WELFARE AND INSTITUTIONS CODE
SECTION 14148-14148.9
14148. (a) The department shall adopt the federal option provided
under Section 4101 of the Omnibus Budget Reconciliation Act of 1987
(Public Law 100-203) to extend eligibility for medical assistance
under Medicaid to all pregnant women and infants with family incomes
not in excess of 185 percent of the federal poverty level. If a
premium is imposed, the amount of the premium shall not exceed 10
percent of the amount by which the family's income, less actual child
care costs, exceeds 150 percent of the federal poverty level as
required by Section 4101 (a) of the 1987 Medicaid Budget
Reconciliation Agreement. The department shall implement this section
by emergency regulation.
(b) Upon order of the Department of Finance, the State Controller
shall transfer funds from Item 4260-101-001 of the Budget Act of 1988
to Item 4260-111-001 of the Budget Act of 1988 during the 1988-89
fiscal year for the purpose of funding outreach efforts for perinatal
services.
(c) Notwithstanding subdivision (a), the state may limit
implementation of this section during the 1988-89 fiscal year, based
upon the availability of department funds. The department may use
maternal and child health funds to finance the increased costs of
implementing an expansion of Medi-Cal eligibility to women and
children with incomes of up to 185 percent of federal poverty levels
if both of the following conditions exist:
(1) The department has allocated for expenditure at least sixteen
million dollars ($16,000,000) in funds redirected from the Medi-Cal
program for that expansion.
(2) If, and to the extent, the department determines that
estimates of costs based on actual data indicate that the funds are
needed to cover costs.
(d) This section shall be fully implemented no later than April 1,
1990.
(e) To assist Medi-Cal eligible pregnant women in receiving
prenatal care promptly, all pregnant women applying for Medi-Cal
shall be determined to have an immediate need. Counties, within
existing resources, shall expedite the eligibility determination
process for all pregnant women on the basis of their immediate needs.
Upon determination of eligibility, a Medi-Cal card shall be issued
immediately.
(f) To the extent federal financial participation is available,
the department shall apply the more liberal income deduction
described in Section 1396a(r) of Title 42 of the United States Code
when determining eligibility for pregnant women and infants under
this section. The amount of this deduction shall be the difference
between the 185 percent and the 200 percent federal poverty level
applicable to the size of the family.
14148.03. (a) Pursuant to options provided in federal law and
notwithstanding any other provision of law, the form used by a
provider to collect information about a pregnant woman pursuant to
the Medi-Cal temporary benefits program under Section 14148.7 as that
program is implemented on January 1, 2003, shall itself qualify as a
simplified application for the Medi-Cal program for pregnant women,
or, if necessary to ensure federal financial participation, the form
shall be modified to add only those elements required for federal
financial participation and be as simple as the department considers
practicable.
(b) For purposes of this section, the department shall determine
whether to grant eligibility for temporary benefits under Section
14148.7 and the county shall make the final eligibility determination
for the Medi-Cal program. The department shall develop and adopt a
process for transferring the application to the county and a followup
process that is as simple as the department considers practicable to
be used by the county if followup is necessary. Based on the
department's instructions, the county shall make a determination
whether followup is necessary to determine the woman's final
eligibility for the Medi-Cal program or to refer the woman to the
Access for Infants and Mothers (AIM) program.
(c) The department shall adopt an electronic enrollment process
for pregnant women to use when applying for the Medi-Cal program from
a provider's office. The application form for this electronic
enrollment shall use the elements of the application form described
in subdivision (a) and the procedures specified in subdivision (b).
This electronic enrollment process shall be known as the Prenatal
Gateway. In developing the Prenatal Gateway required by this
subdivision, the department shall consult with consumer, provider,
county, and health plan representatives.
(d) The purpose of this section is to begin eligibility and
benefits at the time of an eligible pregnant woman's visit to a
provider and to continue eligibility and benefits until a final
eligibility determination is made without the submission of any other
application form to the department, the county, or a single point of
entry and to make the followup process as simple as the department
considers practicable.
(e) The Prenatal Gateway may not be adopted until both of the
following occur:
(1) Sufficient moneys have been deposited in the Special Funds
Account of the Gateway Fund to defray the costs of developing the
Prenatal Gateway.
(2) Sufficient new staff, not to exceed a total of three personnel
years, is available at the department for the purposes of this
section and Section 14148.04 and is funded through nonstate General
Fund sources. Notwithstanding any other provision of law, the
department may hire staff necessary to implement this section.
(f) The department shall implement the Prenatal Gateway within 12
months after the date upon which both of the conditions required
under subdivision (e) have occurred.
(g) To implement this section, the department may contract with
public or private entities, or utilize existing health care service
provider enrollment and payment mechanisms, including the Medi-Cal
program's fiscal intermediary, only if services provided under the
program are specifically identified and reimbursed in a manner that
appropriately claims federal financial reimbursement. Contracts,
including the Medi-Cal fiscal intermediary contract for the Child
Health and Disability Prevention Program, and including any contract
amendment, any system change pursuant to a change order, and any
project or systems development notice shall be exempt from Part 2
(commencing with Section 10100) of Division 2 of the Public Contract
Code, Chapter 7 (commencing with Section 11700) of Part 1 of Division
3 of Title 2 of the Government Code, Section 19130 of the Government
Code, and any policies, procedures, or regulations authorized by
these laws.
14148.04. (a) The department shall adopt, as specified in this
section, an electronic process for families to enroll a deemed
eligible newborn in the Medi-Cal program from hospitals that have
elected to participate in the process. The electronic enrollment
process adopted pursuant to this section shall be known as the
Newborn Hospital Gateway.
(b) With respect to the enrollment of a child under the age of one
year who is deemed to have applied and is deemed eligible for
Medi-Cal benefits under Section 1396a(e)(4) of Title 42 of the United
States Code, the enrollment procedures of the Newborn Hospital
Gateway shall specifically include procedures for confirming the
eligibility of, and issuing a Medi-Cal card to, that child.
(c) In developing the Newborn Hospital Gateway required by this
section, the department shall consult with consumer, provider,
county, and health plan representatives.
(d) The Newborn Hospital Gateway may not be adopted until both of
the following occur:
(1) Sufficient moneys have been deposited in the Special Funds
Account of the Gateway Fund to defray the costs of developing the
Newborn Hospital Gateway.
(2) Sufficient new staff, not to exceed a total of three personnel
years, is available at the department for the purposes of this
section and Section 14148.03 and is funded through nonstate General
Fund sources. Notwithstanding any other provision of law, the
department may hire staff necessary to implement this section.
(e) The department shall implement the Newborn Hospital Gateway
within 12 months after the date upon which both of the conditions
required under subdivision (d) have occurred.
(f) To implement this section, the department may contract with
public or private entities, or utilize existing health care service
provider enrollment and payment mechanisms, including the Medi-Cal
program's fiscal intermediary, only if services provided under the
program are specifically identified and reimbursed in a manner that
appropriately claims federal financial reimbursement. Contracts,
including the Medi-Cal fiscal intermediary contract for the Child
Health and Disability Prevention Program and including any contract
amendment, any system change pursuant to a change order, and any
project or systems development notice shall be exempt from Part 2
(commencing with Section 10100) of Division 2 of the Public Contract
Code, Chapter 7 (commencing with Section 11700) of Part 1 of Division
3 of Title 2 of the Government Code, Section 19130 of the Government
Code, and any policies, procedures, or regulations authorized by
these laws.
14148.05. (a) There is hereby created in the State Treasury the
Gateway Fund.
(b) Moneys in the fund may be expended, upon appropriation by the
Legislature, exclusively for purposes of establishing and maintaining
the Prenatal Gateway, as provided for in Section 14148.03, and the
Newborn Hospital Gateway, as provided for in Section 14148.04, and in
accordance with subdivision (c).
(c) The fund shall consist of the following accounts:
(1) The Special Funds Account, which shall consist of all funds
received by the Controller for purposes of Sections 14148.03 and
14148.04 from private foundations and other nongovernmental sources
and interest accrued thereon. Moneys in this account shall be used
exclusively for the purposes of Sections 14148.03 and 14148.04. The
department shall not be responsible for securing funding from private
foundations or other nongovernmental sources.
(2) The Other Public Funds Account, which shall consist of all
public funds, other than federal or state general funds, received by
the Controller for purposes of Sections 14148.03 and 14148.04 from
state or local sources, including, but not limited to, funds received
under the California Families and Children Act of 1998, Division 108
(commencing with Section 130100) of the Health and Safety Code
(Proposition 10), and the interest accrued thereon.
(3) The Federal Funds Account, which shall consist of all public
funds received by the Controller for purposes of Sections 14148.03
and 14148.04 from federal sources, and the interest accrued thereon.
14148.1. To maximize federal financial participation, the
department shall seek flexibility in implementing the requirements of
Section 121 of the Immigration Reform and Control Act of 1986
(Public Law 99-603) for Medi-Cal eligible women with confirmed
pregnancies.
14148.2. In order to assure access to obstetrical providers in the
Medi-Cal program, the state department shall explore and adopt
policies which improve provider relations with Medi-Cal maternity
care providers. Policies to be considered shall include, but not be
limited to, those which reduce the annual percentage of obstetrical
billings going to the department's suspense file, simplify provider
claim forms, establish toll-free telephone lines for the exclusive
use of maternity care providers, and establish clear reimbursement
guidelines. In addition, the department shall explore policies to
assure that obstetrical claims are processed on a prompt and
predictable basis, the feasibility of establishing a special claims
processing unit for obstetrical claims, and the adequacy of current
reimbursement levels and services reimbursed. The department shall
advise the Chairs of the Assembly Health Committee and the Senate
Health and Human Services Committee by July 1, 1989, on steps taken
to improve provider relations and the impact these steps have had on
provider participation.
14148.3. The department shall seek federal approval to implement
obstetrical case management for Medi-Cal eligible pregnant women when
provided through the Child Health and Disability Prevention program
authorized under Article 6 (commencing with Section 124025) of
Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.
14148.4. (a) The department shall eliminate the Medi-Cal
reimbursement differential for obstetrical services by equalizing the
rates of reimbursement for Caesarean section and non-Caesarean
section care and delivery services. In implementing this section,
savings that otherwise would have accrued due to lowered rates of
reimbursement for Caesarean section services shall be used to fund
across-the-board rate increases for all maternity care and delivery
services.
(b) Revisions to the existing rate structure required to implement
this section shall be adopted as emergency regulations in accordance
with Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code. The adoption of these
regulations shall be deemed an emergency and necessary for the
immediate preservation of the public peace, health and safety, or
general welfare. Notwithstanding Chapter 3.5 of Part 1 of Division 3
of Title 2 of the Government Code, emergency regulations adopted to
implement this act shall not be subject to the review and approval of
the Office of Administrative Law. These regulations shall become
effective immediately upon filing with the Secretary of State.
14148.5. (a) State funded perinatal services shall be provided
under the Medi-Cal program to pregnant women and state funded medical
services to infants up to one year of age in families with incomes
above 185 percent, but not more than 200 percent, of the federal
poverty level, in the same manner that these services are being
provided to the Medi-Cal population, including eligibility
requirements and integration of eligibility determinations and
payment of claims, except as follows:
(1) The assets of the family shall not be considered in making the
eligibility determination.
(2) The income deduction specified in subdivision (f) of Section
14148 shall not be applied.
(b) Services provided under this section shall not be subject to
any share-of-cost requirements.
(c) (1) The department, in implementing the Medi-Cal program and
public health programs, in coordination with the Managed Risk Medical
Insurance Program's Access for Infants and Mothers component, may
provide for outreach activities in order to enhance participation and
access to perinatal services. Funding received pursuant to the
federal provisions shall be used to expand perinatal outreach
activities. These outreach activities shall be implemented if funding
is provided for this purpose by an appropriation in the annual
Budget Act or other statute.
(2) Those outreach activities authorized by paragraph (1) shall be
targeted toward both Medi-Cal and non-Medi-Cal eligible high risk or
uninsured pregnant women and infants. Outreach activities may
include, but not be limited to, all of the following:
(A) Education of the targeted women on the availability and
importance of early prenatal care and referral to Medi-Cal and other
programs.
(B) Information provided through toll-free telephone numbers.
(C) Recruitment and retention of perinatal providers.
(d) Notwithstanding any other provision of law, contracts required
to implement the provisions of this section shall be exempt from the
approval of the Director of General Services and from the provisions
of the Public Contract Code.
(e) The programs authorized in this section shall be operative for
the entire 1996-97 fiscal year.
14148.6. The department shall engage in outreach activities in
order to enhance participation in and access to perinatal services.
14148.7. The department shall implement the federal options
authorized by federal law to assist in the delivery of timely and
continuing prenatal care by establishing the option of presumptive
eligibility under Section 1396r-1 of Title 42 of the United States
Code.
14148.75. At the earliest date that it is administratively
feasible, the department shall adopt the federal medicaid option
under Section 1902(l)(3) of the federal Social Security Act (42
U.S.C. Sec. 1396a(l)(3)) to waive the use of a resource standard for
determining the eligibility of pregnant women, infants, and children.
14148.8. (a) The State Department of Health Services shall provide
Medi-Cal reimbursements to alternative birth centers for
facility-related delivery costs at a statewide all-inclusive rate per
delivery that shall not exceed 80 percent of the average Medi-Cal
reimbursement received by general acute care hospitals with Medi-Cal
contracts and shall be based on an average hospital length of stay of
1.7 days. The reimbursement rate shall be updated annually and shall
be based on the California Medical Assistance Commission's annually
published legislative report of average contract rates for general
acute care hospitals with Medi-Cal contracts. However, the
reimbursement shall not exceed the alternative birth center's charges
to any non-Medi-Cal patient for similar services.
(b) In order to be eligible for reimbursement pursuant to this
section, an alternative birth center shall satisfy the following
criteria as determined by the state department:
(1) At least 150 patients or 50 percent of the patient caseload
served at the center each year, whichever is less, shall be Medi-Cal
patients and low-income patients.
(2) The facility shall be currently certified as a comprehensive
perinatal services provider. If not currently certified, the facility
shall be certified with the first year of operation.
(3) The facilities may utilize certified nurse midwives, certified
nurse practitioners, and clinical nurse specialists where
appropriate.
(4) The facility shall meet the standards for certification
established by the National Association of Childbearing Centers,
including those relating to the proximity and involvement of
hospitals, obstetricians, and pediatricians.
(5) The facility shall establish and maintain a quality assurance
program.
(6) The facility shall maintain newborn followup care for at least
one year.
(7) The gathering of data and preparing reports as required in
subdivision (c).
(c) (1) Each alternative birth center awarded reimbursement
pursuant to this section shall gather data and annually report
outcome measures relating to the safety, cost-effectiveness, and
patient acceptance of the center to the department to be made
available upon request.
(2) The report shall include data on the incidence of maternal and
infant death, preterm newborns, low birth weight newborns, maternal
complications, newborn complications, cesarean sections,
forcep-assisted deliveries, deliveries involving use of anesthesia,
months of prenatal care, family involvement in childbirth,
breast-feeding, infant immunizations, well baby care, adjusted cost
per case for deliveries performed at the center, and cost per case
for women transferred to hospitals for delivery.
(3) The department shall provide the Legislature with an annual
report summarizing the data reported by the centers.
(4) The department shall, to the extent information and resources
are available, as determined by the department, compare the data
provided by the centers with information furnished by other providers
of prenatal and delivery services. The department shall use the
comparative data to determine for the Medi-Cal program whether
alternative birth centers are cost-effective, improve access to
prenatal care, reduce the anticipated incidence of maternal and
newborn complications, and have a high degree of patient acceptance.
(d) The director shall administer this section and establish
standards, procedures, and reimbursement rates, as the director deems
necessary in carrying out this section. The establishment of the
reimbursement rates is not required to be adopted as regulations
pursuant to the Administrative Procedure Act (Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code).
(e) Nothing in this act shall alter the scope of practice for any
health care professional or authorize the delivery of health care
services in a setting or in a manner not authorized by the Health and
Safety Code or the Business and Professions Code.
14148.9. The department shall provide for the receipt and initial
processing of Medi-Cal applications from (a) pregnant women; and (b)
children born after September 30, 1983, who have not yet attained 19
years of age, at facilities other than the county welfare department
as described in Title XIX of the Social Security Act (42 U.S.C., Sec.
1396 and following).
WELFARE AND INSTITUTIONS CODE
SECTION 14148-14148.9
14148. (a) The department shall adopt the federal option provided
under Section 4101 of the Omnibus Budget Reconciliation Act of 1987
(Public Law 100-203) to extend eligibility for medical assistance
under Medicaid to all pregnant women and infants with family incomes
not in excess of 185 percent of the federal poverty level. If a
premium is imposed, the amount of the premium shall not exceed 10
percent of the amount by which the family's income, less actual child
care costs, exceeds 150 percent of the federal poverty level as
required by Section 4101 (a) of the 1987 Medicaid Budget
Reconciliation Agreement. The department shall implement this section
by emergency regulation.
(b) Upon order of the Department of Finance, the State Controller
shall transfer funds from Item 4260-101-001 of the Budget Act of 1988
to Item 4260-111-001 of the Budget Act of 1988 during the 1988-89
fiscal year for the purpose of funding outreach efforts for perinatal
services.
(c) Notwithstanding subdivision (a), the state may limit
implementation of this section during the 1988-89 fiscal year, based
upon the availability of department funds. The department may use
maternal and child health funds to finance the increased costs of
implementing an expansion of Medi-Cal eligibility to women and
children with incomes of up to 185 percent of federal poverty levels
if both of the following conditions exist:
(1) The department has allocated for expenditure at least sixteen
million dollars ($16,000,000) in funds redirected from the Medi-Cal
program for that expansion.
(2) If, and to the extent, the department determines that
estimates of costs based on actual data indicate that the funds are
needed to cover costs.
(d) This section shall be fully implemented no later than April 1,
1990.
(e) To assist Medi-Cal eligible pregnant women in receiving
prenatal care promptly, all pregnant women applying for Medi-Cal
shall be determined to have an immediate need. Counties, within
existing resources, shall expedite the eligibility determination
process for all pregnant women on the basis of their immediate needs.
Upon determination of eligibility, a Medi-Cal card shall be issued
immediately.
(f) To the extent federal financial participation is available,
the department shall apply the more liberal income deduction
described in Section 1396a(r) of Title 42 of the United States Code
when determining eligibility for pregnant women and infants under
this section. The amount of this deduction shall be the difference
between the 185 percent and the 200 percent federal poverty level
applicable to the size of the family.
14148.03. (a) Pursuant to options provided in federal law and
notwithstanding any other provision of law, the form used by a
provider to collect information about a pregnant woman pursuant to
the Medi-Cal temporary benefits program under Section 14148.7 as that
program is implemented on January 1, 2003, shall itself qualify as a
simplified application for the Medi-Cal program for pregnant women,
or, if necessary to ensure federal financial participation, the form
shall be modified to add only those elements required for federal
financial participation and be as simple as the department considers
practicable.
(b) For purposes of this section, the department shall determine
whether to grant eligibility for temporary benefits under Section
14148.7 and the county shall make the final eligibility determination
for the Medi-Cal program. The department shall develop and adopt a
process for transferring the application to the county and a followup
process that is as simple as the department considers practicable to
be used by the county if followup is necessary. Based on the
department's instructions, the county shall make a determination
whether followup is necessary to determine the woman's final
eligibility for the Medi-Cal program or to refer the woman to the
Access for Infants and Mothers (AIM) program.
(c) The department shall adopt an electronic enrollment process
for pregnant women to use when applying for the Medi-Cal program from
a provider's office. The application form for this electronic
enrollment shall use the elements of the application form described
in subdivision (a) and the procedures specified in subdivision (b).
This electronic enrollment process shall be known as the Prenatal
Gateway. In developing the Prenatal Gateway required by this
subdivision, the department shall consult with consumer, provider,
county, and health plan representatives.
(d) The purpose of this section is to begin eligibility and
benefits at the time of an eligible pregnant woman's visit to a
provider and to continue eligibility and benefits until a final
eligibility determination is made without the submission of any other
application form to the department, the county, or a single point of
entry and to make the followup process as simple as the department
considers practicable.
(e) The Prenatal Gateway may not be adopted until both of the
following occur:
(1) Sufficient moneys have been deposited in the Special Funds
Account of the Gateway Fund to defray the costs of developing the
Prenatal Gateway.
(2) Sufficient new staff, not to exceed a total of three personnel
years, is available at the department for the purposes of this
section and Section 14148.04 and is funded through nonstate General
Fund sources. Notwithstanding any other provision of law, the
department may hire staff necessary to implement this section.
(f) The department shall implement the Prenatal Gateway within 12
months after the date upon which both of the conditions required
under subdivision (e) have occurred.
(g) To implement this section, the department may contract with
public or private entities, or utilize existing health care service
provider enrollment and payment mechanisms, including the Medi-Cal
program's fiscal intermediary, only if services provided under the
program are specifically identified and reimbursed in a manner that
appropriately claims federal financial reimbursement. Contracts,
including the Medi-Cal fiscal intermediary contract for the Child
Health and Disability Prevention Program, and including any contract
amendment, any system change pursuant to a change order, and any
project or systems development notice shall be exempt from Part 2
(commencing with Section 10100) of Division 2 of the Public Contract
Code, Chapter 7 (commencing with Section 11700) of Part 1 of Division
3 of Title 2 of the Government Code, Section 19130 of the Government
Code, and any policies, procedures, or regulations authorized by
these laws.
14148.04. (a) The department shall adopt, as specified in this
section, an electronic process for families to enroll a deemed
eligible newborn in the Medi-Cal program from hospitals that have
elected to participate in the process. The electronic enrollment
process adopted pursuant to this section shall be known as the
Newborn Hospital Gateway.
(b) With respect to the enrollment of a child under the age of one
year who is deemed to have applied and is deemed eligible for
Medi-Cal benefits under Section 1396a(e)(4) of Title 42 of the United
States Code, the enrollment procedures of the Newborn Hospital
Gateway shall specifically include procedures for confirming the
eligibility of, and issuing a Medi-Cal card to, that child.
(c) In developing the Newborn Hospital Gateway required by this
section, the department shall consult with consumer, provider,
county, and health plan representatives.
(d) The Newborn Hospital Gateway may not be adopted until both of
the following occur:
(1) Sufficient moneys have been deposited in the Special Funds
Account of the Gateway Fund to defray the costs of developing the
Newborn Hospital Gateway.
(2) Sufficient new staff, not to exceed a total of three personnel
years, is available at the department for the purposes of this
section and Section 14148.03 and is funded through nonstate General
Fund sources. Notwithstanding any other provision of law, the
department may hire staff necessary to implement this section.
(e) The department shall implement the Newborn Hospital Gateway
within 12 months after the date upon which both of the conditions
required under subdivision (d) have occurred.
(f) To implement this section, the department may contract with
public or private entities, or utilize existing health care service
provider enrollment and payment mechanisms, including the Medi-Cal
program's fiscal intermediary, only if services provided under the
program are specifically identified and reimbursed in a manner that
appropriately claims federal financial reimbursement. Contracts,
including the Medi-Cal fiscal intermediary contract for the Child
Health and Disability Prevention Program and including any contract
amendment, any system change pursuant to a change order, and any
project or systems development notice shall be exempt from Part 2
(commencing with Section 10100) of Division 2 of the Public Contract
Code, Chapter 7 (commencing with Section 11700) of Part 1 of Division
3 of Title 2 of the Government Code, Section 19130 of the Government
Code, and any policies, procedures, or regulations authorized by
these laws.
14148.05. (a) There is hereby created in the State Treasury the
Gateway Fund.
(b) Moneys in the fund may be expended, upon appropriation by the
Legislature, exclusively for purposes of establishing and maintaining
the Prenatal Gateway, as provided for in Section 14148.03, and the
Newborn Hospital Gateway, as provided for in Section 14148.04, and in
accordance with subdivision (c).
(c) The fund shall consist of the following accounts:
(1) The Special Funds Account, which shall consist of all funds
received by the Controller for purposes of Sections 14148.03 and
14148.04 from private foundations and other nongovernmental sources
and interest accrued thereon. Moneys in this account shall be used
exclusively for the purposes of Sections 14148.03 and 14148.04. The
department shall not be responsible for securing funding from private
foundations or other nongovernmental sources.
(2) The Other Public Funds Account, which shall consist of all
public funds, other than federal or state general funds, received by
the Controller for purposes of Sections 14148.03 and 14148.04 from
state or local sources, including, but not limited to, funds received
under the California Families and Children Act of 1998, Division 108
(commencing with Section 130100) of the Health and Safety Code
(Proposition 10), and the interest accrued thereon.
(3) The Federal Funds Account, which shall consist of all public
funds received by the Controller for purposes of Sections 14148.03
and 14148.04 from federal sources, and the interest accrued thereon.
14148.1. To maximize federal financial participation, the
department shall seek flexibility in implementing the requirements of
Section 121 of the Immigration Reform and Control Act of 1986
(Public Law 99-603) for Medi-Cal eligible women with confirmed
pregnancies.
14148.2. In order to assure access to obstetrical providers in the
Medi-Cal program, the state department shall explore and adopt
policies which improve provider relations with Medi-Cal maternity
care providers. Policies to be considered shall include, but not be
limited to, those which reduce the annual percentage of obstetrical
billings going to the department's suspense file, simplify provider
claim forms, establish toll-free telephone lines for the exclusive
use of maternity care providers, and establish clear reimbursement
guidelines. In addition, the department shall explore policies to
assure that obstetrical claims are processed on a prompt and
predictable basis, the feasibility of establishing a special claims
processing unit for obstetrical claims, and the adequacy of current
reimbursement levels and services reimbursed. The department shall
advise the Chairs of the Assembly Health Committee and the Senate
Health and Human Services Committee by July 1, 1989, on steps taken
to improve provider relations and the impact these steps have had on
provider participation.
14148.3. The department shall seek federal approval to implement
obstetrical case management for Medi-Cal eligible pregnant women when
provided through the Child Health and Disability Prevention program
authorized under Article 6 (commencing with Section 124025) of
Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.
14148.4. (a) The department shall eliminate the Medi-Cal
reimbursement differential for obstetrical services by equalizing the
rates of reimbursement for Caesarean section and non-Caesarean
section care and delivery services. In implementing this section,
savings that otherwise would have accrued due to lowered rates of
reimbursement for Caesarean section services shall be used to fund
across-the-board rate increases for all maternity care and delivery
services.
(b) Revisions to the existing rate structure required to implement
this section shall be adopted as emergency regulations in accordance
with Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code. The adoption of these
regulations shall be deemed an emergency and necessary for the
immediate preservation of the public peace, health and safety, or
general welfare. Notwithstanding Chapter 3.5 of Part 1 of Division 3
of Title 2 of the Government Code, emergency regulations adopted to
implement this act shall not be subject to the review and approval of
the Office of Administrative Law. These regulations shall become
effective immediately upon filing with the Secretary of State.
14148.5. (a) State funded perinatal services shall be provided
under the Medi-Cal program to pregnant women and state funded medical
services to infants up to one year of age in families with incomes
above 185 percent, but not more than 200 percent, of the federal
poverty level, in the same manner that these services are being
provided to the Medi-Cal population, including eligibility
requirements and integration of eligibility determinations and
payment of claims, except as follows:
(1) The assets of the family shall not be considered in making the
eligibility determination.
(2) The income deduction specified in subdivision (f) of Section
14148 shall not be applied.
(b) Services provided under this section shall not be subject to
any share-of-cost requirements.
(c) (1) The department, in implementing the Medi-Cal program and
public health programs, in coordination with the Managed Risk Medical
Insurance Program's Access for Infants and Mothers component, may
provide for outreach activities in order to enhance participation and
access to perinatal services. Funding received pursuant to the
federal provisions shall be used to expand perinatal outreach
activities. These outreach activities shall be implemented if funding
is provided for this purpose by an appropriation in the annual
Budget Act or other statute.
(2) Those outreach activities authorized by paragraph (1) shall be
targeted toward both Medi-Cal and non-Medi-Cal eligible high risk or
uninsured pregnant women and infants. Outreach activities may
include, but not be limited to, all of the following:
(A) Education of the targeted women on the availability and
importance of early prenatal care and referral to Medi-Cal and other
programs.
(B) Information provided through toll-free telephone numbers.
(C) Recruitment and retention of perinatal providers.
(d) Notwithstanding any other provision of law, contracts required
to implement the provisions of this section shall be exempt from the
approval of the Director of General Services and from the provisions
of the Public Contract Code.
(e) The programs authorized in this section shall be operative for
the entire 1996-97 fiscal year.
14148.6. The department shall engage in outreach activities in
order to enhance participation in and access to perinatal services.
14148.7. The department shall implement the federal options
authorized by federal law to assist in the delivery of timely and
continuing prenatal care by establishing the option of presumptive
eligibility under Section 1396r-1 of Title 42 of the United States
Code.
14148.75. At the earliest date that it is administratively
feasible, the department shall adopt the federal medicaid option
under Section 1902(l)(3) of the federal Social Security Act (42
U.S.C. Sec. 1396a(l)(3)) to waive the use of a resource standard for
determining the eligibility of pregnant women, infants, and children.
14148.8. (a) The State Department of Health Services shall provide
Medi-Cal reimbursements to alternative birth centers for
facility-related delivery costs at a statewide all-inclusive rate per
delivery that shall not exceed 80 percent of the average Medi-Cal
reimbursement received by general acute care hospitals with Medi-Cal
contracts and shall be based on an average hospital length of stay of
1.7 days. The reimbursement rate shall be updated annually and shall
be based on the California Medical Assistance Commission's annually
published legislative report of average contract rates for general
acute care hospitals with Medi-Cal contracts. However, the
reimbursement shall not exceed the alternative birth center's charges
to any non-Medi-Cal patient for similar services.
(b) In order to be eligible for reimbursement pursuant to this
section, an alternative birth center shall satisfy the following
criteria as determined by the state department:
(1) At least 150 patients or 50 percent of the patient caseload
served at the center each year, whichever is less, shall be Medi-Cal
patients and low-income patients.
(2) The facility shall be currently certified as a comprehensive
perinatal services provider. If not currently certified, the facility
shall be certified with the first year of operation.
(3) The facilities may utilize certified nurse midwives, certified
nurse practitioners, and clinical nurse specialists where
appropriate.
(4) The facility shall meet the standards for certification
established by the National Association of Childbearing Centers,
including those relating to the proximity and involvement of
hospitals, obstetricians, and pediatricians.
(5) The facility shall establish and maintain a quality assurance
program.
(6) The facility shall maintain newborn followup care for at least
one year.
(7) The gathering of data and preparing reports as required in
subdivision (c).
(c) (1) Each alternative birth center awarded reimbursement
pursuant to this section shall gather data and annually report
outcome measures relating to the safety, cost-effectiveness, and
patient acceptance of the center to the department to be made
available upon request.
(2) The report shall include data on the incidence of maternal and
infant death, preterm newborns, low birth weight newborns, maternal
complications, newborn complications, cesarean sections,
forcep-assisted deliveries, deliveries involving use of anesthesia,
months of prenatal care, family involvement in childbirth,
breast-feeding, infant immunizations, well baby care, adjusted cost
per case for deliveries performed at the center, and cost per case
for women transferred to hospitals for delivery.
(3) The department shall provide the Legislature with an annual
report summarizing the data reported by the centers.
(4) The department shall, to the extent information and resources
are available, as determined by the department, compare the data
provided by the centers with information furnished by other providers
of prenatal and delivery services. The department shall use the
comparative data to determine for the Medi-Cal program whether
alternative birth centers are cost-effective, improve access to
prenatal care, reduce the anticipated incidence of maternal and
newborn complications, and have a high degree of patient acceptance.
(d) The director shall administer this section and establish
standards, procedures, and reimbursement rates, as the director deems
necessary in carrying out this section. The establishment of the
reimbursement rates is not required to be adopted as regulations
pursuant to the Administrative Procedure Act (Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code).
(e) Nothing in this act shall alter the scope of practice for any
health care professional or authorize the delivery of health care
services in a setting or in a manner not authorized by the Health and
Safety Code or the Business and Professions Code.
14148.9. The department shall provide for the receipt and initial
processing of Medi-Cal applications from (a) pregnant women; and (b)
children born after September 30, 1983, who have not yet attained 19
years of age, at facilities other than the county welfare department
as described in Title XIX of the Social Security Act (42 U.S.C., Sec.
1396 and following).
WELFARE AND INSTITUTIONS CODE
SECTION 14148-14148.9
14148. (a) The department shall adopt the federal option provided
under Section 4101 of the Omnibus Budget Reconciliation Act of 1987
(Public Law 100-203) to extend eligibility for medical assistance
under Medicaid to all pregnant women and infants with family incomes
not in excess of 185 percent of the federal poverty level. If a
premium is imposed, the amount of the premium shall not exceed 10
percent of the amount by which the family's income, less actual child
care costs, exceeds 150 percent of the federal poverty level as
required by Section 4101 (a) of the 1987 Medicaid Budget
Reconciliation Agreement. The department shall implement this section
by emergency regulation.
(b) Upon order of the Department of Finance, the State Controller
shall transfer funds from Item 4260-101-001 of the Budget Act of 1988
to Item 4260-111-001 of the Budget Act of 1988 during the 1988-89
fiscal year for the purpose of funding outreach efforts for perinatal
services.
(c) Notwithstanding subdivision (a), the state may limit
implementation of this section during the 1988-89 fiscal year, based
upon the availability of department funds. The department may use
maternal and child health funds to finance the increased costs of
implementing an expansion of Medi-Cal eligibility to women and
children with incomes of up to 185 percent of federal poverty levels
if both of the following conditions exist:
(1) The department has allocated for expenditure at least sixteen
million dollars ($16,000,000) in funds redirected from the Medi-Cal
program for that expansion.
(2) If, and to the extent, the department determines that
estimates of costs based on actual data indicate that the funds are
needed to cover costs.
(d) This section shall be fully implemented no later than April 1,
1990.
(e) To assist Medi-Cal eligible pregnant women in receiving
prenatal care promptly, all pregnant women applying for Medi-Cal
shall be determined to have an immediate need. Counties, within
existing resources, shall expedite the eligibility determination
process for all pregnant women on the basis of their immediate needs.
Upon determination of eligibility, a Medi-Cal card shall be issued
immediately.
(f) To the extent federal financial participation is available,
the department shall apply the more liberal income deduction
described in Section 1396a(r) of Title 42 of the United States Code
when determining eligibility for pregnant women and infants under
this section. The amount of this deduction shall be the difference
between the 185 percent and the 200 percent federal poverty level
applicable to the size of the family.
14148.03. (a) Pursuant to options provided in federal law and
notwithstanding any other provision of law, the form used by a
provider to collect information about a pregnant woman pursuant to
the Medi-Cal temporary benefits program under Section 14148.7 as that
program is implemented on January 1, 2003, shall itself qualify as a
simplified application for the Medi-Cal program for pregnant women,
or, if necessary to ensure federal financial participation, the form
shall be modified to add only those elements required for federal
financial participation and be as simple as the department considers
practicable.
(b) For purposes of this section, the department shall determine
whether to grant eligibility for temporary benefits under Section
14148.7 and the county shall make the final eligibility determination
for the Medi-Cal program. The department shall develop and adopt a
process for transferring the application to the county and a followup
process that is as simple as the department considers practicable to
be used by the county if followup is necessary. Based on the
department's instructions, the county shall make a determination
whether followup is necessary to determine the woman's final
eligibility for the Medi-Cal program or to refer the woman to the
Access for Infants and Mothers (AIM) program.
(c) The department shall adopt an electronic enrollment process
for pregnant women to use when applying for the Medi-Cal program from
a provider's office. The application form for this electronic
enrollment shall use the elements of the application form described
in subdivision (a) and the procedures specified in subdivision (b).
This electronic enrollment process shall be known as the Prenatal
Gateway. In developing the Prenatal Gateway required by this
subdivision, the department shall consult with consumer, provider,
county, and health plan representatives.
(d) The purpose of this section is to begin eligibility and
benefits at the time of an eligible pregnant woman's visit to a
provider and to continue eligibility and benefits until a final
eligibility determination is made without the submission of any other
application form to the department, the county, or a single point of
entry and to make the followup process as simple as the department
considers practicable.
(e) The Prenatal Gateway may not be adopted until both of the
following occur:
(1) Sufficient moneys have been deposited in the Special Funds
Account of the Gateway Fund to defray the costs of developing the
Prenatal Gateway.
(2) Sufficient new staff, not to exceed a total of three personnel
years, is available at the department for the purposes of this
section and Section 14148.04 and is funded through nonstate General
Fund sources. Notwithstanding any other provision of law, the
department may hire staff necessary to implement this section.
(f) The department shall implement the Prenatal Gateway within 12
months after the date upon which both of the conditions required
under subdivision (e) have occurred.
(g) To implement this section, the department may contract with
public or private entities, or utilize existing health care service
provider enrollment and payment mechanisms, including the Medi-Cal
program's fiscal intermediary, only if services provided under the
program are specifically identified and reimbursed in a manner that
appropriately claims federal financial reimbursement. Contracts,
including the Medi-Cal fiscal intermediary contract for the Child
Health and Disability Prevention Program, and including any contract
amendment, any system change pursuant to a change order, and any
project or systems development notice shall be exempt from Part 2
(commencing with Section 10100) of Division 2 of the Public Contract
Code, Chapter 7 (commencing with Section 11700) of Part 1 of Division
3 of Title 2 of the Government Code, Section 19130 of the Government
Code, and any policies, procedures, or regulations authorized by
these laws.
14148.04. (a) The department shall adopt, as specified in this
section, an electronic process for families to enroll a deemed
eligible newborn in the Medi-Cal program from hospitals that have
elected to participate in the process. The electronic enrollment
process adopted pursuant to this section shall be known as the
Newborn Hospital Gateway.
(b) With respect to the enrollment of a child under the age of one
year who is deemed to have applied and is deemed eligible for
Medi-Cal benefits under Section 1396a(e)(4) of Title 42 of the United
States Code, the enrollment procedures of the Newborn Hospital
Gateway shall specifically include procedures for confirming the
eligibility of, and issuing a Medi-Cal card to, that child.
(c) In developing the Newborn Hospital Gateway required by this
section, the department shall consult with consumer, provider,
county, and health plan representatives.
(d) The Newborn Hospital Gateway may not be adopted until both of
the following occur:
(1) Sufficient moneys have been deposited in the Special Funds
Account of the Gateway Fund to defray the costs of developing the
Newborn Hospital Gateway.
(2) Sufficient new staff, not to exceed a total of three personnel
years, is available at the department for the purposes of this
section and Section 14148.03 and is funded through nonstate General
Fund sources. Notwithstanding any other provision of law, the
department may hire staff necessary to implement this section.
(e) The department shall implement the Newborn Hospital Gateway
within 12 months after the date upon which both of the conditions
required under subdivision (d) have occurred.
(f) To implement this section, the department may contract with
public or private entities, or utilize existing health care service
provider enrollment and payment mechanisms, including the Medi-Cal
program's fiscal intermediary, only if services provided under the
program are specifically identified and reimbursed in a manner that
appropriately claims federal financial reimbursement. Contracts,
including the Medi-Cal fiscal intermediary contract for the Child
Health and Disability Prevention Program and including any contract
amendment, any system change pursuant to a change order, and any
project or systems development notice shall be exempt from Part 2
(commencing with Section 10100) of Division 2 of the Public Contract
Code, Chapter 7 (commencing with Section 11700) of Part 1 of Division
3 of Title 2 of the Government Code, Section 19130 of the Government
Code, and any policies, procedures, or regulations authorized by
these laws.
14148.05. (a) There is hereby created in the State Treasury the
Gateway Fund.
(b) Moneys in the fund may be expended, upon appropriation by the
Legislature, exclusively for purposes of establishing and maintaining
the Prenatal Gateway, as provided for in Section 14148.03, and the
Newborn Hospital Gateway, as provided for in Section 14148.04, and in
accordance with subdivision (c).
(c) The fund shall consist of the following accounts:
(1) The Special Funds Account, which shall consist of all funds
received by the Controller for purposes of Sections 14148.03 and
14148.04 from private foundations and other nongovernmental sources
and interest accrued thereon. Moneys in this account shall be used
exclusively for the purposes of Sections 14148.03 and 14148.04. The
department shall not be responsible for securing funding from private
foundations or other nongovernmental sources.
(2) The Other Public Funds Account, which shall consist of all
public funds, other than federal or state general funds, received by
the Controller for purposes of Sections 14148.03 and 14148.04 from
state or local sources, including, but not limited to, funds received
under the California Families and Children Act of 1998, Division 108
(commencing with Section 130100) of the Health and Safety Code
(Proposition 10), and the interest accrued thereon.
(3) The Federal Funds Account, which shall consist of all public
funds received by the Controller for purposes of Sections 14148.03
and 14148.04 from federal sources, and the interest accrued thereon.
14148.1. To maximize federal financial participation, the
department shall seek flexibility in implementing the requirements of
Section 121 of the Immigration Reform and Control Act of 1986
(Public Law 99-603) for Medi-Cal eligible women with confirmed
pregnancies.
14148.2. In order to assure access to obstetrical providers in the
Medi-Cal program, the state department shall explore and adopt
policies which improve provider relations with Medi-Cal maternity
care providers. Policies to be considered shall include, but not be
limited to, those which reduce the annual percentage of obstetrical
billings going to the department's suspense file, simplify provider
claim forms, establish toll-free telephone lines for the exclusive
use of maternity care providers, and establish clear reimbursement
guidelines. In addition, the department shall explore policies to
assure that obstetrical claims are processed on a prompt and
predictable basis, the feasibility of establishing a special claims
processing unit for obstetrical claims, and the adequacy of current
reimbursement levels and services reimbursed. The department shall
advise the Chairs of the Assembly Health Committee and the Senate
Health and Human Services Committee by July 1, 1989, on steps taken
to improve provider relations and the impact these steps have had on
provider participation.
14148.3. The department shall seek federal approval to implement
obstetrical case management for Medi-Cal eligible pregnant women when
provided through the Child Health and Disability Prevention program
authorized under Article 6 (commencing with Section 124025) of
Chapter 3 of Part 2 of Division 106 of the Health and Safety Code.
14148.4. (a) The department shall eliminate the Medi-Cal
reimbursement differential for obstetrical services by equalizing the
rates of reimbursement for Caesarean section and non-Caesarean
section care and delivery services. In implementing this section,
savings that otherwise would have accrued due to lowered rates of
reimbursement for Caesarean section services shall be used to fund
across-the-board rate increases for all maternity care and delivery
services.
(b) Revisions to the existing rate structure required to implement
this section shall be adopted as emergency regulations in accordance
with Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code. The adoption of these
regulations shall be deemed an emergency and necessary for the
immediate preservation of the public peace, health and safety, or
general welfare. Notwithstanding Chapter 3.5 of Part 1 of Division 3
of Title 2 of the Government Code, emergency regulations adopted to
implement this act shall not be subject to the review and approval of
the Office of Administrative Law. These regulations shall become
effective immediately upon filing with the Secretary of State.
14148.5. (a) State funded perinatal services shall be provided
under the Medi-Cal program to pregnant women and state funded medical
services to infants up to one year of age in families with incomes
above 185 percent, but not more than 200 percent, of the federal
poverty level, in the same manner that these services are being
provided to the Medi-Cal population, including eligibility
requirements and integration of eligibility determinations and
payment of claims, except as follows:
(1) The assets of the family shall not be considered in making the
eligibility determination.
(2) The income deduction specified in subdivision (f) of Section
14148 shall not be applied.
(b) Services provided under this section shall not be subject to
any share-of-cost requirements.
(c) (1) The department, in implementing the Medi-Cal program and
public health programs, in coordination with the Managed Risk Medical
Insurance Program's Access for Infants and Mothers component, may
provide for outreach activities in order to enhance participation and
access to perinatal services. Funding received pursuant to the
federal provisions shall be used to expand perinatal outreach
activities. These outreach activities shall be implemented if funding
is provided for this purpose by an appropriation in the annual
Budget Act or other statute.
(2) Those outreach activities authorized by paragraph (1) shall be
targeted toward both Medi-Cal and non-Medi-Cal eligible high risk or
uninsured pregnant women and infants. Outreach activities may
include, but not be limited to, all of the following:
(A) Education of the targeted women on the availability and
importance of early prenatal care and referral to Medi-Cal and other
programs.
(B) Information provided through toll-free telephone numbers.
(C) Recruitment and retention of perinatal providers.
(d) Notwithstanding any other provision of law, contracts required
to implement the provisions of this section shall be exempt from the
approval of the Director of General Services and from the provisions
of the Public Contract Code.
(e) The programs authorized in this section shall be operative for
the entire 1996-97 fiscal year.
14148.6. The department shall engage in outreach activities in
order to enhance participation in and access to perinatal services.
14148.7. The department shall implement the federal options
authorized by federal law to assist in the delivery of timely and
continuing prenatal care by establishing the option of presumptive
eligibility under Section 1396r-1 of Title 42 of the United States
Code.
14148.75. At the earliest date that it is administratively
feasible, the department shall adopt the federal medicaid option
under Section 1902(l)(3) of the federal Social Security Act (42
U.S.C. Sec. 1396a(l)(3)) to waive the use of a resource standard for
determining the eligibility of pregnant women, infants, and children.
14148.8. (a) The State Department of Health Services shall provide
Medi-Cal reimbursements to alternative birth centers for
facility-related delivery costs at a statewide all-inclusive rate per
delivery that shall not exceed 80 percent of the average Medi-Cal
reimbursement received by general acute care hospitals with Medi-Cal
contracts and shall be based on an average hospital length of stay of
1.7 days. The reimbursement rate shall be updated annually and shall
be based on the California Medical Assistance Commission's annually
published legislative report of average contract rates for general
acute care hospitals with Medi-Cal contracts. However, the
reimbursement shall not exceed the alternative birth center's charges
to any non-Medi-Cal patient for similar services.
(b) In order to be eligible for reimbursement pursuant to this
section, an alternative birth center shall satisfy the following
criteria as determined by the state department:
(1) At least 150 patients or 50 percent of the patient caseload
served at the center each year, whichever is less, shall be Medi-Cal
patients and low-income patients.
(2) The facility shall be currently certified as a comprehensive
perinatal services provider. If not currently certified, the facility
shall be certified with the first year of operation.
(3) The facilities may utilize certified nurse midwives, certified
nurse practitioners, and clinical nurse specialists where
appropriate.
(4) The facility shall meet the standards for certification
established by the National Association of Childbearing Centers,
including those relating to the proximity and involvement of
hospitals, obstetricians, and pediatricians.
(5) The facility shall establish and maintain a quality assurance
program.
(6) The facility shall maintain newborn followup care for at least
one year.
(7) The gathering of data and preparing reports as required in
subdivision (c).
(c) (1) Each alternative birth center awarded reimbursement
pursuant to this section shall gather data and annually report
outcome measures relating to the safety, cost-effectiveness, and
patient acceptance of the center to the department to be made
available upon request.
(2) The report shall include data on the incidence of maternal and
infant death, preterm newborns, low birth weight newborns, maternal
complications, newborn complications, cesarean sections,
forcep-assisted deliveries, deliveries involving use of anesthesia,
months of prenatal care, family involvement in childbirth,
breast-feeding, infant immunizations, well baby care, adjusted cost
per case for deliveries performed at the center, and cost per case
for women transferred to hospitals for delivery.
(3) The department shall provide the Legislature with an annual
report summarizing the data reported by the centers.
(4) The department shall, to the extent information and resources
are available, as determined by the department, compare the data
provided by the centers with information furnished by other providers
of prenatal and delivery services. The department shall use the
comparative data to determine for the Medi-Cal program whether
alternative birth centers are cost-effective, improve access to
prenatal care, reduce the anticipated incidence of maternal and
newborn complications, and have a high degree of patient acceptance.
(d) The director shall administer this section and establish
standards, procedures, and reimbursement rates, as the director deems
necessary in carrying out this section. The establishment of the
reimbursement rates is not required to be adopted as regulations
pursuant to the Administrative Procedure Act (Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the
Government Code).
(e) Nothing in this act shall alter the scope of practice for any
health care professional or authorize the delivery of health care
services in a setting or in a manner not authorized by the Health and
Safety Code or the Business and Professions Code.
14148.9. The department shall provide for the receipt and initial
processing of Medi-Cal applications from (a) pregnant women; and (b)
children born after September 30, 1983, who have not yet attained 19
years of age, at facilities other than the county welfare department
as described in Title XIX of the Social Security Act (42 U.S.C., Sec.
1396 and following).
