14131. The Medi-Cal Benefits Program comprises a
department-administered uniform schedule of health care benefits.
Notwithstanding any other provision of this chapter, "health care
services" shall be limited to the benefits set forth in this article
and in Section 14021.
14131.10. (a) Notwithstanding any other provision of this chapter,
Chapter 8 (commencing with Section 14200), or Chapter 8.75
(commencing with Section 14590), in order to implement changes in the
level of funding for health care services, specific optional
benefits are excluded from coverage under the Medi-Cal program.
(b) (1) The following optional benefits are excluded from coverage
under the Medi-Cal program:
(A) Adult dental services, except as specified in paragraph (2).
(B) Acupuncture services.
(C) Audiology services and speech therapy services.
(D) Chiropractic services.
(E) Optometric and optician services, including services provided
by a fabricating optical laboratory.
(F) Podiatric services.
(G) Psychology services.
(H) Incontinence creams and washes.
(2) Medical and surgical services provided by a doctor of dental
medicine or dental surgery, which, if provided by a physician, would
be considered physician services, and which services may be provided
by either a physician or a dentist in this state, are covered.
(3) Pregnancy-related services and services for the treatment of
other conditions that might complicate the pregnancy are not excluded
from coverage under this section.
(c) The optional benefit exclusions do not apply to either of the
following:
(1) Beneficiaries under the Early and Periodic Screening Diagnosis
and Treatment Program.
(2) Beneficiaries receiving long-term care in a nursing facility
that is both:
(A) A skilled nursing facility or intermediate care facility as
defined in subdivisions (c) and (d) of Section 1250 of the Health and
Safety Code.
(B) Licensed pursuant to subdivision (k) of Section 1250 of the
Health and Safety Code.
(d) This section shall only be implemented to the extent permitted
by federal law.
(e) 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 the provisions of this section by means of
all-county letters, provider bulletins, or similar instructions,
without taking further regulatory action.
(f) This section shall be implemented on the first day of the
month following 90 days after the operative date of this section.
14131.15. (a) In geographic areas in which Medi-Cal managed care
plans contracting under this chapter or Chapter 8 (commencing with
Section 14200) are operating with capacity to enroll additional
qualifying Medi-Cal beneficiaries, the director may, in the interest
of bringing managed care principles to bear on the quality, costs, or
utilization levels of the Medi-Cal program, designate any benefit or
service included in the Medi-Cal program, at state option under
federal medicaid rules, as a covered Medi-Cal benefit only when
provided by a Medi-Cal managed care plan to a Medi-Cal enrollee of
the plan.
(b) Where benefits and services have been designated by the
director under subdivision (a), beneficiaries who are eligible to
enroll in and reside in the service area of a managed care plan, and
who desire coverage for such benefits and services, must enroll in a
Medi-Cal managed care plan to receive them and shall, to the maximum
extent permitted under federal law, remain enrolled in the plan.
(c) When managed care capacity is reached in an area in which
Medi-Cal benefits have been designated under this section, the
director may provide for the delivery of designated benefits or
services to beneficiaries by contract to the extent permitted under
this chapter, on a fee-for-service basis or a combination of both.
(d) Exercise of the director's discretion under this section shall
not preclude Medi-Cal managed care contractors from applying their
established medical necessity criteria, utilization control standards
and policies and utilization review procedures in delivering
designated services as permitted and controlled by Medi-Cal contract
and other state and federal regulatory standards.
(e) Enactment of this section shall not impose any requirement on
a Medi-Cal managed care plan to negotiate or enter into a contract or
any other participation arrangement with any provider of a Medi-Cal
benefit or service designated under subdivision (a).
(f) The department shall seek all federal waivers necessary to
allow for federal financial participation in expenditures under this
section.
14132. The following is the schedule of benefits under this
chapter:
(a) Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
(b) Inpatient hospital services, including, but not limited to,
physician and podiatric services, physical therapy and occupational
therapy, are covered subject to utilization controls.
(c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.
(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers of Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
(4) (A) Nonlegend acetaminophen-containing products, with the
exception of children's Tylenol, selected by the department are not
covered benefits. For the purposes of this paragraph, nonlegend has
the same meaning as defined in subdivision (a) of Section 14105.45.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instruction without taking regulatory action.
(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and equipment
required for dialysis, are covered, subject to utilization controls.
(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
(g) Blood and blood derivatives are covered.
(h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
(A) Periodontal treatment is not a benefit.
(B) Endodontic therapy is not a benefit except for vital
pulpotomy.
(C) Laboratory processed crowns are not a benefit.
(D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
(E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
(F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
(3) Paragraph (2) shall become inoperative July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
(m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
(n) Family planning services are covered, subject to utilization
controls.
(o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).
(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request, adult
day health care is covered for a maximum of three days per week.
(3) As provided in accordance with paragraph (4), adult day health
care is covered for a maximum of five days per week.
(4) As of the date that the director makes the declaration
described in subdivision (g) of Section 14525.1, paragraph (2) shall
become inoperative and paragraph (3) shall become operative.
(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.
(2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and 1770
of the Business and Professions Code may be covered as long as they
are within the scope of Denti-Cal benefits and they are necessary
services provided by a registered dental hygienist in alternative
practice.
(r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under Article 3
(commencing with Section 1480) of Chapter 2.5 of Division 2 of the
Health and Safety Code by a paramedic certified pursuant to that
article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.
(2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming a
Medi-Cal provider.
(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
As used in this subdivision, in-home medical care services,
include, but are not limited to:
(1) Level of care and cost of care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
(t) Home- and community-based services approved by the United
States Department of Health and Human Services may be covered to the
extent that federal financial participation is available for those
services under waivers granted in accordance with Section 1396n of
Title 42 of the United States Code. The director may seek waivers for
any or all home- and community-based services approvable under
Section 1396n of Title 42 of the United States Code. Coverage for
those services shall be limited by the terms, conditions, and
duration of the federal waivers.
(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
(v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
(w) Hospice service which is Medicare-certified hospice service is
covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are
incurred.
(x) When a claim for treatment provided to a beneficiary includes
both services which are authorized and reimbursable under this
chapter, and services which are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
(y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
Services provided pursuant to a waiver obtained from the Secretary
of the United States Department of Health and Human Services
pursuant to this subdivision, and which are not otherwise included in
the Medi-Cal schedule of benefits, shall be available only to the
extent that federal financial participation for these services is
available in accordance with the waiver, and subject to the terms,
conditions, and duration of the waiver. These services shall be
provided to individual beneficiaries in accordance with the client's
needs as identified in the plan of care, and subject to medical
necessity and applicable utilization control.
The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
(aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Program.
(2) The department shall seek a waiver in accordance with Section
1315 of Title 42 of the United States Code, or a state plan amendment
adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI)(ii)(2)
of Title 42 of the United States Code, which was added to Section
1396a of Title 42 of the United States Code by Section 2303(a)(2) of
the federal Patient Protection and Affordable Care Act (PPACA)
(Public Law 111-148), for a program to provide comprehensive clinical
family planning services as described in paragraph (8). Under the
waiver, the program shall be operated only in accordance with the
waiver and the statutes and regulations in paragraph (4) and subject
to the terms, conditions, and duration of the waiver. Under the state
plan amendment, which shall replace the waiver and shall be known as
the Family PACT successor state plan amendment, the program shall be
operated only in accordance with this subdivision and the statutes
and regulations in paragraph (4). The state shall use the standards
and processes imposed by the state on January 1, 2007, including the
application of an eligibility discount factor to the extent required
by the federal Centers for Medicare and Medicaid Services, for
purposes of determining eligibility as permitted under Section 1396a
(a)(10)(A)(ii)(XXI)(ii)(2) of Title 42 of the United States Code. To
the extent that federal financial participation is available, the
program shall continue to conduct education, outreach, enrollment,
service delivery, and evaluation services as specified under the
waiver. The services shall be provided under the program only if the
waiver and, when applicable, the successor state plan amendment are
approved by the federal Centers for Medicare and Medicaid Services
and only to the extent that federal financial participation is
available for the services. Nothing in this section shall prohibit
the department from seeking the Family PACT successor state plan
amendment during the operation of the waiver.
(3) Solely for the purposes of the waiver or Family PACT successor
state plan amendment and notwithstanding any other provision of law,
the collection and use of an individual's social security number
shall be necessary only to the extent required by federal law.
(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
(5) 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, without taking regulatory action, the
provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section by
means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement this
section and the approved waiver in accordance with the requirements
of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division
3 of Title 2 of the Government Code. Beginning six months after the
effective date of the act adding this subdivision, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) or the Family PACT successor state plan amendment is no
longer cost effective, this subdivision shall become inoperative on
the first day of the first month following the issuance of a 30-day
notification of that determination in writing by the Department of
Finance to the chairperson in each house that considers
appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
(8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
(B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
(C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
(i) Psychosocial and medical aspects of contraception.
(ii) Sexuality.
(iii) Fertility.
(iv) Pregnancy.
(v) Parenthood.
(vi) Infertility.
(vii) Reproductive health care.
(viii) Preconception and nutrition counseling.
(ix) Prevention and treatment of sexually transmitted infection.
(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
(xi) Possible contraceptive consequences and followup.
(xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
(E) A complete physical examination on initial and subsequent
periodic visits.
(F) Services, drugs, devices, and supplies deemed by the federal
Centers for Medicare and Medicaid Services to be appropriate for
inclusion in the program.
(9) In order to maximize the availability of federal financial
participation under this subdivision, the director shall have the
discretion to implement the Family PACT successor state plan
amendment retroactively to July 1, 2010.
(ab) Purchase of prescribed enteral formulae is covered, subject
to the Medi-Cal list of enteral formulae and utilization controls.
(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.
14132.01. (a) Notwithstanding any other provision of law, a
community clinic or free clinic licensed pursuant to subdivision (a)
of Section 1204 of the Health and Safety Code or an intermittent
clinic operating pursuant to subdivision (h) of Section 1206 of the
Health and Safety Code, that has a valid license pursuant to Article
13 (commencing with Section 4180) of Chapter 9 of Division 2 of the
Business and Professions Code shall bill and be reimbursed, as
described in this section, for drugs and supplies covered under the
Medi-Cal program and Family PACT Waiver Program.
(b) (1) A clinic described in subdivision (a) shall bill the
Medi-Cal program and Family PACT Waiver Program for drugs and
supplies covered under those programs at the lesser of cost or the
clinic's usual charge made to the general public.
(2) For purposes of this section, "cost" means an aggregate amount
equivalent to the sum of the actual acquisition cost of a drug or
supply plus a clinic dispensing fee not to exceed twelve dollars
($12) per billing unit as identified in either the Family PACT
Policies, Procedures, and Billing Instructions Manual, or the
Medi-Cal Inpatient/Outpatient Provider Manual governing outpatient
clinic billing for drugs and supplies, as applicable. For purposes of
this section, "cost" for a take-home drug that is dispensed for use
by the patient within a specific timeframe of five or less days from
the date medically indicated means actual acquisition cost for that
drug plus a clinic dispensing fee, not to exceed seventeen dollars
($17) per prescription. Reimbursement shall be at the lesser of the
amount billed or the Medi-Cal reimbursement rate, and shall not
exceed the net cost of these drugs or supplies when provided by
retail pharmacies under the Medi-Cal program.
(c) A clinic described in subdivision (a) that furnishes services
free of charge, or at a nominal charge, as defined in subsection (a)
of Section 413.13 of Title 42 of the Code of Federal Regulations, or
that can demonstrate to the department, upon request, that it serves
primarily low-income patients, and its customary practice is to
charge patients on the basis of their ability to pay, shall not be
subject to reimbursement reductions based on its usual charge to the
general public.
(d) Federally qualified health centers and rural health clinics
that are clinics as described in subdivision (a) may bill and be
reimbursed as described in this section, upon electing to be
reimbursed for pharmaceutical goods and services on a fee-for-service
basis, as permitted by subdivision (k) of Section 14132.100.
(e) A clinic that otherwise meets the qualifications set forth in
subdivision (a), that is eligible to, but that has elected not to,
utilize drugs purchased under the 340B Discount Drug Program for its
Medi-Cal patients, shall provide notification to the Health Resources
and Services Administration's Office of Pharmacy Affairs that it is
utilizing non-340B drugs for its Medi-Cal patients in the manner and
to the extent required by federal law.
14132.05. The department shall provide the fiscal and appropriate
policy committees of the Legislature with a copy of their submittal
to the federal Health Care Financing Administration pertaining to any
evaluation completed regarding the Family PACT federal waiver
required by subdivision (aa) of Section 14132.
14132.06. (a) Services specified in this section that are provided
by a local educational agency are covered Medi-Cal benefits, to the
extent federal financial participation is available, and subject to
utilization controls and standards adopted by the department, and
consistent with Medi-Cal requirements for physician prescription,
order, and supervision.
(b) Any provider enrolled on or after January 1, 1993, to provide
services pursuant to this section may bill for those services
provided on or after January 1, 1993.
(c) Nothing in this section shall be interpreted to expand the
current category of professional health care practitioners permitted
to directly bill the Medi-Cal program.
(d) Nothing in this section is intended to increase the scope of
practice of any health professional providing services under this
section or Medi-Cal requirements for physician prescription, order,
and supervision.
(e) (1) For the purposes of this section, the local educational
agency, as a condition of enrollment to provide services under this
section, shall be considered the provider of services. A local
educational agency provider, as a condition of enrollment to provide
services under this section, shall enter into, and maintain, a
contract with the department in accordance with guidelines contained
in regulations adopted by the director and published in Title 22 of
the California Code of Regulations.
(2) Notwithstanding paragraph (1), a local educational agency
providing services pursuant to this section shall utilize current
safety net and traditional health care providers, when those
providers are accessible to specific schoolsites identified by the
local educational agency to participate in this program, rather than
adding duplicate capacity.
(f) For the purposes of this section, covered services may include
all of the following local educational agency services:
(1) Health and mental health evaluations and health and mental
health education.
(2) Medical transportation.
(3) Nursing services.
(4) Occupational therapy.
(5) Physical therapy.
(6) Physician services.
(7) Mental health and counseling services.
(8) School health aide services.
(9) Speech pathology services. These services may be provided by
either of the following:
(A) A licensed speech pathologist.
(B) A credentialed speech-language pathologist, to the extent
authorized by Chapter 5.3 (commencing with Section 2530) of Division
2 of the Business and Professions Code.
(10) Audiology services.
(11) Targeted case management services for children with an
individualized education plan (IEP) or an individualized family
service plan (IFSP).
(g) Local educational agencies may, but need not, provide any or
all of the services specified in subdivision (f).
(h) For the purposes of this section, "local educational agency"
means the governing body of any school district or community college
district, the county office of education, a state special school, a
California State University campus, or a University of California
campus.
(i) Any local educational agency provider enrolled to provide
service pursuant to this section on January 1, 1995, may bill for
targeted case management services for children with an individualized
education plan (IEP) or an individualized family service plan
(IFSP), provided on or after January 1, 1995.
(j) Notwithstanding any other provision of law, a community
college district, a California State University campus, or a
University of California campus, consistent with the requirements of
this section, may bill for services provided to any student,
regardless of age, who is a Medi-Cal recipient.
14132.1. As used in this chapter "surgical center" means a surgical
clinic that is licensed under Section 1203 of the Health and Safety
Code. Pursuant to Section 14105, the director shall establish the
rates of payment for services provided by surgical centers.
14132.10. (a) Pediatric day health care provided by a health
facility licensed under paragraph (11) of subdivision (a) of Section
1250.1 of the Health and Safety Code is a covered benefit under this
chapter subject to terms, conditions, and utilization controls
developed by the department. Pediatric day care does not include
inpatient long-term care or family respite care.
(b) The department shall publish emergency regulations for
pediatric day health care services by October 1, 1997. These
regulations shall reimburse providers at a rate that shall be
determined by the department, consistent with efficiency, economy,
and quality of care until a new rate is determined on the basis of a
cost study conducted by the department.
(c) Coverage for pediatric day health care services shall be
available only to the extent that no additional net program costs are
incurred.
(d) The department shall not approve a request for authorization
of pediatric day health care when the beneficiary for whom the
authorization is requested is an inpatient in a licensed health care
facility.
(e) The department shall not approve a request for authorization
of pediatric day care if the department determines that the total
cost incurred by the Medi-Cal program for providing pediatric day
health care services and all other medically necessary services to
the individual beneficiary is greater than the total cost incurred by
the Medi-Cal program in providing medically equivalent services at
the beneficiary's otherwise appropriate level of institutional or
home care.
(f) Coverage for pediatric day health care services shall be
available only to the extent that federal financial participation in
the cost of providing these services is available pursuant to a
federally approved state plan amendment including those services as a
Medi-Cal program benefit.
14132.100. (a) The federally qualified health center services
described in Section 1396d(a)(2)(C) of Title 42 of the United States
Code are covered benefits.
(b) The rural health clinic services described in Section 1396d(a)
(2)(B) of Title 42 of the United States Code are covered benefits.
(c) Federally qualified health center services and rural health
clinic services shall be reimbursed on a per-visit basis in
accordance with the definition of "visit" set forth in subdivision
(g).
(d) Effective October 1, 2004, and on each October 1, thereafter,
until no longer required by federal law, federally qualified health
center (FQHC) and rural health clinic (RHC) per-visit rates shall be
increased by the Medicare Economic Index applicable to primary care
services in the manner provided for in Section 1396a(bb)(3)(A) of
Title 42 of the United States Code. Prior to January 1, 2004, FQHC
and RHC per-visit rates shall be adjusted by the Medicare Economic
Index in accordance with the methodology set forth in the state plan
in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its
per-visit rate based on a change in the scope of services provided by
the FQHC or RHC. Rate changes based on a change in the scope of
services provided by an FQHC or RHC shall be evaluated in accordance
with Medicare reasonable cost principles, as set forth in Part 413
(commencing with Section 413.1) of Title 42 of the Code of Federal
Regulations, or its successor.
(2) Subject to the conditions set forth in subparagraphs (A) to
(D), inclusive, of paragraph (3), a change in scope of service means
any of the following:
(A) The addition of a new FQHC or RHC service that is not
incorporated in the baseline prospective payment system (PPS) rate,
or a deletion of an FQHC or RHC service that is incorporated in the
baseline PPS rate.
(B) A change in service due to amended regulatory requirements or
rules.
(C) A change in service resulting from relocating or remodeling an
FQHC or RHC.
(D) A change in types of services due to a change in applicable
technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in
the types of patients served, including, but not limited to,
populations with HIV or AIDS, or other chronic diseases, or homeless,
elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision
(a) or (b), or in the provider mix of an FQHC or RHC or one of its
sites.
(G) Changes in operating costs attributable to capital
expenditures associated with a modification of the scope of any of
the services described in subdivision (a) or (b), including new or
expanded service facilities, regulatory compliance, or changes in
technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing
teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal
Health Resources and Service Administration (HRSA).
(3) No change in costs shall, in and of itself, be considered a
scope-of-service change unless all of the following apply:
(A) The increase or decrease in cost is attributable to an
increase or decrease in the scope of services defined in subdivisions
(a) and (b), as applicable.
(B) The cost is allowable under Medicare reasonable cost
principles set forth in Part 413 (commencing with Section 413) of
Subchapter B of Chapter 4 of Title 42 of the Code of Federal
Regulations, or its successor.
(C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination
thereof.
(D) The net change in the FQHC's or RHC's rate equals or exceeds
1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs
that filed consolidated cost reports for multiple sites to establish
the initial prospective payment reimbursement rate, the 1.75-percent
threshold shall be applied to the average per-visit rate of all sites
for the purposes of calculating the cost associated with a
scope-of-service change. "Net change" means the per-visit rate change
attributable to the cumulative effect of all increases and decreases
for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service
changes once per fiscal year, only within 90 days following the
beginning of the FQHC's or RHC's fiscal year. Any approved increase
or decrease in the provider's rate shall be retroactive to the
beginning of the FQHC's or RHC's fiscal year in which the request is
submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate change
request within 90 days of the beginning of any FQHC or RHC fiscal
year occurring after the effective date of this section, if, during
the FQHC's or RHC's prior fiscal year, the FQHC or RHC experienced a
decrease in the scope of services provided that the FQHC or RHC
either knew or should have known would have resulted in a
significantly lower per-visit rate. If an FQHC or RHC discontinues
providing onsite pharmacy or dental services, it shall submit a
scope-of-service rate change request within 90 days of the beginning
of the following fiscal year. The rate change shall be effective as
provided for in paragraph (4). As used in this paragraph,
"significantly lower" means an average per-visit rate decrease in
excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved
scope-of-service change or changes were initially implemented on or
after the first day of an FQHC's or RHC's fiscal year ending in
calendar year 2001, but before the adoption and issuance of written
instructions for applying for a scope-of-service change, the adjusted
reimbursement rate for that scope-of-service change shall be made
retroactive to the date the scope-of-service change was initially
implemented. Scope-of-service changes under this paragraph shall be
required to be submitted within the later of 150 days after the
adoption and issuance of the written instructions by the department,
or 150 days after the end of the FQHC's or RHC's fiscal year ending
in 2003.
(7) All references in this subdivision to "fiscal year" shall be
construed to be references to the fiscal year of the individual FQHC
or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a supplemental payment if
extraordinary circumstances beyond the control of the FQHC or RHC
occur after December 31, 2001, and PPS payments are insufficient due
to these extraordinary circumstances. Supplemental payments arising
from extraordinary circumstances under this subdivision shall be
solely and exclusively within the discretion of the department and
shall not be subject to subdivision (l). These supplemental payments
shall be determined separately from the scope-of-service adjustments
described in subdivision (e). Extraordinary circumstances include,
but are not limited to, acts of nature, changes in applicable
requirements in the Health and Safety Code, changes in applicable
licensure requirements, and changes in applicable rules or
regulations. Mere inflation of costs alone, absent extraordinary
circumstances, shall not be grounds for supplemental payment. If an
FQHC's or RHC's PPS rate is sufficient to cover its overall costs,
including those associated with the extraordinary circumstances, then
a supplemental payment is not warranted.
(2) The department shall accept requests for supplemental payment
at any time throughout the prospective payment rate year.
(3) Requests for supplemental payments shall be submitted in
writing to the department and shall set forth the reasons for the
request. Each request shall be accompanied by sufficient
documentation to enable the department to act upon the request.
Documentation shall include the data necessary to demonstrate that
the circumstances for which supplemental payment is requested meet
the requirements set forth in this section. Documentation shall
include all of the following:
(A) A presentation of data to demonstrate reasons for the FQHC's
or RHC's request for a supplemental payment.
(B) Documentation showing the cost implications. The cost impact
shall be material and significant, two hundred thousand dollars
($200,000) or 1 percent of a facility's total costs, whichever is
less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall be
paid as lump-sum amounts for those years and not as revised PPS
rates, and shall be repaid by the FQHC or RHC to the extent that it
is not expended for the specified purposes.
(6) The department shall notify the provider of the department's
discretionary decision in writing.
(g) (1) An FQHC or RHC "visit" means a face-to-face encounter
between an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, clinical psychologist,
licensed clinical social worker, or a visiting nurse. For purposes of
this section, "physician" shall be interpreted in a manner
consistent with the Centers for Medicare and Medicaid Services'
Medicare Rural Health Clinic and Federally Qualified Health Center
Manual (Publication 27), or its successor, only to the extent that it
defines the professionals whose services are reimbursable on a
per-visit basis and not as to the types of services that these
professionals may render during these visits and shall include a
physician and surgeon, podiatrist, dentist, optometrist, and
chiropractor. A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a comprehensive perinatal services
practitioner, as defined in Section 51179.1 of Title 22 of the
California Code of Regulations, providing comprehensive perinatal
services, a four-hour day of attendance at an adult day health care
center, and any other provider identified in the state plan's
definition of an FQHC or RHC visit.
(2) (A) A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a dental hygienist or a dental
hygienist in alternative practice.
(B) Notwithstanding subdivision (e), an FQHC or RHC that currently
includes the cost of the services of a dental hygienist in
alternative practice for the purposes of establishing its FQHC or RHC
rate shall apply for an adjustment to its per-visit rate, and, after
the rate adjustment has been approved by the department, shall bill
these services as a separate visit. However, multiple encounters with
dental professionals that take place on the same day shall
constitute a single visit. The department shall develop the
appropriate forms to determine which FQHC's or RHC rates shall be
adjusted and to facilitate the calculation of the adjusted rates. An
FQHC's or RHC's application for, or the department's approval of, a
rate adjustment pursuant to this subparagraph shall not constitute a
change in scope of service within the meaning of subdivision (e). An
FQHC or RHC that applies for an adjustment to its rate pursuant to
this subparagraph may continue to bill for all other FQHC or RHC
visits at its existing per-visit rate, subject to reconciliation,
until the rate adjustment for visits between an FQHC or RHC patient
and a dental hygienist or a dental hygienist in alternative practice
has been approved. Any approved increase or decrease in the provider'
s rate shall be made within six months after the date of receipt of
the department's rate adjustment forms pursuant to this subparagraph
and shall be retroactive to the beginning of the fiscal year in which
the FQHC or RHC submits the request, but in no case shall the
effective date be earlier than January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist or
dental hygienist in alternative practice services, and later elects
to add these services, shall process the addition of these services
as a change in scope of service pursuant to subdivision (e).
(h) If FQHC or RHC services are partially reimbursed by a
third-party payer, such as a managed care entity (as defined in
Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the
Medicare Program, or the Child Health and Disability Prevention
(CHDP) program, the department shall reimburse an FQHC or RHC for the
difference between its per-visit PPS rate and receipts from other
plans or programs on a contract-by-contract basis and not in the
aggregate, and may not include managed care financial incentive
payments that are required by federal law to be excluded from the
calculation.
(i) (1) An entity that first qualifies as an FQHC or RHC in the
year 2001 or later, a newly licensed facility at a new location added
to an existing FQHC or RHC, and any entity that is an existing FQHC
or RHC that is relocated to a new site shall each have its
reimbursement rate established in accordance with one of the
following methods, as selected by the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount
that is equal to the average of the per-visit rates of three
comparable FQHCs or RHCs located in the same or adjacent area with a
similar caseload.
(B) In the absence of three comparable FQHCs or RHCs with a
similar caseload, the rate may be calculated on a per-visit basis in
an amount that is equal to the average of the per-visit rates of
three comparable FQHCs or RHCs located in the same or an adjacent
service area, or in a reasonably similar geographic area with respect
to relevant social, health care, and economic characteristics.
(C) At a new entity's one-time election, the department shall
establish a reimbursement rate, calculated on a per-visit basis, that
is equal to 100 percent of the projected allowable costs to the FQHC
or RHC of furnishing FQHC or RHC services during the first 12 months
of operation as an FQHC or RHC. After the first 12-month period, the
projected per-visit rate shall be increased by the Medicare Economic
Index then in effect. The projected allowable costs for the first 12
months shall be cost settled and the prospective payment
reimbursement rate shall be adjusted based on actual and allowable
cost per visit.
(D) The department may adopt any further and additional methods of
setting reimbursement rates for newly qualified FQHCs or RHCs as are
consistent with Section 1396a(bb)(4) of Title 42 of the United
States Code.
(2) In order for an FQHC or RHC to establish the comparability of
its caseload for purposes of subparagraph (A) or (B) of paragraph
(1), the department shall require that the FQHC or RHC submit its
most recent annual utilization report as submitted to the Office of
Statewide Health Planning and Development, unless the FQHC or RHC was
not required to file an annual utilization report. FQHCs or RHCs
that have experienced changes in their services or caseload
subsequent to the filing of the annual utilization report may submit
to the department a completed report in the format applicable to the
prior calendar year. FQHCs or RHCs that have not previously submitted
an annual utilization report shall submit to the department a
completed report in the format applicable to the prior calendar year.
The FQHC or RHC shall not be required to submit the annual
utilization report for the comparable FQHCs or RHCs to the
department, but shall be required to identify the comparable FQHCs or
RHCs.
(3) The rate for any newly qualified entity set forth under this
subdivision shall be effective retroactively to the later of the date
that the entity was first qualified by the applicable federal agency
as an FQHC or RHC, the date a new facility at a new location was
added to an existing FQHC or RHC, or the date on which an existing
FQHC or RHC was relocated to a new site. The FQHC or RHC shall be
permitted to continue billing for Medi-Cal covered benefits on a
fee-for-service basis until it is informed of its enrollment as an
FQHC or RHC, and the department shall reconcile the difference
between the fee-for-service payments and the FQHC's or RHC's
prospective payment rate at that time.
(j) Visits occurring at an intermittent clinic site, as defined in
subdivision (h) of Section 1206 of the Health and Safety Code, of an
existing FQHC or RHC, or in a mobile unit as defined by paragraph
(2) of subdivision (b) of Section 1765.105 of the Health and Safety
Code, shall be billed by and reimbursed at the same rate as the FQHC
or RHC establishing the intermittent clinic site or the mobile unit,
subject to the right of the FQHC or RHC to request a scope-of-service
adjustment to the rate.
(k) An FQHC or RHC may elect to have pharmacy or dental services
reimbursed on a fee-for-service basis, utilizing the current fee
schedules established for those services. These costs shall be
adjusted out of the FQHC's or RHC's clinic base rate as
scope-of-service changes. An FQHC or RHC that reverses its election
under this subdivision shall revert to its prior rate, subject to an
increase to account for all MEI increases occurring during the
intervening time period, and subject to any increase or decrease
associated with applicable scope-of-services adjustments as provided
in subdivision (e).
(l) FQHCs and RHCs may appeal a grievance or complaint concerning
ratesetting, scope-of-service changes, and settlement of cost report
audits, in the manner prescribed by Section 14171. The rights and
remedies provided under this subdivision are cumulative to the rights
and remedies available under all other provisions of law of this
state.
(m) The department shall, by no later than March 30, 2008,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
(n) The department shall implement this section only to the extent
that federal financial participation is obtained.
14132.101. (a) Notwithstanding paragraphs (4) and (5) of
subdivision (e) of Section 14132.100, a scope-of-service change
request, whether mandatory or permissive, shall be timely when filed
within 150 days following the beginning of the federally qualified
health center's or rural health clinic's fiscal year following the
year in which the change occurred.
(b) Notwithstanding subdivision (a), and notwithstanding
subdivision (e) of Section 14132.100, a federally qualified health
center described in Section 14132.102 shall be deemed to have filed a
scope-of-service change in a timely manner upon compliance with the
requirements set forth in subdivision (c) of Section 14132.102.
14132.102. (a) With the exception of clinics and hospital
outpatient departments that are subject to Section 14105.24,
federally qualified health centers (FQHCs) that are receiving
cost-based reimbursement under the terms of the Los Angeles County
1115 Waiver Demonstration Project on June 30, 2005, shall be required
to transition to a prospective payment system (PPS) rate upon
expiration of that waiver. These FQHCs shall be referred to in this
section as "Los Angeles cost-based FQHCs."
(b) For visits occurring on or after July 1, 2005, Los Angeles
cost-based FQHCs shall receive a PPS rate equivalent to the
following:
(1) FQHC sites that were in existence during the FQHC's 2000
fiscal year shall be permitted to elect their 2000 per-visit rates or
the average of the 1999 and 2000 per-visit rates as reported on the
cost reports submitted for those fiscal years adjusted as described
in subdivision (c).
(2) FQHC sites that were first qualified as an FQHC after the site'
s 2000 fiscal year shall receive a base rate equivalent to the first
full fiscal year rate, as audited on the cost report submitted for
that fiscal year and adjusted as described in subdivision (c).
(3) Sites that were first qualified as an FQHC after the site's
2000 fiscal year, and that have not yet filed a cost report for their
first full fiscal year shall have a rate set in accordance with
subdivision (i) of Section 14132.100 and adjusted as described in
subdivision (c).
(c) The base rates described in this section shall be adjusted in
the manner described in subdivision (d), paragraphs (1), (2), (3),
and (7) of subdivision (e), and subdivision (f) of Section 14132.100.
(d) For Los Angeles cost-based FQHCs, as defined in subdivision
(a), no new cost reports shall be required in order to claim
scope-of-service changes occurring in fiscal years prior to July 1,
2005. Only the following information shall be required by the
department:
(1) A description of the events triggering any applicable rate
changes in the form of Worksheet 1 of the Change in Scope-of-Service
Request form developed for fiscal years 2004 and thereafter, modified
to identify the applicable fiscal year in which the scope change
occurred.
(2) The two worksheets to the Change in Scope-of-Service Request
form summarizing the health center's health care practitioners and
services for the applicable fiscal year or years.
(e) Change in Scope-of-Service Request forms for changes occurring
prior to July 1, 2005, shall be filed with the department no later
than July 1, 2006, and shall be deemed to have been filed only when
both the Medi-Cal cost report for the applicable period and the
referenced Change in Scope-of-Service Request form worksheets have
been filed with the department. The date of filing shall be the date
on which either the Medi-Cal cost report or the referenced Change in
Scope-of-Service Request forms are received by the department,
whichever is later.
(f) Notwithstanding Section 14132.107, the department shall
calculate a tentative scope-of-service rate adjustment based on 80
percent of the difference in the "as reported" scope-of-service per
visit cost. This adjustment shall occur no later than 150 days after
receipt of the Medi-Cal cost report and the referenced Change in
Scope-of-Service Request forms. Within 12 months after receipt of
request forms, the department shall complete its FQHC fiscal year
audit of the Medi-Cal cost report and associated Change in
Scope-of-Service Request and final rate adjustment pursuant to that
audit. The final rate adjustment will be retroactive to July 1, 2005.
Nothing in this subdivision shall be construed to extend the time
period for review and finalization of cost reports as set forth in
Section 14170.
(g) The department shall, by no later than March 30, 2006,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
(h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, and only to
the extent that all necessary federal approvals are obtained and
there is an appropriation for the purposes of implementing this
section, the department may implement this section without taking any
regulatory action and by means of a provider bulletin or similar
instructions.
14132.107. Claims for reimbursement under subdivision (e) of
Section 14132.100 shall be finalized by the department within 150
days of receipt of the claims for reimbursement. These claims for
reimbursement shall be paid within 30 days of being finalized by the
department. However, the payment of those amounts that are disputed
shall be subject to the requirements, timeframes, and procedures
specified in Section 14171. Scope changes going forward shall be
finalized within 90 days of receipt and paid within 30 days of being
finalized by the department.
14132.108.
14131. The Medi-Cal Benefits Program comprises a
department-administered uniform schedule of health care benefits.
Notwithstanding any other provision of this chapter, "health care
services" shall be limited to the benefits set forth in this article
and in Section 14021.
14131.10. (a) Notwithstanding any other provision of this chapter,
Chapter 8 (commencing with Section 14200), or Chapter 8.75
(commencing with Section 14590), in order to implement changes in the
level of funding for health care services, specific optional
benefits are excluded from coverage under the Medi-Cal program.
(b) (1) The following optional benefits are excluded from coverage
under the Medi-Cal program:
(A) Adult dental services, except as specified in paragraph (2).
(B) Acupuncture services.
(C) Audiology services and speech therapy services.
(D) Chiropractic services.
(E) Optometric and optician services, including services provided
by a fabricating optical laboratory.
(F) Podiatric services.
(G) Psychology services.
(H) Incontinence creams and washes.
(2) Medical and surgical services provided by a doctor of dental
medicine or dental surgery, which, if provided by a physician, would
be considered physician services, and which services may be provided
by either a physician or a dentist in this state, are covered.
(3) Pregnancy-related services and services for the treatment of
other conditions that might complicate the pregnancy are not excluded
from coverage under this section.
(c) The optional benefit exclusions do not apply to either of the
following:
(1) Beneficiaries under the Early and Periodic Screening Diagnosis
and Treatment Program.
(2) Beneficiaries receiving long-term care in a nursing facility
that is both:
(A) A skilled nursing facility or intermediate care facility as
defined in subdivisions (c) and (d) of Section 1250 of the Health and
Safety Code.
(B) Licensed pursuant to subdivision (k) of Section 1250 of the
Health and Safety Code.
(d) This section shall only be implemented to the extent permitted
by federal law.
(e) 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 the provisions of this section by means of
all-county letters, provider bulletins, or similar instructions,
without taking further regulatory action.
(f) This section shall be implemented on the first day of the
month following 90 days after the operative date of this section.
14131.15. (a) In geographic areas in which Medi-Cal managed care
plans contracting under this chapter or Chapter 8 (commencing with
Section 14200) are operating with capacity to enroll additional
qualifying Medi-Cal beneficiaries, the director may, in the interest
of bringing managed care principles to bear on the quality, costs, or
utilization levels of the Medi-Cal program, designate any benefit or
service included in the Medi-Cal program, at state option under
federal medicaid rules, as a covered Medi-Cal benefit only when
provided by a Medi-Cal managed care plan to a Medi-Cal enrollee of
the plan.
(b) Where benefits and services have been designated by the
director under subdivision (a), beneficiaries who are eligible to
enroll in and reside in the service area of a managed care plan, and
who desire coverage for such benefits and services, must enroll in a
Medi-Cal managed care plan to receive them and shall, to the maximum
extent permitted under federal law, remain enrolled in the plan.
(c) When managed care capacity is reached in an area in which
Medi-Cal benefits have been designated under this section, the
director may provide for the delivery of designated benefits or
services to beneficiaries by contract to the extent permitted under
this chapter, on a fee-for-service basis or a combination of both.
(d) Exercise of the director's discretion under this section shall
not preclude Medi-Cal managed care contractors from applying their
established medical necessity criteria, utilization control standards
and policies and utilization review procedures in delivering
designated services as permitted and controlled by Medi-Cal contract
and other state and federal regulatory standards.
(e) Enactment of this section shall not impose any requirement on
a Medi-Cal managed care plan to negotiate or enter into a contract or
any other participation arrangement with any provider of a Medi-Cal
benefit or service designated under subdivision (a).
(f) The department shall seek all federal waivers necessary to
allow for federal financial participation in expenditures under this
section.
14132. The following is the schedule of benefits under this
chapter:
(a) Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
(b) Inpatient hospital services, including, but not limited to,
physician and podiatric services, physical therapy and occupational
therapy, are covered subject to utilization controls.
(c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.
(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers of Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
(4) (A) Nonlegend acetaminophen-containing products, with the
exception of children's Tylenol, selected by the department are not
covered benefits. For the purposes of this paragraph, nonlegend has
the same meaning as defined in subdivision (a) of Section 14105.45.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instruction without taking regulatory action.
(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and equipment
required for dialysis, are covered, subject to utilization controls.
(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
(g) Blood and blood derivatives are covered.
(h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
(A) Periodontal treatment is not a benefit.
(B) Endodontic therapy is not a benefit except for vital
pulpotomy.
(C) Laboratory processed crowns are not a benefit.
(D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
(E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
(F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
(3) Paragraph (2) shall become inoperative July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
(m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
(n) Family planning services are covered, subject to utilization
controls.
(o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).
(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request, adult
day health care is covered for a maximum of three days per week.
(3) As provided in accordance with paragraph (4), adult day health
care is covered for a maximum of five days per week.
(4) As of the date that the director makes the declaration
described in subdivision (g) of Section 14525.1, paragraph (2) shall
become inoperative and paragraph (3) shall become operative.
(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.
(2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and 1770
of the Business and Professions Code may be covered as long as they
are within the scope of Denti-Cal benefits and they are necessary
services provided by a registered dental hygienist in alternative
practice.
(r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under Article 3
(commencing with Section 1480) of Chapter 2.5 of Division 2 of the
Health and Safety Code by a paramedic certified pursuant to that
article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.
(2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming a
Medi-Cal provider.
(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
As used in this subdivision, in-home medical care services,
include, but are not limited to:
(1) Level of care and cost of care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
(t) Home- and community-based services approved by the United
States Department of Health and Human Services may be covered to the
extent that federal financial participation is available for those
services under waivers granted in accordance with Section 1396n of
Title 42 of the United States Code. The director may seek waivers for
any or all home- and community-based services approvable under
Section 1396n of Title 42 of the United States Code. Coverage for
those services shall be limited by the terms, conditions, and
duration of the federal waivers.
(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
(v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
(w) Hospice service which is Medicare-certified hospice service is
covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are
incurred.
(x) When a claim for treatment provided to a beneficiary includes
both services which are authorized and reimbursable under this
chapter, and services which are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
(y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
Services provided pursuant to a waiver obtained from the Secretary
of the United States Department of Health and Human Services
pursuant to this subdivision, and which are not otherwise included in
the Medi-Cal schedule of benefits, shall be available only to the
extent that federal financial participation for these services is
available in accordance with the waiver, and subject to the terms,
conditions, and duration of the waiver. These services shall be
provided to individual beneficiaries in accordance with the client's
needs as identified in the plan of care, and subject to medical
necessity and applicable utilization control.
The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
(aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Program.
(2) The department shall seek a waiver in accordance with Section
1315 of Title 42 of the United States Code, or a state plan amendment
adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI)(ii)(2)
of Title 42 of the United States Code, which was added to Section
1396a of Title 42 of the United States Code by Section 2303(a)(2) of
the federal Patient Protection and Affordable Care Act (PPACA)
(Public Law 111-148), for a program to provide comprehensive clinical
family planning services as described in paragraph (8). Under the
waiver, the program shall be operated only in accordance with the
waiver and the statutes and regulations in paragraph (4) and subject
to the terms, conditions, and duration of the waiver. Under the state
plan amendment, which shall replace the waiver and shall be known as
the Family PACT successor state plan amendment, the program shall be
operated only in accordance with this subdivision and the statutes
and regulations in paragraph (4). The state shall use the standards
and processes imposed by the state on January 1, 2007, including the
application of an eligibility discount factor to the extent required
by the federal Centers for Medicare and Medicaid Services, for
purposes of determining eligibility as permitted under Section 1396a
(a)(10)(A)(ii)(XXI)(ii)(2) of Title 42 of the United States Code. To
the extent that federal financial participation is available, the
program shall continue to conduct education, outreach, enrollment,
service delivery, and evaluation services as specified under the
waiver. The services shall be provided under the program only if the
waiver and, when applicable, the successor state plan amendment are
approved by the federal Centers for Medicare and Medicaid Services
and only to the extent that federal financial participation is
available for the services. Nothing in this section shall prohibit
the department from seeking the Family PACT successor state plan
amendment during the operation of the waiver.
(3) Solely for the purposes of the waiver or Family PACT successor
state plan amendment and notwithstanding any other provision of law,
the collection and use of an individual's social security number
shall be necessary only to the extent required by federal law.
(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
(5) 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, without taking regulatory action, the
provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section by
means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement this
section and the approved waiver in accordance with the requirements
of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division
3 of Title 2 of the Government Code. Beginning six months after the
effective date of the act adding this subdivision, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) or the Family PACT successor state plan amendment is no
longer cost effective, this subdivision shall become inoperative on
the first day of the first month following the issuance of a 30-day
notification of that determination in writing by the Department of
Finance to the chairperson in each house that considers
appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
(8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
(B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
(C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
(i) Psychosocial and medical aspects of contraception.
(ii) Sexuality.
(iii) Fertility.
(iv) Pregnancy.
(v) Parenthood.
(vi) Infertility.
(vii) Reproductive health care.
(viii) Preconception and nutrition counseling.
(ix) Prevention and treatment of sexually transmitted infection.
(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
(xi) Possible contraceptive consequences and followup.
(xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
(E) A complete physical examination on initial and subsequent
periodic visits.
(F) Services, drugs, devices, and supplies deemed by the federal
Centers for Medicare and Medicaid Services to be appropriate for
inclusion in the program.
(9) In order to maximize the availability of federal financial
participation under this subdivision, the director shall have the
discretion to implement the Family PACT successor state plan
amendment retroactively to July 1, 2010.
(ab) Purchase of prescribed enteral formulae is covered, subject
to the Medi-Cal list of enteral formulae and utilization controls.
(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.
14132.01. (a) Notwithstanding any other provision of law, a
community clinic or free clinic licensed pursuant to subdivision (a)
of Section 1204 of the Health and Safety Code or an intermittent
clinic operating pursuant to subdivision (h) of Section 1206 of the
Health and Safety Code, that has a valid license pursuant to Article
13 (commencing with Section 4180) of Chapter 9 of Division 2 of the
Business and Professions Code shall bill and be reimbursed, as
described in this section, for drugs and supplies covered under the
Medi-Cal program and Family PACT Waiver Program.
(b) (1) A clinic described in subdivision (a) shall bill the
Medi-Cal program and Family PACT Waiver Program for drugs and
supplies covered under those programs at the lesser of cost or the
clinic's usual charge made to the general public.
(2) For purposes of this section, "cost" means an aggregate amount
equivalent to the sum of the actual acquisition cost of a drug or
supply plus a clinic dispensing fee not to exceed twelve dollars
($12) per billing unit as identified in either the Family PACT
Policies, Procedures, and Billing Instructions Manual, or the
Medi-Cal Inpatient/Outpatient Provider Manual governing outpatient
clinic billing for drugs and supplies, as applicable. For purposes of
this section, "cost" for a take-home drug that is dispensed for use
by the patient within a specific timeframe of five or less days from
the date medically indicated means actual acquisition cost for that
drug plus a clinic dispensing fee, not to exceed seventeen dollars
($17) per prescription. Reimbursement shall be at the lesser of the
amount billed or the Medi-Cal reimbursement rate, and shall not
exceed the net cost of these drugs or supplies when provided by
retail pharmacies under the Medi-Cal program.
(c) A clinic described in subdivision (a) that furnishes services
free of charge, or at a nominal charge, as defined in subsection (a)
of Section 413.13 of Title 42 of the Code of Federal Regulations, or
that can demonstrate to the department, upon request, that it serves
primarily low-income patients, and its customary practice is to
charge patients on the basis of their ability to pay, shall not be
subject to reimbursement reductions based on its usual charge to the
general public.
(d) Federally qualified health centers and rural health clinics
that are clinics as described in subdivision (a) may bill and be
reimbursed as described in this section, upon electing to be
reimbursed for pharmaceutical goods and services on a fee-for-service
basis, as permitted by subdivision (k) of Section 14132.100.
(e) A clinic that otherwise meets the qualifications set forth in
subdivision (a), that is eligible to, but that has elected not to,
utilize drugs purchased under the 340B Discount Drug Program for its
Medi-Cal patients, shall provide notification to the Health Resources
and Services Administration's Office of Pharmacy Affairs that it is
utilizing non-340B drugs for its Medi-Cal patients in the manner and
to the extent required by federal law.
14132.05. The department shall provide the fiscal and appropriate
policy committees of the Legislature with a copy of their submittal
to the federal Health Care Financing Administration pertaining to any
evaluation completed regarding the Family PACT federal waiver
required by subdivision (aa) of Section 14132.
14132.06. (a) Services specified in this section that are provided
by a local educational agency are covered Medi-Cal benefits, to the
extent federal financial participation is available, and subject to
utilization controls and standards adopted by the department, and
consistent with Medi-Cal requirements for physician prescription,
order, and supervision.
(b) Any provider enrolled on or after January 1, 1993, to provide
services pursuant to this section may bill for those services
provided on or after January 1, 1993.
(c) Nothing in this section shall be interpreted to expand the
current category of professional health care practitioners permitted
to directly bill the Medi-Cal program.
(d) Nothing in this section is intended to increase the scope of
practice of any health professional providing services under this
section or Medi-Cal requirements for physician prescription, order,
and supervision.
(e) (1) For the purposes of this section, the local educational
agency, as a condition of enrollment to provide services under this
section, shall be considered the provider of services. A local
educational agency provider, as a condition of enrollment to provide
services under this section, shall enter into, and maintain, a
contract with the department in accordance with guidelines contained
in regulations adopted by the director and published in Title 22 of
the California Code of Regulations.
(2) Notwithstanding paragraph (1), a local educational agency
providing services pursuant to this section shall utilize current
safety net and traditional health care providers, when those
providers are accessible to specific schoolsites identified by the
local educational agency to participate in this program, rather than
adding duplicate capacity.
(f) For the purposes of this section, covered services may include
all of the following local educational agency services:
(1) Health and mental health evaluations and health and mental
health education.
(2) Medical transportation.
(3) Nursing services.
(4) Occupational therapy.
(5) Physical therapy.
(6) Physician services.
(7) Mental health and counseling services.
(8) School health aide services.
(9) Speech pathology services. These services may be provided by
either of the following:
(A) A licensed speech pathologist.
(B) A credentialed speech-language pathologist, to the extent
authorized by Chapter 5.3 (commencing with Section 2530) of Division
2 of the Business and Professions Code.
(10) Audiology services.
(11) Targeted case management services for children with an
individualized education plan (IEP) or an individualized family
service plan (IFSP).
(g) Local educational agencies may, but need not, provide any or
all of the services specified in subdivision (f).
(h) For the purposes of this section, "local educational agency"
means the governing body of any school district or community college
district, the county office of education, a state special school, a
California State University campus, or a University of California
campus.
(i) Any local educational agency provider enrolled to provide
service pursuant to this section on January 1, 1995, may bill for
targeted case management services for children with an individualized
education plan (IEP) or an individualized family service plan
(IFSP), provided on or after January 1, 1995.
(j) Notwithstanding any other provision of law, a community
college district, a California State University campus, or a
University of California campus, consistent with the requirements of
this section, may bill for services provided to any student,
regardless of age, who is a Medi-Cal recipient.
14132.1. As used in this chapter "surgical center" means a surgical
clinic that is licensed under Section 1203 of the Health and Safety
Code. Pursuant to Section 14105, the director shall establish the
rates of payment for services provided by surgical centers.
14132.10. (a) Pediatric day health care provided by a health
facility licensed under paragraph (11) of subdivision (a) of Section
1250.1 of the Health and Safety Code is a covered benefit under this
chapter subject to terms, conditions, and utilization controls
developed by the department. Pediatric day care does not include
inpatient long-term care or family respite care.
(b) The department shall publish emergency regulations for
pediatric day health care services by October 1, 1997. These
regulations shall reimburse providers at a rate that shall be
determined by the department, consistent with efficiency, economy,
and quality of care until a new rate is determined on the basis of a
cost study conducted by the department.
(c) Coverage for pediatric day health care services shall be
available only to the extent that no additional net program costs are
incurred.
(d) The department shall not approve a request for authorization
of pediatric day health care when the beneficiary for whom the
authorization is requested is an inpatient in a licensed health care
facility.
(e) The department shall not approve a request for authorization
of pediatric day care if the department determines that the total
cost incurred by the Medi-Cal program for providing pediatric day
health care services and all other medically necessary services to
the individual beneficiary is greater than the total cost incurred by
the Medi-Cal program in providing medically equivalent services at
the beneficiary's otherwise appropriate level of institutional or
home care.
(f) Coverage for pediatric day health care services shall be
available only to the extent that federal financial participation in
the cost of providing these services is available pursuant to a
federally approved state plan amendment including those services as a
Medi-Cal program benefit.
14132.100. (a) The federally qualified health center services
described in Section 1396d(a)(2)(C) of Title 42 of the United States
Code are covered benefits.
(b) The rural health clinic services described in Section 1396d(a)
(2)(B) of Title 42 of the United States Code are covered benefits.
(c) Federally qualified health center services and rural health
clinic services shall be reimbursed on a per-visit basis in
accordance with the definition of "visit" set forth in subdivision
(g).
(d) Effective October 1, 2004, and on each October 1, thereafter,
until no longer required by federal law, federally qualified health
center (FQHC) and rural health clinic (RHC) per-visit rates shall be
increased by the Medicare Economic Index applicable to primary care
services in the manner provided for in Section 1396a(bb)(3)(A) of
Title 42 of the United States Code. Prior to January 1, 2004, FQHC
and RHC per-visit rates shall be adjusted by the Medicare Economic
Index in accordance with the methodology set forth in the state plan
in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its
per-visit rate based on a change in the scope of services provided by
the FQHC or RHC. Rate changes based on a change in the scope of
services provided by an FQHC or RHC shall be evaluated in accordance
with Medicare reasonable cost principles, as set forth in Part 413
(commencing with Section 413.1) of Title 42 of the Code of Federal
Regulations, or its successor.
(2) Subject to the conditions set forth in subparagraphs (A) to
(D), inclusive, of paragraph (3), a change in scope of service means
any of the following:
(A) The addition of a new FQHC or RHC service that is not
incorporated in the baseline prospective payment system (PPS) rate,
or a deletion of an FQHC or RHC service that is incorporated in the
baseline PPS rate.
(B) A change in service due to amended regulatory requirements or
rules.
(C) A change in service resulting from relocating or remodeling an
FQHC or RHC.
(D) A change in types of services due to a change in applicable
technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in
the types of patients served, including, but not limited to,
populations with HIV or AIDS, or other chronic diseases, or homeless,
elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision
(a) or (b), or in the provider mix of an FQHC or RHC or one of its
sites.
(G) Changes in operating costs attributable to capital
expenditures associated with a modification of the scope of any of
the services described in subdivision (a) or (b), including new or
expanded service facilities, regulatory compliance, or changes in
technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing
teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal
Health Resources and Service Administration (HRSA).
(3) No change in costs shall, in and of itself, be considered a
scope-of-service change unless all of the following apply:
(A) The increase or decrease in cost is attributable to an
increase or decrease in the scope of services defined in subdivisions
(a) and (b), as applicable.
(B) The cost is allowable under Medicare reasonable cost
principles set forth in Part 413 (commencing with Section 413) of
Subchapter B of Chapter 4 of Title 42 of the Code of Federal
Regulations, or its successor.
(C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination
thereof.
(D) The net change in the FQHC's or RHC's rate equals or exceeds
1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs
that filed consolidated cost reports for multiple sites to establish
the initial prospective payment reimbursement rate, the 1.75-percent
threshold shall be applied to the average per-visit rate of all sites
for the purposes of calculating the cost associated with a
scope-of-service change. "Net change" means the per-visit rate change
attributable to the cumulative effect of all increases and decreases
for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service
changes once per fiscal year, only within 90 days following the
beginning of the FQHC's or RHC's fiscal year. Any approved increase
or decrease in the provider's rate shall be retroactive to the
beginning of the FQHC's or RHC's fiscal year in which the request is
submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate change
request within 90 days of the beginning of any FQHC or RHC fiscal
year occurring after the effective date of this section, if, during
the FQHC's or RHC's prior fiscal year, the FQHC or RHC experienced a
decrease in the scope of services provided that the FQHC or RHC
either knew or should have known would have resulted in a
significantly lower per-visit rate. If an FQHC or RHC discontinues
providing onsite pharmacy or dental services, it shall submit a
scope-of-service rate change request within 90 days of the beginning
of the following fiscal year. The rate change shall be effective as
provided for in paragraph (4). As used in this paragraph,
"significantly lower" means an average per-visit rate decrease in
excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved
scope-of-service change or changes were initially implemented on or
after the first day of an FQHC's or RHC's fiscal year ending in
calendar year 2001, but before the adoption and issuance of written
instructions for applying for a scope-of-service change, the adjusted
reimbursement rate for that scope-of-service change shall be made
retroactive to the date the scope-of-service change was initially
implemented. Scope-of-service changes under this paragraph shall be
required to be submitted within the later of 150 days after the
adoption and issuance of the written instructions by the department,
or 150 days after the end of the FQHC's or RHC's fiscal year ending
in 2003.
(7) All references in this subdivision to "fiscal year" shall be
construed to be references to the fiscal year of the individual FQHC
or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a supplemental payment if
extraordinary circumstances beyond the control of the FQHC or RHC
occur after December 31, 2001, and PPS payments are insufficient due
to these extraordinary circumstances. Supplemental payments arising
from extraordinary circumstances under this subdivision shall be
solely and exclusively within the discretion of the department and
shall not be subject to subdivision (l). These supplemental payments
shall be determined separately from the scope-of-service adjustments
described in subdivision (e). Extraordinary circumstances include,
but are not limited to, acts of nature, changes in applicable
requirements in the Health and Safety Code, changes in applicable
licensure requirements, and changes in applicable rules or
regulations. Mere inflation of costs alone, absent extraordinary
circumstances, shall not be grounds for supplemental payment. If an
FQHC's or RHC's PPS rate is sufficient to cover its overall costs,
including those associated with the extraordinary circumstances, then
a supplemental payment is not warranted.
(2) The department shall accept requests for supplemental payment
at any time throughout the prospective payment rate year.
(3) Requests for supplemental payments shall be submitted in
writing to the department and shall set forth the reasons for the
request. Each request shall be accompanied by sufficient
documentation to enable the department to act upon the request.
Documentation shall include the data necessary to demonstrate that
the circumstances for which supplemental payment is requested meet
the requirements set forth in this section. Documentation shall
include all of the following:
(A) A presentation of data to demonstrate reasons for the FQHC's
or RHC's request for a supplemental payment.
(B) Documentation showing the cost implications. The cost impact
shall be material and significant, two hundred thousand dollars
($200,000) or 1 percent of a facility's total costs, whichever is
less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall be
paid as lump-sum amounts for those years and not as revised PPS
rates, and shall be repaid by the FQHC or RHC to the extent that it
is not expended for the specified purposes.
(6) The department shall notify the provider of the department's
discretionary decision in writing.
(g) (1) An FQHC or RHC "visit" means a face-to-face encounter
between an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, clinical psychologist,
licensed clinical social worker, or a visiting nurse. For purposes of
this section, "physician" shall be interpreted in a manner
consistent with the Centers for Medicare and Medicaid Services'
Medicare Rural Health Clinic and Federally Qualified Health Center
Manual (Publication 27), or its successor, only to the extent that it
defines the professionals whose services are reimbursable on a
per-visit basis and not as to the types of services that these
professionals may render during these visits and shall include a
physician and surgeon, podiatrist, dentist, optometrist, and
chiropractor. A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a comprehensive perinatal services
practitioner, as defined in Section 51179.1 of Title 22 of the
California Code of Regulations, providing comprehensive perinatal
services, a four-hour day of attendance at an adult day health care
center, and any other provider identified in the state plan's
definition of an FQHC or RHC visit.
(2) (A) A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a dental hygienist or a dental
hygienist in alternative practice.
(B) Notwithstanding subdivision (e), an FQHC or RHC that currently
includes the cost of the services of a dental hygienist in
alternative practice for the purposes of establishing its FQHC or RHC
rate shall apply for an adjustment to its per-visit rate, and, after
the rate adjustment has been approved by the department, shall bill
these services as a separate visit. However, multiple encounters with
dental professionals that take place on the same day shall
constitute a single visit. The department shall develop the
appropriate forms to determine which FQHC's or RHC rates shall be
adjusted and to facilitate the calculation of the adjusted rates. An
FQHC's or RHC's application for, or the department's approval of, a
rate adjustment pursuant to this subparagraph shall not constitute a
change in scope of service within the meaning of subdivision (e). An
FQHC or RHC that applies for an adjustment to its rate pursuant to
this subparagraph may continue to bill for all other FQHC or RHC
visits at its existing per-visit rate, subject to reconciliation,
until the rate adjustment for visits between an FQHC or RHC patient
and a dental hygienist or a dental hygienist in alternative practice
has been approved. Any approved increase or decrease in the provider'
s rate shall be made within six months after the date of receipt of
the department's rate adjustment forms pursuant to this subparagraph
and shall be retroactive to the beginning of the fiscal year in which
the FQHC or RHC submits the request, but in no case shall the
effective date be earlier than January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist or
dental hygienist in alternative practice services, and later elects
to add these services, shall process the addition of these services
as a change in scope of service pursuant to subdivision (e).
(h) If FQHC or RHC services are partially reimbursed by a
third-party payer, such as a managed care entity (as defined in
Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the
Medicare Program, or the Child Health and Disability Prevention
(CHDP) program, the department shall reimburse an FQHC or RHC for the
difference between its per-visit PPS rate and receipts from other
plans or programs on a contract-by-contract basis and not in the
aggregate, and may not include managed care financial incentive
payments that are required by federal law to be excluded from the
calculation.
(i) (1) An entity that first qualifies as an FQHC or RHC in the
year 2001 or later, a newly licensed facility at a new location added
to an existing FQHC or RHC, and any entity that is an existing FQHC
or RHC that is relocated to a new site shall each have its
reimbursement rate established in accordance with one of the
following methods, as selected by the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount
that is equal to the average of the per-visit rates of three
comparable FQHCs or RHCs located in the same or adjacent area with a
similar caseload.
(B) In the absence of three comparable FQHCs or RHCs with a
similar caseload, the rate may be calculated on a per-visit basis in
an amount that is equal to the average of the per-visit rates of
three comparable FQHCs or RHCs located in the same or an adjacent
service area, or in a reasonably similar geographic area with respect
to relevant social, health care, and economic characteristics.
(C) At a new entity's one-time election, the department shall
establish a reimbursement rate, calculated on a per-visit basis, that
is equal to 100 percent of the projected allowable costs to the FQHC
or RHC of furnishing FQHC or RHC services during the first 12 months
of operation as an FQHC or RHC. After the first 12-month period, the
projected per-visit rate shall be increased by the Medicare Economic
Index then in effect. The projected allowable costs for the first 12
months shall be cost settled and the prospective payment
reimbursement rate shall be adjusted based on actual and allowable
cost per visit.
(D) The department may adopt any further and additional methods of
setting reimbursement rates for newly qualified FQHCs or RHCs as are
consistent with Section 1396a(bb)(4) of Title 42 of the United
States Code.
(2) In order for an FQHC or RHC to establish the comparability of
its caseload for purposes of subparagraph (A) or (B) of paragraph
(1), the department shall require that the FQHC or RHC submit its
most recent annual utilization report as submitted to the Office of
Statewide Health Planning and Development, unless the FQHC or RHC was
not required to file an annual utilization report. FQHCs or RHCs
that have experienced changes in their services or caseload
subsequent to the filing of the annual utilization report may submit
to the department a completed report in the format applicable to the
prior calendar year. FQHCs or RHCs that have not previously submitted
an annual utilization report shall submit to the department a
completed report in the format applicable to the prior calendar year.
The FQHC or RHC shall not be required to submit the annual
utilization report for the comparable FQHCs or RHCs to the
department, but shall be required to identify the comparable FQHCs or
RHCs.
(3) The rate for any newly qualified entity set forth under this
subdivision shall be effective retroactively to the later of the date
that the entity was first qualified by the applicable federal agency
as an FQHC or RHC, the date a new facility at a new location was
added to an existing FQHC or RHC, or the date on which an existing
FQHC or RHC was relocated to a new site. The FQHC or RHC shall be
permitted to continue billing for Medi-Cal covered benefits on a
fee-for-service basis until it is informed of its enrollment as an
FQHC or RHC, and the department shall reconcile the difference
between the fee-for-service payments and the FQHC's or RHC's
prospective payment rate at that time.
(j) Visits occurring at an intermittent clinic site, as defined in
subdivision (h) of Section 1206 of the Health and Safety Code, of an
existing FQHC or RHC, or in a mobile unit as defined by paragraph
(2) of subdivision (b) of Section 1765.105 of the Health and Safety
Code, shall be billed by and reimbursed at the same rate as the FQHC
or RHC establishing the intermittent clinic site or the mobile unit,
subject to the right of the FQHC or RHC to request a scope-of-service
adjustment to the rate.
(k) An FQHC or RHC may elect to have pharmacy or dental services
reimbursed on a fee-for-service basis, utilizing the current fee
schedules established for those services. These costs shall be
adjusted out of the FQHC's or RHC's clinic base rate as
scope-of-service changes. An FQHC or RHC that reverses its election
under this subdivision shall revert to its prior rate, subject to an
increase to account for all MEI increases occurring during the
intervening time period, and subject to any increase or decrease
associated with applicable scope-of-services adjustments as provided
in subdivision (e).
(l) FQHCs and RHCs may appeal a grievance or complaint concerning
ratesetting, scope-of-service changes, and settlement of cost report
audits, in the manner prescribed by Section 14171. The rights and
remedies provided under this subdivision are cumulative to the rights
and remedies available under all other provisions of law of this
state.
(m) The department shall, by no later than March 30, 2008,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
(n) The department shall implement this section only to the extent
that federal financial participation is obtained.
14132.101. (a) Notwithstanding paragraphs (4) and (5) of
subdivision (e) of Section 14132.100, a scope-of-service change
request, whether mandatory or permissive, shall be timely when filed
within 150 days following the beginning of the federally qualified
health center's or rural health clinic's fiscal year following the
year in which the change occurred.
(b) Notwithstanding subdivision (a), and notwithstanding
subdivision (e) of Section 14132.100, a federally qualified health
center described in Section 14132.102 shall be deemed to have filed a
scope-of-service change in a timely manner upon compliance with the
requirements set forth in subdivision (c) of Section 14132.102.
14132.102. (a) With the exception of clinics and hospital
outpatient departments that are subject to Section 14105.24,
federally qualified health centers (FQHCs) that are receiving
cost-based reimbursement under the terms of the Los Angeles County
1115 Waiver Demonstration Project on June 30, 2005, shall be required
to transition to a prospective payment system (PPS) rate upon
expiration of that waiver. These FQHCs shall be referred to in this
section as "Los Angeles cost-based FQHCs."
(b) For visits occurring on or after July 1, 2005, Los Angeles
cost-based FQHCs shall receive a PPS rate equivalent to the
following:
(1) FQHC sites that were in existence during the FQHC's 2000
fiscal year shall be permitted to elect their 2000 per-visit rates or
the average of the 1999 and 2000 per-visit rates as reported on the
cost reports submitted for those fiscal years adjusted as described
in subdivision (c).
(2) FQHC sites that were first qualified as an FQHC after the site'
s 2000 fiscal year shall receive a base rate equivalent to the first
full fiscal year rate, as audited on the cost report submitted for
that fiscal year and adjusted as described in subdivision (c).
(3) Sites that were first qualified as an FQHC after the site's
2000 fiscal year, and that have not yet filed a cost report for their
first full fiscal year shall have a rate set in accordance with
subdivision (i) of Section 14132.100 and adjusted as described in
subdivision (c).
(c) The base rates described in this section shall be adjusted in
the manner described in subdivision (d), paragraphs (1), (2), (3),
and (7) of subdivision (e), and subdivision (f) of Section 14132.100.
(d) For Los Angeles cost-based FQHCs, as defined in subdivision
(a), no new cost reports shall be required in order to claim
scope-of-service changes occurring in fiscal years prior to July 1,
2005. Only the following information shall be required by the
department:
(1) A description of the events triggering any applicable rate
changes in the form of Worksheet 1 of the Change in Scope-of-Service
Request form developed for fiscal years 2004 and thereafter, modified
to identify the applicable fiscal year in which the scope change
occurred.
(2) The two worksheets to the Change in Scope-of-Service Request
form summarizing the health center's health care practitioners and
services for the applicable fiscal year or years.
(e) Change in Scope-of-Service Request forms for changes occurring
prior to July 1, 2005, shall be filed with the department no later
than July 1, 2006, and shall be deemed to have been filed only when
both the Medi-Cal cost report for the applicable period and the
referenced Change in Scope-of-Service Request form worksheets have
been filed with the department. The date of filing shall be the date
on which either the Medi-Cal cost report or the referenced Change in
Scope-of-Service Request forms are received by the department,
whichever is later.
(f) Notwithstanding Section 14132.107, the department shall
calculate a tentative scope-of-service rate adjustment based on 80
percent of the difference in the "as reported" scope-of-service per
visit cost. This adjustment shall occur no later than 150 days after
receipt of the Medi-Cal cost report and the referenced Change in
Scope-of-Service Request forms. Within 12 months after receipt of
request forms, the department shall complete its FQHC fiscal year
audit of the Medi-Cal cost report and associated Change in
Scope-of-Service Request and final rate adjustment pursuant to that
audit. The final rate adjustment will be retroactive to July 1, 2005.
Nothing in this subdivision shall be construed to extend the time
period for review and finalization of cost reports as set forth in
Section 14170.
(g) The department shall, by no later than March 30, 2006,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
(h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, and only to
the extent that all necessary federal approvals are obtained and
there is an appropriation for the purposes of implementing this
section, the department may implement this section without taking any
regulatory action and by means of a provider bulletin or similar
instructions.
14132.107. Claims for reimbursement under subdivision (e) of
Section 14132.100 shall be finalized by the department within 150
days of receipt of the claims for reimbursement. These claims for
reimbursement shall be paid within 30 days of being finalized by the
department. However, the payment of those amounts that are disputed
shall be subject to the requirements, timeframes, and procedures
specified in Section 14171. Scope changes going forward shall be
finalized within 90 days of receipt and paid within 30 days of being
finalized by the department.
14132.108.
14131. The Medi-Cal Benefits Program comprises a
department-administered uniform schedule of health care benefits.
Notwithstanding any other provision of this chapter, "health care
services" shall be limited to the benefits set forth in this article
and in Section 14021.
14131.10. (a) Notwithstanding any other provision of this chapter,
Chapter 8 (commencing with Section 14200), or Chapter 8.75
(commencing with Section 14590), in order to implement changes in the
level of funding for health care services, specific optional
benefits are excluded from coverage under the Medi-Cal program.
(b) (1) The following optional benefits are excluded from coverage
under the Medi-Cal program:
(A) Adult dental services, except as specified in paragraph (2).
(B) Acupuncture services.
(C) Audiology services and speech therapy services.
(D) Chiropractic services.
(E) Optometric and optician services, including services provided
by a fabricating optical laboratory.
(F) Podiatric services.
(G) Psychology services.
(H) Incontinence creams and washes.
(2) Medical and surgical services provided by a doctor of dental
medicine or dental surgery, which, if provided by a physician, would
be considered physician services, and which services may be provided
by either a physician or a dentist in this state, are covered.
(3) Pregnancy-related services and services for the treatment of
other conditions that might complicate the pregnancy are not excluded
from coverage under this section.
(c) The optional benefit exclusions do not apply to either of the
following:
(1) Beneficiaries under the Early and Periodic Screening Diagnosis
and Treatment Program.
(2) Beneficiaries receiving long-term care in a nursing facility
that is both:
(A) A skilled nursing facility or intermediate care facility as
defined in subdivisions (c) and (d) of Section 1250 of the Health and
Safety Code.
(B) Licensed pursuant to subdivision (k) of Section 1250 of the
Health and Safety Code.
(d) This section shall only be implemented to the extent permitted
by federal law.
(e) 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 the provisions of this section by means of
all-county letters, provider bulletins, or similar instructions,
without taking further regulatory action.
(f) This section shall be implemented on the first day of the
month following 90 days after the operative date of this section.
14131.15. (a) In geographic areas in which Medi-Cal managed care
plans contracting under this chapter or Chapter 8 (commencing with
Section 14200) are operating with capacity to enroll additional
qualifying Medi-Cal beneficiaries, the director may, in the interest
of bringing managed care principles to bear on the quality, costs, or
utilization levels of the Medi-Cal program, designate any benefit or
service included in the Medi-Cal program, at state option under
federal medicaid rules, as a covered Medi-Cal benefit only when
provided by a Medi-Cal managed care plan to a Medi-Cal enrollee of
the plan.
(b) Where benefits and services have been designated by the
director under subdivision (a), beneficiaries who are eligible to
enroll in and reside in the service area of a managed care plan, and
who desire coverage for such benefits and services, must enroll in a
Medi-Cal managed care plan to receive them and shall, to the maximum
extent permitted under federal law, remain enrolled in the plan.
(c) When managed care capacity is reached in an area in which
Medi-Cal benefits have been designated under this section, the
director may provide for the delivery of designated benefits or
services to beneficiaries by contract to the extent permitted under
this chapter, on a fee-for-service basis or a combination of both.
(d) Exercise of the director's discretion under this section shall
not preclude Medi-Cal managed care contractors from applying their
established medical necessity criteria, utilization control standards
and policies and utilization review procedures in delivering
designated services as permitted and controlled by Medi-Cal contract
and other state and federal regulatory standards.
(e) Enactment of this section shall not impose any requirement on
a Medi-Cal managed care plan to negotiate or enter into a contract or
any other participation arrangement with any provider of a Medi-Cal
benefit or service designated under subdivision (a).
(f) The department shall seek all federal waivers necessary to
allow for federal financial participation in expenditures under this
section.
14132. The following is the schedule of benefits under this
chapter:
(a) Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
(b) Inpatient hospital services, including, but not limited to,
physician and podiatric services, physical therapy and occupational
therapy, are covered subject to utilization controls.
(c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.
(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers of Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
(4) (A) Nonlegend acetaminophen-containing products, with the
exception of children's Tylenol, selected by the department are not
covered benefits. For the purposes of this paragraph, nonlegend has
the same meaning as defined in subdivision (a) of Section 14105.45.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instruction without taking regulatory action.
(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and equipment
required for dialysis, are covered, subject to utilization controls.
(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
(g) Blood and blood derivatives are covered.
(h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
(A) Periodontal treatment is not a benefit.
(B) Endodontic therapy is not a benefit except for vital
pulpotomy.
(C) Laboratory processed crowns are not a benefit.
(D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
(E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
(F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
(3) Paragraph (2) shall become inoperative July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
(m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
(n) Family planning services are covered, subject to utilization
controls.
(o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).
(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request, adult
day health care is covered for a maximum of three days per week.
(3) As provided in accordance with paragraph (4), adult day health
care is covered for a maximum of five days per week.
(4) As of the date that the director makes the declaration
described in subdivision (g) of Section 14525.1, paragraph (2) shall
become inoperative and paragraph (3) shall become operative.
(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.
(2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and 1770
of the Business and Professions Code may be covered as long as they
are within the scope of Denti-Cal benefits and they are necessary
services provided by a registered dental hygienist in alternative
practice.
(r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under Article 3
(commencing with Section 1480) of Chapter 2.5 of Division 2 of the
Health and Safety Code by a paramedic certified pursuant to that
article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.
(2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming a
Medi-Cal provider.
(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
As used in this subdivision, in-home medical care services,
include, but are not limited to:
(1) Level of care and cost of care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
(t) Home- and community-based services approved by the United
States Department of Health and Human Services may be covered to the
extent that federal financial participation is available for those
services under waivers granted in accordance with Section 1396n of
Title 42 of the United States Code. The director may seek waivers for
any or all home- and community-based services approvable under
Section 1396n of Title 42 of the United States Code. Coverage for
those services shall be limited by the terms, conditions, and
duration of the federal waivers.
(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
(v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
(w) Hospice service which is Medicare-certified hospice service is
covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are
incurred.
(x) When a claim for treatment provided to a beneficiary includes
both services which are authorized and reimbursable under this
chapter, and services which are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
(y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
Services provided pursuant to a waiver obtained from the Secretary
of the United States Department of Health and Human Services
pursuant to this subdivision, and which are not otherwise included in
the Medi-Cal schedule of benefits, shall be available only to the
extent that federal financial participation for these services is
available in accordance with the waiver, and subject to the terms,
conditions, and duration of the waiver. These services shall be
provided to individual beneficiaries in accordance with the client's
needs as identified in the plan of care, and subject to medical
necessity and applicable utilization control.
The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
(aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Program.
(2) The department shall seek a waiver in accordance with Section
1315 of Title 42 of the United States Code, or a state plan amendment
adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI)(ii)(2)
of Title 42 of the United States Code, which was added to Section
1396a of Title 42 of the United States Code by Section 2303(a)(2) of
the federal Patient Protection and Affordable Care Act (PPACA)
(Public Law 111-148), for a program to provide comprehensive clinical
family planning services as described in paragraph (8). Under the
waiver, the program shall be operated only in accordance with the
waiver and the statutes and regulations in paragraph (4) and subject
to the terms, conditions, and duration of the waiver. Under the state
plan amendment, which shall replace the waiver and shall be known as
the Family PACT successor state plan amendment, the program shall be
operated only in accordance with this subdivision and the statutes
and regulations in paragraph (4). The state shall use the standards
and processes imposed by the state on January 1, 2007, including the
application of an eligibility discount factor to the extent required
by the federal Centers for Medicare and Medicaid Services, for
purposes of determining eligibility as permitted under Section 1396a
(a)(10)(A)(ii)(XXI)(ii)(2) of Title 42 of the United States Code. To
the extent that federal financial participation is available, the
program shall continue to conduct education, outreach, enrollment,
service delivery, and evaluation services as specified under the
waiver. The services shall be provided under the program only if the
waiver and, when applicable, the successor state plan amendment are
approved by the federal Centers for Medicare and Medicaid Services
and only to the extent that federal financial participation is
available for the services. Nothing in this section shall prohibit
the department from seeking the Family PACT successor state plan
amendment during the operation of the waiver.
(3) Solely for the purposes of the waiver or Family PACT successor
state plan amendment and notwithstanding any other provision of law,
the collection and use of an individual's social security number
shall be necessary only to the extent required by federal law.
(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
(5) 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, without taking regulatory action, the
provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section by
means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement this
section and the approved waiver in accordance with the requirements
of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division
3 of Title 2 of the Government Code. Beginning six months after the
effective date of the act adding this subdivision, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) or the Family PACT successor state plan amendment is no
longer cost effective, this subdivision shall become inoperative on
the first day of the first month following the issuance of a 30-day
notification of that determination in writing by the Department of
Finance to the chairperson in each house that considers
appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
(8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
(B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
(C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
(i) Psychosocial and medical aspects of contraception.
(ii) Sexuality.
(iii) Fertility.
(iv) Pregnancy.
(v) Parenthood.
(vi) Infertility.
(vii) Reproductive health care.
(viii) Preconception and nutrition counseling.
(ix) Prevention and treatment of sexually transmitted infection.
(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
(xi) Possible contraceptive consequences and followup.
(xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
(E) A complete physical examination on initial and subsequent
periodic visits.
(F) Services, drugs, devices, and supplies deemed by the federal
Centers for Medicare and Medicaid Services to be appropriate for
inclusion in the program.
(9) In order to maximize the availability of federal financial
participation under this subdivision, the director shall have the
discretion to implement the Family PACT successor state plan
amendment retroactively to July 1, 2010.
(ab) Purchase of prescribed enteral formulae is covered, subject
to the Medi-Cal list of enteral formulae and utilization controls.
(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.
14132.01. (a) Notwithstanding any other provision of law, a
community clinic or free clinic licensed pursuant to subdivision (a)
of Section 1204 of the Health and Safety Code or an intermittent
clinic operating pursuant to subdivision (h) of Section 1206 of the
Health and Safety Code, that has a valid license pursuant to Article
13 (commencing with Section 4180) of Chapter 9 of Division 2 of the
Business and Professions Code shall bill and be reimbursed, as
described in this section, for drugs and supplies covered under the
Medi-Cal program and Family PACT Waiver Program.
(b) (1) A clinic described in subdivision (a) shall bill the
Medi-Cal program and Family PACT Waiver Program for drugs and
supplies covered under those programs at the lesser of cost or the
clinic's usual charge made to the general public.
(2) For purposes of this section, "cost" means an aggregate amount
equivalent to the sum of the actual acquisition cost of a drug or
supply plus a clinic dispensing fee not to exceed twelve dollars
($12) per billing unit as identified in either the Family PACT
Policies, Procedures, and Billing Instructions Manual, or the
Medi-Cal Inpatient/Outpatient Provider Manual governing outpatient
clinic billing for drugs and supplies, as applicable. For purposes of
this section, "cost" for a take-home drug that is dispensed for use
by the patient within a specific timeframe of five or less days from
the date medically indicated means actual acquisition cost for that
drug plus a clinic dispensing fee, not to exceed seventeen dollars
($17) per prescription. Reimbursement shall be at the lesser of the
amount billed or the Medi-Cal reimbursement rate, and shall not
exceed the net cost of these drugs or supplies when provided by
retail pharmacies under the Medi-Cal program.
(c) A clinic described in subdivision (a) that furnishes services
free of charge, or at a nominal charge, as defined in subsection (a)
of Section 413.13 of Title 42 of the Code of Federal Regulations, or
that can demonstrate to the department, upon request, that it serves
primarily low-income patients, and its customary practice is to
charge patients on the basis of their ability to pay, shall not be
subject to reimbursement reductions based on its usual charge to the
general public.
(d) Federally qualified health centers and rural health clinics
that are clinics as described in subdivision (a) may bill and be
reimbursed as described in this section, upon electing to be
reimbursed for pharmaceutical goods and services on a fee-for-service
basis, as permitted by subdivision (k) of Section 14132.100.
(e) A clinic that otherwise meets the qualifications set forth in
subdivision (a), that is eligible to, but that has elected not to,
utilize drugs purchased under the 340B Discount Drug Program for its
Medi-Cal patients, shall provide notification to the Health Resources
and Services Administration's Office of Pharmacy Affairs that it is
utilizing non-340B drugs for its Medi-Cal patients in the manner and
to the extent required by federal law.
14132.05. The department shall provide the fiscal and appropriate
policy committees of the Legislature with a copy of their submittal
to the federal Health Care Financing Administration pertaining to any
evaluation completed regarding the Family PACT federal waiver
required by subdivision (aa) of Section 14132.
14132.06. (a) Services specified in this section that are provided
by a local educational agency are covered Medi-Cal benefits, to the
extent federal financial participation is available, and subject to
utilization controls and standards adopted by the department, and
consistent with Medi-Cal requirements for physician prescription,
order, and supervision.
(b) Any provider enrolled on or after January 1, 1993, to provide
services pursuant to this section may bill for those services
provided on or after January 1, 1993.
(c) Nothing in this section shall be interpreted to expand the
current category of professional health care practitioners permitted
to directly bill the Medi-Cal program.
(d) Nothing in this section is intended to increase the scope of
practice of any health professional providing services under this
section or Medi-Cal requirements for physician prescription, order,
and supervision.
(e) (1) For the purposes of this section, the local educational
agency, as a condition of enrollment to provide services under this
section, shall be considered the provider of services. A local
educational agency provider, as a condition of enrollment to provide
services under this section, shall enter into, and maintain, a
contract with the department in accordance with guidelines contained
in regulations adopted by the director and published in Title 22 of
the California Code of Regulations.
(2) Notwithstanding paragraph (1), a local educational agency
providing services pursuant to this section shall utilize current
safety net and traditional health care providers, when those
providers are accessible to specific schoolsites identified by the
local educational agency to participate in this program, rather than
adding duplicate capacity.
(f) For the purposes of this section, covered services may include
all of the following local educational agency services:
(1) Health and mental health evaluations and health and mental
health education.
(2) Medical transportation.
(3) Nursing services.
(4) Occupational therapy.
(5) Physical therapy.
(6) Physician services.
(7) Mental health and counseling services.
(8) School health aide services.
(9) Speech pathology services. These services may be provided by
either of the following:
(A) A licensed speech pathologist.
(B) A credentialed speech-language pathologist, to the extent
authorized by Chapter 5.3 (commencing with Section 2530) of Division
2 of the Business and Professions Code.
(10) Audiology services.
(11) Targeted case management services for children with an
individualized education plan (IEP) or an individualized family
service plan (IFSP).
(g) Local educational agencies may, but need not, provide any or
all of the services specified in subdivision (f).
(h) For the purposes of this section, "local educational agency"
means the governing body of any school district or community college
district, the county office of education, a state special school, a
California State University campus, or a University of California
campus.
(i) Any local educational agency provider enrolled to provide
service pursuant to this section on January 1, 1995, may bill for
targeted case management services for children with an individualized
education plan (IEP) or an individualized family service plan
(IFSP), provided on or after January 1, 1995.
(j) Notwithstanding any other provision of law, a community
college district, a California State University campus, or a
University of California campus, consistent with the requirements of
this section, may bill for services provided to any student,
regardless of age, who is a Medi-Cal recipient.
14132.1. As used in this chapter "surgical center" means a surgical
clinic that is licensed under Section 1203 of the Health and Safety
Code. Pursuant to Section 14105, the director shall establish the
rates of payment for services provided by surgical centers.
14132.10. (a) Pediatric day health care provided by a health
facility licensed under paragraph (11) of subdivision (a) of Section
1250.1 of the Health and Safety Code is a covered benefit under this
chapter subject to terms, conditions, and utilization controls
developed by the department. Pediatric day care does not include
inpatient long-term care or family respite care.
(b) The department shall publish emergency regulations for
pediatric day health care services by October 1, 1997. These
regulations shall reimburse providers at a rate that shall be
determined by the department, consistent with efficiency, economy,
and quality of care until a new rate is determined on the basis of a
cost study conducted by the department.
(c) Coverage for pediatric day health care services shall be
available only to the extent that no additional net program costs are
incurred.
(d) The department shall not approve a request for authorization
of pediatric day health care when the beneficiary for whom the
authorization is requested is an inpatient in a licensed health care
facility.
(e) The department shall not approve a request for authorization
of pediatric day care if the department determines that the total
cost incurred by the Medi-Cal program for providing pediatric day
health care services and all other medically necessary services to
the individual beneficiary is greater than the total cost incurred by
the Medi-Cal program in providing medically equivalent services at
the beneficiary's otherwise appropriate level of institutional or
home care.
(f) Coverage for pediatric day health care services shall be
available only to the extent that federal financial participation in
the cost of providing these services is available pursuant to a
federally approved state plan amendment including those services as a
Medi-Cal program benefit.
14132.100. (a) The federally qualified health center services
described in Section 1396d(a)(2)(C) of Title 42 of the United States
Code are covered benefits.
(b) The rural health clinic services described in Section 1396d(a)
(2)(B) of Title 42 of the United States Code are covered benefits.
(c) Federally qualified health center services and rural health
clinic services shall be reimbursed on a per-visit basis in
accordance with the definition of "visit" set forth in subdivision
(g).
(d) Effective October 1, 2004, and on each October 1, thereafter,
until no longer required by federal law, federally qualified health
center (FQHC) and rural health clinic (RHC) per-visit rates shall be
increased by the Medicare Economic Index applicable to primary care
services in the manner provided for in Section 1396a(bb)(3)(A) of
Title 42 of the United States Code. Prior to January 1, 2004, FQHC
and RHC per-visit rates shall be adjusted by the Medicare Economic
Index in accordance with the methodology set forth in the state plan
in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its
per-visit rate based on a change in the scope of services provided by
the FQHC or RHC. Rate changes based on a change in the scope of
services provided by an FQHC or RHC shall be evaluated in accordance
with Medicare reasonable cost principles, as set forth in Part 413
(commencing with Section 413.1) of Title 42 of the Code of Federal
Regulations, or its successor.
(2) Subject to the conditions set forth in subparagraphs (A) to
(D), inclusive, of paragraph (3), a change in scope of service means
any of the following:
(A) The addition of a new FQHC or RHC service that is not
incorporated in the baseline prospective payment system (PPS) rate,
or a deletion of an FQHC or RHC service that is incorporated in the
baseline PPS rate.
(B) A change in service due to amended regulatory requirements or
rules.
(C) A change in service resulting from relocating or remodeling an
FQHC or RHC.
(D) A change in types of services due to a change in applicable
technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in
the types of patients served, including, but not limited to,
populations with HIV or AIDS, or other chronic diseases, or homeless,
elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision
(a) or (b), or in the provider mix of an FQHC or RHC or one of its
sites.
(G) Changes in operating costs attributable to capital
expenditures associated with a modification of the scope of any of
the services described in subdivision (a) or (b), including new or
expanded service facilities, regulatory compliance, or changes in
technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing
teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal
Health Resources and Service Administration (HRSA).
(3) No change in costs shall, in and of itself, be considered a
scope-of-service change unless all of the following apply:
(A) The increase or decrease in cost is attributable to an
increase or decrease in the scope of services defined in subdivisions
(a) and (b), as applicable.
(B) The cost is allowable under Medicare reasonable cost
principles set forth in Part 413 (commencing with Section 413) of
Subchapter B of Chapter 4 of Title 42 of the Code of Federal
Regulations, or its successor.
(C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination
thereof.
(D) The net change in the FQHC's or RHC's rate equals or exceeds
1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs
that filed consolidated cost reports for multiple sites to establish
the initial prospective payment reimbursement rate, the 1.75-percent
threshold shall be applied to the average per-visit rate of all sites
for the purposes of calculating the cost associated with a
scope-of-service change. "Net change" means the per-visit rate change
attributable to the cumulative effect of all increases and decreases
for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service
changes once per fiscal year, only within 90 days following the
beginning of the FQHC's or RHC's fiscal year. Any approved increase
or decrease in the provider's rate shall be retroactive to the
beginning of the FQHC's or RHC's fiscal year in which the request is
submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate change
request within 90 days of the beginning of any FQHC or RHC fiscal
year occurring after the effective date of this section, if, during
the FQHC's or RHC's prior fiscal year, the FQHC or RHC experienced a
decrease in the scope of services provided that the FQHC or RHC
either knew or should have known would have resulted in a
significantly lower per-visit rate. If an FQHC or RHC discontinues
providing onsite pharmacy or dental services, it shall submit a
scope-of-service rate change request within 90 days of the beginning
of the following fiscal year. The rate change shall be effective as
provided for in paragraph (4). As used in this paragraph,
"significantly lower" means an average per-visit rate decrease in
excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved
scope-of-service change or changes were initially implemented on or
after the first day of an FQHC's or RHC's fiscal year ending in
calendar year 2001, but before the adoption and issuance of written
instructions for applying for a scope-of-service change, the adjusted
reimbursement rate for that scope-of-service change shall be made
retroactive to the date the scope-of-service change was initially
implemented. Scope-of-service changes under this paragraph shall be
required to be submitted within the later of 150 days after the
adoption and issuance of the written instructions by the department,
or 150 days after the end of the FQHC's or RHC's fiscal year ending
in 2003.
(7) All references in this subdivision to "fiscal year" shall be
construed to be references to the fiscal year of the individual FQHC
or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a supplemental payment if
extraordinary circumstances beyond the control of the FQHC or RHC
occur after December 31, 2001, and PPS payments are insufficient due
to these extraordinary circumstances. Supplemental payments arising
from extraordinary circumstances under this subdivision shall be
solely and exclusively within the discretion of the department and
shall not be subject to subdivision (l). These supplemental payments
shall be determined separately from the scope-of-service adjustments
described in subdivision (e). Extraordinary circumstances include,
but are not limited to, acts of nature, changes in applicable
requirements in the Health and Safety Code, changes in applicable
licensure requirements, and changes in applicable rules or
regulations. Mere inflation of costs alone, absent extraordinary
circumstances, shall not be grounds for supplemental payment. If an
FQHC's or RHC's PPS rate is sufficient to cover its overall costs,
including those associated with the extraordinary circumstances, then
a supplemental payment is not warranted.
(2) The department shall accept requests for supplemental payment
at any time throughout the prospective payment rate year.
(3) Requests for supplemental payments shall be submitted in
writing to the department and shall set forth the reasons for the
request. Each request shall be accompanied by sufficient
documentation to enable the department to act upon the request.
Documentation shall include the data necessary to demonstrate that
the circumstances for which supplemental payment is requested meet
the requirements set forth in this section. Documentation shall
include all of the following:
(A) A presentation of data to demonstrate reasons for the FQHC's
or RHC's request for a supplemental payment.
(B) Documentation showing the cost implications. The cost impact
shall be material and significant, two hundred thousand dollars
($200,000) or 1 percent of a facility's total costs, whichever is
less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall be
paid as lump-sum amounts for those years and not as revised PPS
rates, and shall be repaid by the FQHC or RHC to the extent that it
is not expended for the specified purposes.
(6) The department shall notify the provider of the department's
discretionary decision in writing.
(g) (1) An FQHC or RHC "visit" means a face-to-face encounter
between an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, clinical psychologist,
licensed clinical social worker, or a visiting nurse. For purposes of
this section, "physician" shall be interpreted in a manner
consistent with the Centers for Medicare and Medicaid Services'
Medicare Rural Health Clinic and Federally Qualified Health Center
Manual (Publication 27), or its successor, only to the extent that it
defines the professionals whose services are reimbursable on a
per-visit basis and not as to the types of services that these
professionals may render during these visits and shall include a
physician and surgeon, podiatrist, dentist, optometrist, and
chiropractor. A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a comprehensive perinatal services
practitioner, as defined in Section 51179.1 of Title 22 of the
California Code of Regulations, providing comprehensive perinatal
services, a four-hour day of attendance at an adult day health care
center, and any other provider identified in the state plan's
definition of an FQHC or RHC visit.
(2) (A) A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a dental hygienist or a dental
hygienist in alternative practice.
(B) Notwithstanding subdivision (e), an FQHC or RHC that currently
includes the cost of the services of a dental hygienist in
alternative practice for the purposes of establishing its FQHC or RHC
rate shall apply for an adjustment to its per-visit rate, and, after
the rate adjustment has been approved by the department, shall bill
these services as a separate visit. However, multiple encounters with
dental professionals that take place on the same day shall
constitute a single visit. The department shall develop the
appropriate forms to determine which FQHC's or RHC rates shall be
adjusted and to facilitate the calculation of the adjusted rates. An
FQHC's or RHC's application for, or the department's approval of, a
rate adjustment pursuant to this subparagraph shall not constitute a
change in scope of service within the meaning of subdivision (e). An
FQHC or RHC that applies for an adjustment to its rate pursuant to
this subparagraph may continue to bill for all other FQHC or RHC
visits at its existing per-visit rate, subject to reconciliation,
until the rate adjustment for visits between an FQHC or RHC patient
and a dental hygienist or a dental hygienist in alternative practice
has been approved. Any approved increase or decrease in the provider'
s rate shall be made within six months after the date of receipt of
the department's rate adjustment forms pursuant to this subparagraph
and shall be retroactive to the beginning of the fiscal year in which
the FQHC or RHC submits the request, but in no case shall the
effective date be earlier than January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist or
dental hygienist in alternative practice services, and later elects
to add these services, shall process the addition of these services
as a change in scope of service pursuant to subdivision (e).
(h) If FQHC or RHC services are partially reimbursed by a
third-party payer, such as a managed care entity (as defined in
Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the
Medicare Program, or the Child Health and Disability Prevention
(CHDP) program, the department shall reimburse an FQHC or RHC for the
difference between its per-visit PPS rate and receipts from other
plans or programs on a contract-by-contract basis and not in the
aggregate, and may not include managed care financial incentive
payments that are required by federal law to be excluded from the
calculation.
(i) (1) An entity that first qualifies as an FQHC or RHC in the
year 2001 or later, a newly licensed facility at a new location added
to an existing FQHC or RHC, and any entity that is an existing FQHC
or RHC that is relocated to a new site shall each have its
reimbursement rate established in accordance with one of the
following methods, as selected by the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount
that is equal to the average of the per-visit rates of three
comparable FQHCs or RHCs located in the same or adjacent area with a
similar caseload.
(B) In the absence of three comparable FQHCs or RHCs with a
similar caseload, the rate may be calculated on a per-visit basis in
an amount that is equal to the average of the per-visit rates of
three comparable FQHCs or RHCs located in the same or an adjacent
service area, or in a reasonably similar geographic area with respect
to relevant social, health care, and economic characteristics.
(C) At a new entity's one-time election, the department shall
establish a reimbursement rate, calculated on a per-visit basis, that
is equal to 100 percent of the projected allowable costs to the FQHC
or RHC of furnishing FQHC or RHC services during the first 12 months
of operation as an FQHC or RHC. After the first 12-month period, the
projected per-visit rate shall be increased by the Medicare Economic
Index then in effect. The projected allowable costs for the first 12
months shall be cost settled and the prospective payment
reimbursement rate shall be adjusted based on actual and allowable
cost per visit.
(D) The department may adopt any further and additional methods of
setting reimbursement rates for newly qualified FQHCs or RHCs as are
consistent with Section 1396a(bb)(4) of Title 42 of the United
States Code.
(2) In order for an FQHC or RHC to establish the comparability of
its caseload for purposes of subparagraph (A) or (B) of paragraph
(1), the department shall require that the FQHC or RHC submit its
most recent annual utilization report as submitted to the Office of
Statewide Health Planning and Development, unless the FQHC or RHC was
not required to file an annual utilization report. FQHCs or RHCs
that have experienced changes in their services or caseload
subsequent to the filing of the annual utilization report may submit
to the department a completed report in the format applicable to the
prior calendar year. FQHCs or RHCs that have not previously submitted
an annual utilization report shall submit to the department a
completed report in the format applicable to the prior calendar year.
The FQHC or RHC shall not be required to submit the annual
utilization report for the comparable FQHCs or RHCs to the
department, but shall be required to identify the comparable FQHCs or
RHCs.
(3) The rate for any newly qualified entity set forth under this
subdivision shall be effective retroactively to the later of the date
that the entity was first qualified by the applicable federal agency
as an FQHC or RHC, the date a new facility at a new location was
added to an existing FQHC or RHC, or the date on which an existing
FQHC or RHC was relocated to a new site. The FQHC or RHC shall be
permitted to continue billing for Medi-Cal covered benefits on a
fee-for-service basis until it is informed of its enrollment as an
FQHC or RHC, and the department shall reconcile the difference
between the fee-for-service payments and the FQHC's or RHC's
prospective payment rate at that time.
(j) Visits occurring at an intermittent clinic site, as defined in
subdivision (h) of Section 1206 of the Health and Safety Code, of an
existing FQHC or RHC, or in a mobile unit as defined by paragraph
(2) of subdivision (b) of Section 1765.105 of the Health and Safety
Code, shall be billed by and reimbursed at the same rate as the FQHC
or RHC establishing the intermittent clinic site or the mobile unit,
subject to the right of the FQHC or RHC to request a scope-of-service
adjustment to the rate.
(k) An FQHC or RHC may elect to have pharmacy or dental services
reimbursed on a fee-for-service basis, utilizing the current fee
schedules established for those services. These costs shall be
adjusted out of the FQHC's or RHC's clinic base rate as
scope-of-service changes. An FQHC or RHC that reverses its election
under this subdivision shall revert to its prior rate, subject to an
increase to account for all MEI increases occurring during the
intervening time period, and subject to any increase or decrease
associated with applicable scope-of-services adjustments as provided
in subdivision (e).
(l) FQHCs and RHCs may appeal a grievance or complaint concerning
ratesetting, scope-of-service changes, and settlement of cost report
audits, in the manner prescribed by Section 14171. The rights and
remedies provided under this subdivision are cumulative to the rights
and remedies available under all other provisions of law of this
state.
(m) The department shall, by no later than March 30, 2008,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
(n) The department shall implement this section only to the extent
that federal financial participation is obtained.
14132.101. (a) Notwithstanding paragraphs (4) and (5) of
subdivision (e) of Section 14132.100, a scope-of-service change
request, whether mandatory or permissive, shall be timely when filed
within 150 days following the beginning of the federally qualified
health center's or rural health clinic's fiscal year following the
year in which the change occurred.
(b) Notwithstanding subdivision (a), and notwithstanding
subdivision (e) of Section 14132.100, a federally qualified health
center described in Section 14132.102 shall be deemed to have filed a
scope-of-service change in a timely manner upon compliance with the
requirements set forth in subdivision (c) of Section 14132.102.
14132.102. (a) With the exception of clinics and hospital
outpatient departments that are subject to Section 14105.24,
federally qualified health centers (FQHCs) that are receiving
cost-based reimbursement under the terms of the Los Angeles County
1115 Waiver Demonstration Project on June 30, 2005, shall be required
to transition to a prospective payment system (PPS) rate upon
expiration of that waiver. These FQHCs shall be referred to in this
section as "Los Angeles cost-based FQHCs."
(b) For visits occurring on or after July 1, 2005, Los Angeles
cost-based FQHCs shall receive a PPS rate equivalent to the
following:
(1) FQHC sites that were in existence during the FQHC's 2000
fiscal year shall be permitted to elect their 2000 per-visit rates or
the average of the 1999 and 2000 per-visit rates as reported on the
cost reports submitted for those fiscal years adjusted as described
in subdivision (c).
(2) FQHC sites that were first qualified as an FQHC after the site'
s 2000 fiscal year shall receive a base rate equivalent to the first
full fiscal year rate, as audited on the cost report submitted for
that fiscal year and adjusted as described in subdivision (c).
(3) Sites that were first qualified as an FQHC after the site's
2000 fiscal year, and that have not yet filed a cost report for their
first full fiscal year shall have a rate set in accordance with
subdivision (i) of Section 14132.100 and adjusted as described in
subdivision (c).
(c) The base rates described in this section shall be adjusted in
the manner described in subdivision (d), paragraphs (1), (2), (3),
and (7) of subdivision (e), and subdivision (f) of Section 14132.100.
(d) For Los Angeles cost-based FQHCs, as defined in subdivision
(a), no new cost reports shall be required in order to claim
scope-of-service changes occurring in fiscal years prior to July 1,
2005. Only the following information shall be required by the
department:
(1) A description of the events triggering any applicable rate
changes in the form of Worksheet 1 of the Change in Scope-of-Service
Request form developed for fiscal years 2004 and thereafter, modified
to identify the applicable fiscal year in which the scope change
occurred.
(2) The two worksheets to the Change in Scope-of-Service Request
form summarizing the health center's health care practitioners and
services for the applicable fiscal year or years.
(e) Change in Scope-of-Service Request forms for changes occurring
prior to July 1, 2005, shall be filed with the department no later
than July 1, 2006, and shall be deemed to have been filed only when
both the Medi-Cal cost report for the applicable period and the
referenced Change in Scope-of-Service Request form worksheets have
been filed with the department. The date of filing shall be the date
on which either the Medi-Cal cost report or the referenced Change in
Scope-of-Service Request forms are received by the department,
whichever is later.
(f) Notwithstanding Section 14132.107, the department shall
calculate a tentative scope-of-service rate adjustment based on 80
percent of the difference in the "as reported" scope-of-service per
visit cost. This adjustment shall occur no later than 150 days after
receipt of the Medi-Cal cost report and the referenced Change in
Scope-of-Service Request forms. Within 12 months after receipt of
request forms, the department shall complete its FQHC fiscal year
audit of the Medi-Cal cost report and associated Change in
Scope-of-Service Request and final rate adjustment pursuant to that
audit. The final rate adjustment will be retroactive to July 1, 2005.
Nothing in this subdivision shall be construed to extend the time
period for review and finalization of cost reports as set forth in
Section 14170.
(g) The department shall, by no later than March 30, 2006,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
(h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, and only to
the extent that all necessary federal approvals are obtained and
there is an appropriation for the purposes of implementing this
section, the department may implement this section without taking any
regulatory action and by means of a provider bulletin or similar
instructions.
14132.107. Claims for reimbursement under subdivision (e) of
Section 14132.100 shall be finalized by the department within 150
days of receipt of the claims for reimbursement. These claims for
reimbursement shall be paid within 30 days of being finalized by the
department. However, the payment of those amounts that are disputed
shall be subject to the requirements, timeframes, and procedures
specified in Section 14171. Scope changes going forward shall be
finalized within 90 days of receipt and paid within 30 days of being
finalized by the department.
14132.108.
