until the
effective date of the final decision of the department.
(7) Except as otherwise provided herein, all hearings to review
the imposition of sanctions, including temporary suspension orders,
shall be held pursuant to the procedures set forth in Section 100171
of the Health and Safety Code.
(e) The department may collect civil penalties imposed pursuant to
this section by withholding the amount of the penalty from
capitation payments owed by the department to the contractor.
14088.25. (a) The department may conduct onsite reviews of a
provider or facility that has agreed with the primary care case
management contractor or a potential contractor to provide services
to beneficiaries enrolled with the contractor. These reviews may be
for purposes such as evaluating the capabilities of potential
contractors, monitoring quality of care, investigating complaints,
and ensuring contractor compliance with the terms of the contract
entered into pursuant to this article.
(b) Prior to adding a provider or facility to an existing network
of providers and facilities, the primary care case management
contractor shall submit a complete prequalification package to the
department. The department shall provide to the contractor written
acknowledgment that the package is complete within 10 working days.
(c) (1) If the provider or facility proposed for addition to the
contractor's existing network is currently enrolled in the Medi-Cal
program, the provider or facility may begin treating beneficiaries
enrolled with the contractor immediately upon the contractor's
receipt of the acknowledgment required by subdivision (b), subject to
paragraph (2) and subdivision (d).
(2) Whenever warranted, the department may rescind the privilege
provided for in paragraph (1) by advance notification to the
contractor, pending the onsite review required by subdivision (d).
Notification shall be in writing and describe the conditions that
support the rescission of the privilege.
(d) (1) The department shall conduct an onsite review of the
provider or facility within a reasonable period of time after receipt
of the package, which shall be not more than 60 days after receipt
of the package, unless there are extenuating circumstances.
(2) The department shall notify the contractor in writing of the
department's final decision on the request to add the provider or
facility to the contractor's existing network within 10 working days
of the date of the review.
(e) In the conduct of the onsite review of the provider or
facility, the department shall not condition approval of the site on
adherence by the provider or facility to requirements that are not
contained in any statute, regulation, or commonly accepted community
standard of medical practice that directly applies to the category of
provider or facility being inspected. This subdivision does not,
however, relieve the contractor of any obligations under the contract
entered into pursuant to this article.
WELFARE AND INSTITUTIONS CODE
SECTION 14088-14088.25
14088. (a) It is the purpose of this article to ensure that the
Medi-Cal program shall be operated in the most cost-effective and
efficient manner possible with the optimum number of Medi-Cal
providers and shall assure quality of care and known access to
services.
(b) For the purposes of this article, the following definitions
shall apply:
(1) "Primary care provider" means either of the following:
(A) Any internist, general practitioner,
obstetrician/gynecologist, pediatrician or family practice physician
or any primary care clinic, rural health clinic, community clinic or
hospital outpatient clinic currently enrolled in the Medi-Cal
program, which agrees to provide case management to Medi-Cal
beneficiaries.
(B) A county or other political subdivision that employs,
operates, or contracts with, any of the primary care providers listed
in subparagraph (A), and that agrees to use that primary care
provider for the purposes of contracting under this article.
(2) "Primary care case management" means responsibility for the
provision of referral, consultation, ordering of therapy, admission
to hospitals, follow up care, and prepayment approval of referred
services.
(3) "Designation form" or "form" means a form supplied by the
department to be executed by a Medi-Cal beneficiary and a primary
care provider or other entity eligible pursuant to this article who
has entered into a contract with the department pursuant to this
article, setting forth the beneficiary's choice of contractor and an
agreement to be limited by the case management decisions of that
contractor and the contractor's agreement to be responsible for that
beneficiary's case management and medical care, as specified in this
article.
(4) "Emergency services" means health care services rendered by an
eligible Medi-Cal provider to a Medi-Cal beneficiary for those
health services required for alleviation of severe pain or immediate
diagnosis and treatment of unforeseen medical conditions which if not
immediately diagnosed and treated could lead to disability or death.
(5) "Modified primary care case management" means primary care
case management wherein capitated services are limited to primary
care physician office visits only.
(6) "Service area" means an area designated by either a single
federal Postal ZIP Code or by two or more Postal ZIP Codes that are
contiguous.
14088.05. For purposes of this article, "primary care case
management plan" means a primary care provider or other entity who
has contracted with the department pursuant to this article.
14088.2. The primary care provider or other entity eligible
pursuant to this article with whom a contract has been entered into
pursuant to this article shall have responsibility for providing for
case management as defined, pursuant to Section 14088.
14088.4. (a) No reimbursement shall be provided, for any
beneficiary receiving case management services, for any services
covered by the contract entered into pursuant to this article, except
emergency services and dental services, not authorized pursuant to
case management decisions made by the appropriate contractor.
(b) Notwithstanding subdivision (a), a provider shall be
reimbursed for covered services rendered to a beneficiary, when the
department's automated eligibility verification system, developed
pursuant to Section 14042, fails to indicate that the beneficiary is
subject to receiving case management services, provided that claims
for these services meet all other requirements for valid claims under
the program.
14088.5. The beneficiary shall be permitted to disenroll from any
contract entered into pursuant to this article upon request, except
where prohibited under the provisions of any federal waivers obtained
by the department.
14088.6. In order to achieve maximum cost savings, the Legislature
hereby determines that an expedited contract process for contracts
under this article is necessary. Therefore, contracts under this
article may be on a nonbid basis and shall be exempt from the
provisions of Chapter 2 (commencing with Section 10290) of Part 2 of
Division 2 of the Public Contract Code.
14088.7. Primary care providers and other entities with whom a
contract has been entered into pursuant to this article shall be
exempt from Chapter 2.2 (commencing with Section 1340) of Division 2
of the Health and Safety Code for purposes of carrying out the
contracts.
14088.8. (a) The department may establish modified primary care
case management contracts pursuant to this article. This authority
shall be subject to the department seeking and obtaining all
necessary federal waivers to implement this section.
(b) In establishing modified primary care case management
contracts pursuant to this article, the department may enter into
contracts with providers whose application to develop a full primary
care case management contract has been accepted by the department and
who are working with the department to document, develop, and
install the required systems, policies, and procedures. These
contracts may provide for the following:
(1) The modified primary care case management contract would have
effect only until the contractor's full primary care case management
contract is executed.
(2) The scope of services covered and the case management and
utilization control responsibilities of the contractor may be more
limited than under a full primary care case management.
(3) Formal enrollment of Medi-Cal beneficiaries with the
contractor would occur but the contractor could be reimbursed on a
fee-for-service basis for the services the contractor provides to
them. Beneficiaries enrolling under the modified primary care case
management contract would remain enrolled under the full primary care
case management contract entered into by the contractor.
(4) Contractor quality of care requirements could be modified to
reflect the contractor's fee-for-service managed care mode of health
care delivery.
(5) Evaluation by the department of the contractor's efficiency,
case management effectiveness and the calculation of any savings and
savings sharing would reflect the temporary fee-for-service approach
under which the contractor is operating.
(c) Contracts shall not be entered into by the department unless
the waivers or revision to any existing waiver are granted by the
federal government. The provisions for which appropriate federal
waivers cannot be obtained shall not be implemented, but provisions
for which waivers are either obtained or found to be unnecessary
shall be unaffected by the inability to obtain federal waivers for
other provisions.
14088.85. (a) The department may enter into primary care case
management contracts with primary care providers that serve persons
infected with human immunodeficiency virus (HIV). Except as otherwise
provided in this section, contracts made pursuant to this section
shall be subject to all the requirements of this article and
regulations of the department.
(b) Primary care providers contracted with pursuant to this
section may provide services exclusively to Medi-Cal eligible persons
infected with HIV.
(c) Capitation payment rates for primary care providers under this
section shall be calculated based on the equivalent fee-for-service
costs of providing care to HIV infected patients rather than on the
equivalent fee-for-service cost of providing care to all Medi-Cal
patients.
14088.12. Primary care case management contractors shall establish,
maintain, and conduct an active, ongoing outreach and recruitment
effort to add primary care and specialty providers to their networks
to the extent necessary to meet the health care needs of their
enrollees. Contractors shall submit to the department documentation
regarding the participation and availability of primary care and
specialty providers added to their network on or after enactment of
this section. The department may enter into primary care case
management contracts with children's hospitals.
14088.13. The department shall approve those Medi-Cal services for
which the contractor is at risk that shall be provided in any
contract or contracts for services under the primary care provider
case management program. Medi-Cal services provided under any
contract or contracts for services under this article shall be
subject to review and approval by the department.
14088.14. The department may enter into contracts pursuant to this
article with nurse practitioners, acting within the scope of practice
of a nurse practitioner, certified nurse midwives, acting within the
scope of practice of a certified nurse midwife, and, for the purpose
of providing services to populations with special medical problems,
with any physician who has specialized in an area of medicine
relevant to the special population to be served and who is currently
enrolled in the Medi-Cal program.
14088.15. A plan shall not use false advertising or false
statements to induce enrollment. No solicitation of enrollees shall
include the granting or offering of any monetary or other valuable
consideration for enrollment.
14088.16. The department or a county which has contracted for the
provision of services pursuant to this article may, within service
areas designated by the department, enter into contracts with primary
care providers. The contracts shall be on a capitated rate or
risk-sharing basis, or a combination of both. The rate of payment for
services shall not vary solely according to the category of
licensure of the facility in which the services are rendered by
providers within each service area. The rate of payment established
under the contract shall not exceed the total per capita amount which
the department estimates would be payable for all services and
requirements covered under the contract if all such services and
requirements were to be furnished Medi-Cal beneficiaries under the
Medi-Cal fee-for-service program.
Prior to entering into any contract for primary care case
management under this chapter, the department shall provide public
notice of its intent to enter into such a contract. Furthermore, the
department shall develop specific criteria for evaluating potential
contractors which ensure that all types of primary care providers are
given equal consideration in the contractor selection process.
14088.17. (a) The department may contract under this article, on an
exclusive or nonexclusive basis, with an established professional
organization with a membership which consists of physicians who
engage in the types of practices or who provide services in the
locations set forth in subdivision (a) of Section 14088.
(b) (1) A contract under this section shall be implemented in a
manner consistent with any federal waivers which are obtained by the
department to enable such an arrangement.
(2) Where federal waivers permit restrictions on beneficiary
freedom of choice, the contract shall provide covered Medi-Cal
beneficiaries with an initial choice of a primary care physician and
a procedure through which a beneficiary may change primary care
physicians with good cause.
(c) This section shall apply only to the provision of services to
beneficiaries who, for purposes of Medi-Cal eligibility
determination, are residents of Lake County, Mendocino County, or
Sonoma County.
14088.18. (a) In order to increase the number of nonprofit
providers under this article, the department may enter into contracts
each fiscal year under this section with eligible nonprofit
organizations to provide a one-time interest-bearing loan, repayable
at the Pooled Money Investment Account rate, to that eligible
organization.
(b) Contracts entered into pursuant to this section shall be
limited to contracts within those counties where the department does
not have contracts authorized by this article on the effective date
of this section.
(c) Any loan entered into pursuant to this section shall not
exceed one hundred thousand dollars ($100,000).
(d) The department shall adopt standards and procedures for loan
applications and repayment of the loans made pursuant to this
section.
(e) The department shall make no loan pursuant to this section
until the department has made savings payments to contractors who
have entered into contracts under this article on or before the
effective date of this section.
(f) For purposes of this section, "eligible nonprofit organization"
means any organization which meets all of the following
requirements:
(1) The organization is exempt from taxation under Section 501(c)
(3) or 501(c)(25)(C)(iii) of the federal Internal Revenue Code.
(2) The organization is organized to provide health care to the
medically underserved and to provide services in service areas.
14088.19. (a) The department may enter into primary care case
management contracts pursuant to this article with any health care
service plan that is licensed by the Director of the Department of
Managed Health Care pursuant to the Knox-Keene Health Care Service
Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of
Division 2 of the Health and Safety Code).
The terms of the contracts entered into pursuant to this section
shall be exempt from those provisions of Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code that
regulate health care service plan contracts. Nothing in this section
shall preclude the Director of the Department of Managed Health Care
from otherwise regulating a health care service plan subject to the
Knox-Keene Health Service Plan Act of 1975 (Chapter 2.2 (commencing
with Section 1340) of Division 2 of the Health and Safety Code).
(b) When a health care service plan enters into a contract
pursuant to this article and also pursuant to Chapter 8 (commencing
with Section 14200), there shall be no duplication of service areas
between the two contracts without prior written approval by the
department.
14088.22. Sections 14408, 14409, 14410, and 14411 shall apply to
primary care case management plans.
14088.23. (a) The department may apply one or more of the following
sanctions against any contractor for failure to comply with the
requirements of this article, regulations adopted by the department,
the contract between the contractor and the department, or for other
good cause shown. Good cause includes, but is not necessarily limited
to, three repeated and uncorrected findings of serious deficiencies
that have the potential to endanger patient care, as defined by the
department in accordance with this section, identified in the medical
audits conducted by the department:
(1) Terminate the contract.
(2) Suspend enrollment and marketing activities.
(3) Require the contractor to suspend or terminate personnel of
the contractor or to terminate participation by subcontractors
specified by the department.
(4) Impose civil penalties not to exceed ten thousand dollars
($10,000) per violation pursuant to regulations adopted by the
director. Unless imposed in error, penalties shall not be returned to
the plan.
(5) Take other appropriate action as determined necessary by the
department.
(b) The department shall give the contractor and any other persons
who may be directly interested not less than 30 days' notice of its
intention to impose any of the sanctions authorized by this section.
(c) The notice required by subdivision (b) shall be written, and
shall specify each requirement that has not been met, the proposed
effective date of the sanction or sanctions, and the amount and
duration of each proposed sanction.
(d) (1) Within five working days after the receipt of the written
notice required by subdivision (b), the contractor may submit notice
of its intent to comply with the requirements specified in the
written notice.
(2) If the contractor submits the notice of intent authorized by
paragraph (1), the department shall allow the contractor to
demonstrate its compliance with the requirements specified in the
department's written notice. Substantial compliance shall be achieved
within 30 calendar days from the date of the submission of the
notice of intent to comply by the contractor. Within 15 days
following the completion of the 30-day compliance correction period,
the department shall review the corrective actions taken by the
contractor and, if appropriate, approve those actions.
(3) If a contractor subject to notice to apply sanctions under
subdivision (b) does not demonstrate appropriate corrective
compliance within the 30-day corrective action period or does not
submit a notice of intent to comply with the requirements specified
in the notice required by subdivision (b), the department shall
notify the contractor, in writing, of the effective date and terms of
the sanction or sanctions applied pursuant to this section.
(4) The department may make one or more of the following temporary
suspension orders as an immediate sanction: temporarily suspend
enrollment activities, temporarily suspend marketing activities,
require the contractor temporarily to suspend specified personnel of
the contractor, or require the contractor temporarily to suspend
participation by a specified subcontractor. The temporary suspension
orders may be effective beginning on the first day after the
expiration of the 30-day compliance correction period, if the
contractor submitted a notice of intent to comply, but has not
demonstrated appropriate corrective action, or beginning on the first
day after the notice required by subdivision (b) if the contractor
did not submit a notice of intent to comply. All other sanctions
shall be effective no earlier than 20 days after the notice specified
in paragraph (3).
(5) If the department issues a temporary suspension order as an
immediate sanction, it shall notify the contractor of the nature and
effective date of the temporary suspension and at the same time shall
serve the provider with an accusation. Upon receipt of a notice of
defense filed by the contractor, the department shall, within 15
days, set the matter for hearing, which shall be held as soon as
possible, but not later than 30 days after receipt of the notice of
hearing by the contractor. The hearing may be continued at the
request of the contractor if a continuance is necessary to permit
presentation of an adequate defense. The temporary suspension order
shall remain in effect until the hearing is completed and the
department has made a final determination on the merits. However, the
temporary suspension order shall be deemed vacated if the director
fails to make a final determination on the merits within 60 days
after the original hearing has been completed.
(6) A contractor may request a hearing in connection with any
sanctions applied pursuant to this section, other than those
contained in a temporary suspension order, within 15 working days
after the notice of the effective date of the sanctions has been
given pursuant to paragraph (3), by sending a letter so stating to
the address specified in the notice. The department shall stay
implementation of the sanction upon receipt of the request for a
hearing. Implementation of the sanction shall remain stayed until the
effective date of the final decision of the department.
(7) Except as otherwise provided herein, all hearings to review
the imposition of sanctions, including temporary suspension orders,
shall be held pursuant to the procedures set forth in Section 100171
of the Health and Safety Code.
(e) The department may collect civil penalties imposed pursuant to
this section by withholding the amount of the penalty from
capitation payments owed by the department to the contractor.
14088.25. (a) The department may conduct onsite reviews of a
provider or facility that has agreed with the primary care case
management contractor or a potential contractor to provide services
to beneficiaries enrolled with the contractor. These reviews may be
for purposes such as evaluating the capabilities of potential
contractors, monitoring quality of care, investigating complaints,
and ensuring contractor compliance with the terms of the contract
entered into pursuant to this article.
(b) Prior to adding a provider or facility to an existing network
of providers and facilities, the primary care case management
contractor shall submit a complete prequalification package to the
department. The department shall provide to the contractor written
acknowledgment that the package is complete within 10 working days.
(c) (1) If the provider or facility proposed for addition to the
contractor's existing network is currently enrolled in the Medi-Cal
program, the provider or facility may begin treating beneficiaries
enrolled with the contractor immediately upon the contractor's
receipt of the acknowledgment required by subdivision (b), subject to
paragraph (2) and subdivision (d).
(2) Whenever warranted, the department may rescind the privilege
provided for in paragraph (1) by advance notification to the
contractor, pending the onsite review required by subdivision (d).
Notification shall be in writing and describe the conditions that
support the rescission of the privilege.
(d) (1) The department shall conduct an onsite review of the
provider or facility within a reasonable period of time after receipt
of the package, which shall be not more than 60 days after receipt
of the package, unless there are extenuating circumstances.
(2) The department shall notify the contractor in writing of the
department's final decision on the request to add the provider or
facility to the contractor's existing network within 10 working days
of the date of the review.
(e) In the conduct of the onsite review of the provider or
facility, the department shall not condition approval of the site on
adherence by the provider or facility to requirements that are not
contained in any statute, regulation, or commonly accepted community
standard of medical practice that directly applies to the category of
provider or facility being inspected. This subdivision does not,
however, relieve the contractor of any obligations under the contract
entered into pursuant to this article.
WELFARE AND INSTITUTIONS CODE
SECTION 14088-14088.25
14088. (a) It is the purpose of this article to ensure that the
Medi-Cal program shall be operated in the most cost-effective and
efficient manner possible with the optimum number of Medi-Cal
providers and shall assure quality of care and known access to
services.
(b) For the purposes of this article, the following definitions
shall apply:
(1) "Primary care provider" means either of the following:
(A) Any internist, general practitioner,
obstetrician/gynecologist, pediatrician or family practice physician
or any primary care clinic, rural health clinic, community clinic or
hospital outpatient clinic currently enrolled in the Medi-Cal
program, which agrees to provide case management to Medi-Cal
beneficiaries.
(B) A county or other political subdivision that employs,
operates, or contracts with, any of the primary care providers listed
in subparagraph (A), and that agrees to use that primary care
provider for the purposes of contracting under this article.
(2) "Primary care case management" means responsibility for the
provision of referral, consultation, ordering of therapy, admission
to hospitals, follow up care, and prepayment approval of referred
services.
(3) "Designation form" or "form" means a form supplied by the
department to be executed by a Medi-Cal beneficiary and a primary
care provider or other entity eligible pursuant to this article who
has entered into a contract with the department pursuant to this
article, setting forth the beneficiary's choice of contractor and an
agreement to be limited by the case management decisions of that
contractor and the contractor's agreement to be responsible for that
beneficiary's case management and medical care, as specified in this
article.
(4) "Emergency services" means health care services rendered by an
eligible Medi-Cal provider to a Medi-Cal beneficiary for those
health services required for alleviation of severe pain or immediate
diagnosis and treatment of unforeseen medical conditions which if not
immediately diagnosed and treated could lead to disability or death.
(5) "Modified primary care case management" means primary care
case management wherein capitated services are limited to primary
care physician office visits only.
(6) "Service area" means an area designated by either a single
federal Postal ZIP Code or by two or more Postal ZIP Codes that are
contiguous.
14088.05. For purposes of this article, "primary care case
management plan" means a primary care provider or other entity who
has contracted with the department pursuant to this article.
14088.2. The primary care provider or other entity eligible
pursuant to this article with whom a contract has been entered into
pursuant to this article shall have responsibility for providing for
case management as defined, pursuant to Section 14088.
14088.4. (a) No reimbursement shall be provided, for any
beneficiary receiving case management services, for any services
covered by the contract entered into pursuant to this article, except
emergency services and dental services, not authorized pursuant to
case management decisions made by the appropriate contractor.
(b) Notwithstanding subdivision (a), a provider shall be
reimbursed for covered services rendered to a beneficiary, when the
department's automated eligibility verification system, developed
pursuant to Section 14042, fails to indicate that the beneficiary is
subject to receiving case management services, provided that claims
for these services meet all other requirements for valid claims under
the program.
14088.5. The beneficiary shall be permitted to disenroll from any
contract entered into pursuant to this article upon request, except
where prohibited under the provisions of any federal waivers obtained
by the department.
14088.6. In order to achieve maximum cost savings, the Legislature
hereby determines that an expedited contract process for contracts
under this article is necessary. Therefore, contracts under this
article may be on a nonbid basis and shall be exempt from the
provisions of Chapter 2 (commencing with Section 10290) of Part 2 of
Division 2 of the Public Contract Code.
14088.7. Primary care providers and other entities with whom a
contract has been entered into pursuant to this article shall be
exempt from Chapter 2.2 (commencing with Section 1340) of Division 2
of the Health and Safety Code for purposes of carrying out the
contracts.
14088.8. (a) The department may establish modified primary care
case management contracts pursuant to this article. This authority
shall be subject to the department seeking and obtaining all
necessary federal waivers to implement this section.
(b) In establishing modified primary care case management
contracts pursuant to this article, the department may enter into
contracts with providers whose application to develop a full primary
care case management contract has been accepted by the department and
who are working with the department to document, develop, and
install the required systems, policies, and procedures. These
contracts may provide for the following:
(1) The modified primary care case management contract would have
effect only until the contractor's full primary care case management
contract is executed.
(2) The scope of services covered and the case management and
utilization control responsibilities of the contractor may be more
limited than under a full primary care case management.
(3) Formal enrollment of Medi-Cal beneficiaries with the
contractor would occur but the contractor could be reimbursed on a
fee-for-service basis for the services the contractor provides to
them. Beneficiaries enrolling under the modified primary care case
management contract would remain enrolled under the full primary care
case management contract entered into by the contractor.
(4) Contractor quality of care requirements could be modified to
reflect the contractor's fee-for-service managed care mode of health
care delivery.
(5) Evaluation by the department of the contractor's efficiency,
case management effectiveness and the calculation of any savings and
savings sharing would reflect the temporary fee-for-service approach
under which the contractor is operating.
(c) Contracts shall not be entered into by the department unless
the waivers or revision to any existing waiver are granted by the
federal government. The provisions for which appropriate federal
waivers cannot be obtained shall not be implemented, but provisions
for which waivers are either obtained or found to be unnecessary
shall be unaffected by the inability to obtain federal waivers for
other provisions.
14088.85. (a) The department may enter into primary care case
management contracts with primary care providers that serve persons
infected with human immunodeficiency virus (HIV). Except as otherwise
provided in this section, contracts made pursuant to this section
shall be subject to all the requirements of this article and
regulations of the department.
(b) Primary care providers contracted with pursuant to this
section may provide services exclusively to Medi-Cal eligible persons
infected with HIV.
(c) Capitation payment rates for primary care providers under this
section shall be calculated based on the equivalent fee-for-service
costs of providing care to HIV infected patients rather than on the
equivalent fee-for-service cost of providing care to all Medi-Cal
patients.
14088.12. Primary care case management contractors shall establish,
maintain, and conduct an active, ongoing outreach and recruitment
effort to add primary care and specialty providers to their networks
to the extent necessary to meet the health care needs of their
enrollees. Contractors shall submit to the department documentation
regarding the participation and availability of primary care and
specialty providers added to their network on or after enactment of
this section. The department may enter into primary care case
management contracts with children's hospitals.
14088.13. The department shall approve those Medi-Cal services for
which the contractor is at risk that shall be provided in any
contract or contracts for services under the primary care provider
case management program. Medi-Cal services provided under any
contract or contracts for services under this article shall be
subject to review and approval by the department.
14088.14. The department may enter into contracts pursuant to this
article with nurse practitioners, acting within the scope of practice
of a nurse practitioner, certified nurse midwives, acting within the
scope of practice of a certified nurse midwife, and, for the purpose
of providing services to populations with special medical problems,
with any physician who has specialized in an area of medicine
relevant to the special population to be served and who is currently
enrolled in the Medi-Cal program.
14088.15. A plan shall not use false advertising or false
statements to induce enrollment. No solicitation of enrollees shall
include the granting or offering of any monetary or other valuable
consideration for enrollment.
14088.16. The department or a county which has contracted for the
provision of services pursuant to this article may, within service
areas designated by the department, enter into contracts with primary
care providers. The contracts shall be on a capitated rate or
risk-sharing basis, or a combination of both. The rate of payment for
services shall not vary solely according to the category of
licensure of the facility in which the services are rendered by
providers within each service area. The rate of payment established
under the contract shall not exceed the total per capita amount which
the department estimates would be payable for all services and
requirements covered under the contract if all such services and
requirements were to be furnished Medi-Cal beneficiaries under the
Medi-Cal fee-for-service program.
Prior to entering into any contract for primary care case
management under this chapter, the department shall provide public
notice of its intent to enter into such a contract. Furthermore, the
department shall develop specific criteria for evaluating potential
contractors which ensure that all types of primary care providers are
given equal consideration in the contractor selection process.
14088.17. (a) The department may contract under this article, on an
exclusive or nonexclusive basis, with an established professional
organization with a membership which consists of physicians who
engage in the types of practices or who provide services in the
locations set forth in subdivision (a) of Section 14088.
(b) (1) A contract under this section shall be implemented in a
manner consistent with any federal waivers which are obtained by the
department to enable such an arrangement.
(2) Where federal waivers permit restrictions on beneficiary
freedom of choice, the contract shall provide covered Medi-Cal
beneficiaries with an initial choice of a primary care physician and
a procedure through which a beneficiary may change primary care
physicians with good cause.
(c) This section shall apply only to the provision of services to
beneficiaries who, for purposes of Medi-Cal eligibility
determination, are residents of Lake County, Mendocino County, or
Sonoma County.
14088.18. (a) In order to increase the number of nonprofit
providers under this article, the department may enter into contracts
each fiscal year under this section with eligible nonprofit
organizations to provide a one-time interest-bearing loan, repayable
at the Pooled Money Investment Account rate, to that eligible
organization.
(b) Contracts entered into pursuant to this section shall be
limited to contracts within those counties where the department does
not have contracts authorized by this article on the effective date
of this section.
(c) Any loan entered into pursuant to this section shall not
exceed one hundred thousand dollars ($100,000).
(d) The department shall adopt standards and procedures for loan
applications and repayment of the loans made pursuant to this
section.
(e) The department shall make no loan pursuant to this section
until the department has made savings payments to contractors who
have entered into contracts under this article on or before the
effective date of this section.
(f) For purposes of this section, "eligible nonprofit organization"
means any organization which meets all of the following
requirements:
(1) The organization is exempt from taxation under Section 501(c)
(3) or 501(c)(25)(C)(iii) of the federal Internal Revenue Code.
(2) The organization is organized to provide health care to the
medically underserved and to provide services in service areas.
14088.19. (a) The department may enter into primary care case
management contracts pursuant to this article with any health care
service plan that is licensed by the Director of the Department of
Managed Health Care pursuant to the Knox-Keene Health Care Service
Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of
Division 2 of the Health and Safety Code).
The terms of the contracts entered into pursuant to this section
shall be exempt from those provisions of Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code that
regulate health care service plan contracts. Nothing in this section
shall preclude the Director of the Department of Managed Health Care
from otherwise regulating a health care service plan subject to the
Knox-Keene Health Service Plan Act of 1975 (Chapter 2.2 (commencing
with Section 1340) of Division 2 of the Health and Safety Code).
(b) When a health care service plan enters into a contract
pursuant to this article and also pursuant to Chapter 8 (commencing
with Section 14200), there shall be no duplication of service areas
between the two contracts without prior written approval by the
department.
14088.22. Sections 14408, 14409, 14410, and 14411 shall apply to
primary care case management plans.
14088.23. (a) The department may apply one or more of the following
sanctions against any contractor for failure to comply with the
requirements of this article, regulations adopted by the department,
the contract between the contractor and the department, or for other
good cause shown. Good cause includes, but is not necessarily limited
to, three repeated and uncorrected findings of serious deficiencies
that have the potential to endanger patient care, as defined by the
department in accordance with this section, identified in the medical
audits conducted by the department:
(1) Terminate the contract.
(2) Suspend enrollment and marketing activities.
(3) Require the contractor to suspend or terminate personnel of
the contractor or to terminate participation by subcontractors
specified by the department.
(4) Impose civil penalties not to exceed ten thousand dollars
($10,000) per violation pursuant to regulations adopted by the
director. Unless imposed in error, penalties shall not be returned to
the plan.
(5) Take other appropriate action as determined necessary by the
department.
(b) The department shall give the contractor and any other persons
who may be directly interested not less than 30 days' notice of its
intention to impose any of the sanctions authorized by this section.
(c) The notice required by subdivision (b) shall be written, and
shall specify each requirement that has not been met, the proposed
effective date of the sanction or sanctions, and the amount and
duration of each proposed sanction.
(d) (1) Within five working days after the receipt of the written
notice required by subdivision (b), the contractor may submit notice
of its intent to comply with the requirements specified in the
written notice.
(2) If the contractor submits the notice of intent authorized by
paragraph (1), the department shall allow the contractor to
demonstrate its compliance with the requirements specified in the
department's written notice. Substantial compliance shall be achieved
within 30 calendar days from the date of the submission of the
notice of intent to comply by the contractor. Within 15 days
following the completion of the 30-day compliance correction period,
the department shall review the corrective actions taken by the
contractor and, if appropriate, approve those actions.
(3) If a contractor subject to notice to apply sanctions under
subdivision (b) does not demonstrate appropriate corrective
compliance within the 30-day corrective action period or does not
submit a notice of intent to comply with the requirements specified
in the notice required by subdivision (b), the department shall
notify the contractor, in writing, of the effective date and terms of
the sanction or sanctions applied pursuant to this section.
(4) The department may make one or more of the following temporary
suspension orders as an immediate sanction: temporarily suspend
enrollment activities, temporarily suspend marketing activities,
require the contractor temporarily to suspend specified personnel of
the contractor, or require the contractor temporarily to suspend
participation by a specified subcontractor. The temporary suspension
orders may be effective beginning on the first day after the
expiration of the 30-day compliance correction period, if the
contractor submitted a notice of intent to comply, but has not
demonstrated appropriate corrective action, or beginning on the first
day after the notice required by subdivision (b) if the contractor
did not submit a notice of intent to comply. All other sanctions
shall be effective no earlier than 20 days after the notice specified
in paragraph (3).
(5) If the department issues a temporary suspension order as an
immediate sanction, it shall notify the contractor of the nature and
effective date of the temporary suspension and at the same time shall
serve the provider with an accusation. Upon receipt of a notice of
defense filed by the contractor, the department shall, within 15
days, set the matter for hearing, which shall be held as soon as
possible, but not later than 30 days after receipt of the notice of
hearing by the contractor. The hearing may be continued at the
request of the contractor if a continuance is necessary to permit
presentation of an adequate defense. The temporary suspension order
shall remain in effect until the hearing is completed and the
department has made a final determination on the merits. However, the
temporary suspension order shall be deemed vacated if the director
fails to make a final determination on the merits within 60 days
after the original hearing has been completed.
(6) A contractor may request a hearing in connection with any
sanctions applied pursuant to this section, other than those
contained in a temporary suspension order, within 15 working days
after the notice of the effective date of the sanctions has been
given pursuant to paragraph (3), by sending a letter so stating to
the address specified in the notice. The department shall stay
implementation of the sanction upon receipt of the request for a
hearing. Implementation of the sanction shall remain stayed until the
effective date of the final decision of the department.
(7) Except as otherwise provided herein, all hearings to review
the imposition of sanctions, including temporary suspension orders,
shall be held pursuant to the procedures set forth in Section 100171
of the Health and Safety Code.
(e) The department may collect civil penalties imposed pursuant to
this section by withholding the amount of the penalty from
capitation payments owed by the department to the contractor.
14088.25. (a) The department may conduct onsite reviews of a
provider or facility that has agreed with the primary care case
management contractor or a potential contractor to provide services
to beneficiaries enrolled with the contractor. These reviews may be
for purposes such as evaluating the capabilities of potential
contractors, monitoring quality of care, investigating complaints,
and ensuring contractor compliance with the terms of the contract
entered into pursuant to this article.
(b) Prior to adding a provider or facility to an existing network
of providers and facilities, the primary care case management
contractor shall submit a complete prequalification package to the
department. The department shall provide to the contractor written
acknowledgment that the package is complete within 10 working days.
(c) (1) If the provider or facility proposed for addition to the
contractor's existing network is currently enrolled in the Medi-Cal
program, the provider or facility may begin treating beneficiaries
enrolled with the contractor immediately upon the contractor's
receipt of the acknowledgment required by subdivision (b), subject to
paragraph (2) and subdivision (d).
(2) Whenever warranted, the department may rescind the privilege
provided for in paragraph (1) by advance notification to the
contractor, pending the onsite review required by subdivision (d).
Notification shall be in writing and describe the conditions that
support the rescission of the privilege.
(d) (1) The department shall conduct an onsite review of the
provider or facility within a reasonable period of time after receipt
of the package, which shall be not more than 60 days after receipt
of the package, unless there are extenuating circumstances.
(2) The department shall notify the contractor in writing of the
department's final decision on the request to add the provider or
facility to the contractor's existing network within 10 working days
of the date of the review.
(e) In the conduct of the onsite review of the provider or
facility, the department shall not condition approval of the site on
adherence by the provider or facility to requirements that are not
contained in any statute, regulation, or commonly accepted community
standard of medical practice that directly applies to the category of
provider or facility being inspected. This subdivision does not,
however, relieve the contractor of any obligations under the contract
entered into pursuant to this article.
