24000. There is established in the State Department of Health
Services the State-Only Family Planning Program to provide
comprehensive clinical family planning services to low-income men and
women. This division shall be known and may be cited as the
State-Only Family Planning Program.
24001. (a) (1) For purposes of this division, "family planning"
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, natural family planning,
abstinence methods and basic, limited fertility management. 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. Family planning shall not
include abortion, pregnancy testing solely for the purposes of
referral for abortion or services ancillary to abortions, not
including contraceptives, or pregnancy care that is not incident to
the diagnosis of pregnancy.
(2) Family planning services for males shall be expanded to
include laboratory tests for sexually transmitted infections and
comprehensive physical examinations. Within 60 days of approval of
the Family Planning, Access, Care, and Treatment (Family PACT) Waiver
Program, provided for pursuant to subdivision (aa) of Section 14132,
the department shall seek to amend the waiver to add this expansion.
The implementation of this paragraph shall be dependent upon federal
approval and receipt of federal financial participation.
(b) For purposes of this division, "department" means the State
Department of Health Services.
24003. (a) A person shall be eligible to receive services pursuant
to this chapter provided that the following conditions are met:
(1) The person is a resident of California.
(2) The person has a family income at or below 200 percent of the
federal poverty level.
(3) The person has no other source of health care coverage unless
the use of that health care coverage would create a barrier to access
because of confidentiality.
(4) The person is not otherwise eligible for existing Medi-Cal
services without a share of cost.
(b) Notwithstanding any other provision of law, the provision of
family planning services shall not require the consent of anyone
other than the person who is to receive the services.
(c) Eligibility shall be determined at point of service by the
provider. The provider shall obtain information on the individual's
family size, income, and health care coverage and then, based on that
information, determine if the individual meets the eligibility
criteria specified in subdivision (a). All individuals who meet the
eligibility requirements shall be certified by the provider as
eligible for services under the program. A Medi-Cal share of cost
shall not be used to deny access to family planning services under
the program. The department may require the collection on a voluntary
basis or the use of the individual's social security number, or
both. No services shall be denied to a client if a social security
number is not provided.
(d) Eligibility shall be based on the individual's
self-declaration of gross annual or monthly income, family size, and
other source of health care coverage, signed under penalty of perjury
at each annual eligibility certification. No asset information shall
be used to determine eligibility.
(e) The department may establish a copayment system for services
provided pursuant to this chapter that is based upon the income level
of the individual and the cost of the service provided. No
individual whose documented family income is at or below 100 percent
of the federal poverty level shall be subject to copayment. The
copayment fee shall not be used to deny access to family planning
services. State reimbursement to the provider shall be offset by that
amount of the copayment collected from the eligible individual. The
department shall notify providers on an annual basis of the copayment
fee schedule.
24003.2. The basic preventive health services covered under this
program shall include measles, mumps, and rubella vaccines for women
of reproductive age. Within 60 days of approval of the Family
Planning, Access, Care, and Treatment (Family PACT) Waiver Program,
provided for pursuant to subdivision (aa) of Section 14132, the
department shall seek to amend the waiver to add this expansion. The
implementation of this section shall be dependent upon federal
approval and receipt of federal financial participation.
24003.5. Any male or female of reproductive age who is not at risk
for pregnancy and is eligible for the program shall have available
the scope of benefits provided by the program. Within 60 days of
approval of the Family Planning, Access, Care, and Treatment (Family
PACT) Waiver Program, provided for pursuant to subdivision (aa) of
Section 14132, the department shall seek to amend the waiver to add
this expansion. The implementation of this section shall be dependent
upon federal approval and receipt of federal financial
participation.
24005. (a) This section shall apply to the Family Planning Access
Care and Treatment Waiver program identified in subdivision (aa) of
Section 14132 and this program.
(b) Only licensed medical personnel with family planning skills,
knowledge, and competency may provide the full range of family
planning medical services covered in this program.
(c) Medi-Cal enrolled providers, as determined by the department,
shall be eligible to provide family planning services under the
program when these services are within their scope of practice and
licensure. Those clinical providers electing to participate in the
program and approved by the department shall provide the full scope
of family planning education, counseling, and medical services
specified for the program, either directly or by referral, consistent
with standards of care issued by the department.
(d) The department shall require providers to enter into clinical
agreements with the department to ensure compliance with standards
and requirements to maintain the fiscal integrity of the program.
Provider applicants, providers, and persons with an ownership or
control interest, as defined in federal medicaid regulations, shall
be required to submit to the department their social security numbers
to the full extent allowed under federal law. All state and federal
statutes and regulations pertaining to the audit or examination of
Medi-Cal providers shall apply to this program.
(e) Clinical provider agreements shall be signed by the provider
under penalty of perjury. The department may screen applicants at the
initial application and at any reapplication pursuant to
requirements developed by the department to determine provider
suitability for the program.
(f) The department may complete a background check on clinical
provider applicants for the purpose of verifying the accuracy of
information provided to the department for purposes of enrolling in
the program and in order to prevent fraud and abuse. The background
check may include, but not be limited to, unannounced onsite
inspection prior to enrollment, review of business records, and data
searches. If discrepancies are found to exist during the
preenrollment period, the department may conduct additional
inspections prior to enrollment. Failure to remediate significant
discrepancies as prescribed by the director may result in denial of
the application for enrollment. Providers that do not provide
services consistent with the standards of care or that do not comply
with the department's rules related to the fiscal integrity of the
program may be disenrolled as a provider from the program at the sole
discretion of the department.
(g) The department shall not enroll any applicant who, within the
previous 10 years:
(1) Has been convicted of any felony or misdemeanor that involves
fraud or abuse in any government program, that relates to neglect or
abuse of a patient in connection with the delivery of a health care
item or service, or that is in connection with the interference with,
or obstruction of, any investigation into health care related fraud
or abuse.
(2) Has been found liable for fraud or abuse in any civil
proceeding, or that has entered into a settlement in lieu of
conviction for fraud or abuse in any government program.
(h) In addition, the department may deny enrollment to any
applicant that, at the time of application, is under investigation by
the department or any local, state, or federal government law
enforcement agency for fraud or abuse. The department shall not deny
enrollment to an otherwise qualified applicant whose felony or
misdemeanor charges did not result in a conviction solely on the
basis of the prior charges. If it is discovered that a provider is
under investigation by the department or any local, state, or federal
government law enforcement agency for fraud or abuse, that provider
shall be subject to immediate disenrollment from the program.
(i) (1) The program shall disenroll as a program provider any
individual who, or any entity that, has a license, certificate, or
other approval to provide health care, which is revoked or suspended
by a federal, California, or other state's licensing, certification,
or other approval authority, has otherwise lost that license,
certificate, or approval, or has surrendered that license,
certificate, or approval while a disciplinary hearing on the license,
certificate, or approval was pending. The disenrollment shall be
effective on the date the license, certificate, or approval is
revoked, lost, or surrendered.
(2) A provider shall be subject to disenrollment if the provider
submits claims for payment for the services, goods, supplies, or
merchandise provided, directly or indirectly, to a program
beneficiary, by an individual or entity that has been previously
suspended, excluded, or otherwise made ineligible to receive,
directly or indirectly, reimbursement from the program or from the
Medi-Cal program and the individual has previously been listed on
either the Suspended and Ineligible Provider List, which is published
by the department, to identify suspended and otherwise ineligible
providers or any list published by the federal Office of the
Inspector General regarding the suspension or exclusion of
individuals or entities from the federal Medicare and medicaid
programs, to identify suspended, excluded, or otherwise ineligible
providers.
(3) The department shall deactivate, immediately and without prior
notice, the provider numbers used by a provider to obtain
reimbursement from the program when warrants or documents mailed to a
provider's mailing address, its pay to address, or its service
address, if any, are returned by the United States Postal Service as
not deliverable or when a provider has not submitted a claim for
reimbursement from the program for one year. Prior to taking this
action, the department shall use due diligence in attempting to
contact the provider at its last known telephone number and to
ascertain if the return by the United States Postal Service is by
mistake and shall use due diligence in attempting to contact the
provider by telephone or in writing to ascertain whether the provider
wishes to continue to participate in the Medi-Cal program. If
deactivation pursuant to this section occurs, the provider shall meet
the requirements for reapplication as specified in regulation.
(4) For purposes of this subdivision:
(A) "Mailing address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which it wishes to receive general program
correspondence.
(B) "Pay to address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which it wishes to receive warrants.
(C) "Service address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which the provider will provide services to program
beneficiaries.
(j) Subject to Article 4 (commencing with Section 19130) of
Chapter 5 of Division 5 of Title 2 of the Government Code, the
department may enter into contracts to secure consultant services or
information technology including, but not limited to, software, data,
or analytical techniques or methodologies for the purpose of fraud
or abuse detection and prevention. Contracts under this section shall
be exempt from the Public Contract Code.
(k) Enrolled providers shall attend specific orientation approved
by the department in comprehensive family planning services. Enrolled
providers who insert IUDs or contraceptive implants shall have
received prior clinical training specific to these procedures.
(l) Upon receipt of reliable evidence that would be admissible
under the administrative adjudication provisions of Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code, of fraud or willful misrepresentation by a
provider under the program or commencement of a suspension under
Section 14123, the department may do any of the following:
(1) Collect any State-Only Family Planning program or Family
Planning Access Care and Treatment Waiver program overpayment
identified through an audit or examination, or any portion thereof
from any provider. Notwithstanding Section 100171 of the Health and
Safety Code, a provider may appeal the collection of overpayments
under this section pursuant to procedures established in Article 5.3
(commencing with Section 14170) of Part 3 of Division 9. Overpayments
collected under this section shall not be returned to the provider
during the pendency of any appeal and may be offset to satisfy audit
or appeal findings, if the findings are against the provider.
Overpayments shall be returned to a provider with interest if
findings are in favor of the provider.
(2) Withhold payment for any goods or services, or any portion
thereof, from any State-Only Family Planning program or Family
Planning Access Care and Treatment Waiver program provider. The
department shall notify the provider within five days of any
withholding of payment under this section. The notice shall do all of
the following:
(A) State that payments are being withheld in accordance with this
paragraph and that the withholding is for a temporary period and
will not continue after it is determined that the evidence of fraud
or willful misrepresentation is insufficient or when legal
proceedings relating to the alleged fraud or willful
misrepresentation are completed.
(B) Cite the circumstances under which the withholding of the
payments will be terminated.
(C) Specify, when appropriate, the type or types of claimed
payments being withheld.
(D) Inform the provider of the right to submit written evidence
that is evidence that would be admissible under the administrative
adjudication provisions of Chapter 5 (commencing with Section 11500)
of Part 1 of Division 3 of Title 2 of the Government Code, for
consideration by the department.
(3) Notwithstanding Section 100171 of the Health and Safety Code,
a provider may appeal a withholding of payment under this section
pursuant to Section 14043.65. Payments withheld under this section
shall not be returned to the provider during the pendency of any
appeal and may be offset to satisfy audit or appeal findings.
(m) As used in this section:
(1) "Abuse" means either of the following:
(A) Practices that are inconsistent with sound fiscal or business
practices and result in unnecessary cost to the medicaid program, the
Medicare program, the Medi-Cal program, including the Family
Planning Access Care and Treatment Waiver program, identified in
subdivision (aa) of Section 14132, another state's medicaid program,
or the State-Only Family Planning program, or other health care
programs operated, or financed in whole or in part, by the federal
government or any state or local agency in this state or any other
state.
(B) Practices that are inconsistent with sound medical practices
and result in reimbursement, by any of the programs referred to in
subparagraph (A) or other health care programs operated, or financed
in whole or in part, by the federal government or any state or local
agency in this state or any other state, for services that are
unnecessary or for substandard items or services that fail to meet
professionally recognized standards for health care.
(2) "Fraud" means an intentional deception or misrepresentation
made by a person with the knowledge that the deception could result
in some unauthorized benefit to himself or herself or some other
person. It includes any act that constitutes fraud under applicable
federal or state law.
(3) "Provider" means any individual, partnership, group,
association, corporation, institution, or entity, and the officers,
directors, owners, managing employees, or agents of any partnership,
group, association, corporation, institution, or entity, that
provides services, goods, supplies, or merchandise, directly or
indirectly, to a beneficiary and that has been enrolled in the
program.
(4) "Convicted" means any of the following:
(A) A judgment of conviction has been entered against an
individual or entity by a federal, state, or local court, regardless
of whether there is a post-trial motion or an appeal pending or the
judgment of conviction or other record relating to the criminal
conduct has been expunged or otherwise removed.
(B) A federal, state, or local court has made a finding of guilt
against an individual or entity.
(C) A federal, state, or local court has accepted a plea of guilty
or nolo contendere by an individual or entity.
(D) An individual or entity has entered into participation in a
first offender, deferred adjudication, or other program or
arrangement where judgment of conviction has been withheld.
(5) "Professionally recognized standards of health care" means
statewide or national standards of care, whether in writing or not,
that professional peers of the individual or entity whose provision
of care is an issue, recognize as applying to those peers practicing
or providing care within a state. When the United States Department
of Health and Human Services has declared a treatment modality not to
be safe and effective, practitioners that employ that treatment
modality shall be deemed not to meet professionally recognized
standards of health care. This definition shall not be construed to
mean that all other treatments meet professionally recognized
standards of care.
(6) "Unnecessary or substandard items or services" means those
that are either of the following:
(A) Substantially in excess of the provider's usual charges or
costs for the items or services.
(B) Furnished, or caused to be furnished, to patients, whether or
not covered by Medicare, medicaid, or any of the state health care
programs to which the definitions of applicant and provider apply,
and which are substantially in excess of the patient's needs, or of a
quality that fails to meet professionally recognized standards of
health care. The department's determination that the items or
services furnished were excessive or of unacceptable quality shall be
made on the basis of information, including sanction reports, from
the following sources:
(i) The professional review organization for the area served by
the individual or entity.
(ii) State or local licensing or certification authorities.
(iii) Fiscal agents or contractors, or private insurance
companies.
(iv) State or local professional societies.
(v) Any other sources deemed appropriate by the department.
(7) "Enrolled or enrollment in the program" means authorized under
any and all processes by the department or its agents or contractors
to receive, directly or indirectly, reimbursement for the provision
of services, goods, supplies, or merchandise to a program
beneficiary.
(n) In lieu of, or in addition to, the imposition of any other
sanctions available, including the imposition of a civil penalty
under Sections 14123.2 or 14171.6, the program may impose on
providers any or all of the penalties pursuant to Section 14123.25,
in accordance with the provisions of that section. In addition,
program providers shall be subject to the penalties contained in
Section 14107.
(o) (1) Notwithstanding any other provision of law, every primary
supplier of pharmaceuticals, medical equipment, or supplies shall
maintain accounting records to demonstrate the manufacture, assembly,
purchase, or acquisition and subsequent sale, of any
pharmaceuticals, medical equipment, or supplies, to providers.
Accounting records shall include, but not be limited to, inventory
records, general ledgers, financial statements, purchase and sales
journals, and invoices, prescription records, bills of lading, and
delivery records.
(2) For purposes of this subdivision, the term "primary supplier"
means any manufacturer, principal labeler, assembler, wholesaler, or
retailer.
(3) Accounting records maintained pursuant to paragraph (1) shall
be subject to audit or examination by the department or its agents.
The audit or examination may include, but is not limited to,
verification of what was claimed by the provider. These accounting
records shall be maintained for three years from the date of sale or
the date of service.
(p) Each provider of health care services rendered to any program
beneficiary shall keep and maintain records of each service rendered,
the beneficiary to whom rendered, the date, and such additional
information as the department may by regulation require. Records
required to be kept and maintained pursuant to this subdivision shall
be retained by the provider for a period of three years from the
date the service was rendered.
(q) A program provider applicant or a program provider shall
furnish information or copies of records and documentation requested
by the department. Failure to comply with the department's request
shall be grounds for denial of the application or automatic
disenrollment of the provider.
(r) A program provider may assign signature authority for
transmission of claims to a billing agent subject to Sections 14040,
14040.1, and 14040.5.
(s) Moneys payable or rights existing under this division shall be
subject to any claim, lien, or offset of the State of California,
and any claim of the United States of America made pursuant to
federal statute, but shall not otherwise be subject to enforcement of
a money judgment or other legal process, and no transfer or
assignment, at law or in equity, of any right of a provider of health
care to any payment shall be enforceable against the state, a fiscal
intermediary, or carrier.
24007. (a) The department shall determine the scope of benefits for
the program, which shall include, but is not limited to, the
following:
(1) Family planning related services and male and female
sterilization. Family planning services for men and women include
emergency and complication services directly related to the
contraceptive method and followup, consultation and referral
services, as indicated, which may require treatment authorization
requests.
(2) All United States Department of Health and Human Services,
Federal Drug Administration-approved birth control methods, devices,
and supplies that are in keeping with current standards of practice
and from which the individual may choose.
(3) Culturally and linguistically appropriate health education and
counseling services, including informed consent; psychosocial and
medical aspects of contraception, sexuality, fertility, pregnancy,
and parenthood; infertility; reproductive health care; preconceptual
and nutrition counseling; prevention and treatment of sexually
transmitted infection; use of contraceptive methods, devices, and
supplies; possible contraceptive consequences and followup;
interpersonal communication and negotiation of relationships to
assist individuals and couples in effective contraceptive method use
and planning families.
(4) A comprehensive health history, updated at 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.
(5) A complete physical examination on initial and subsequent
periodic visits.
(b) Benefits under this program shall be effective in 30 days
after notice to providers, but not sooner than January 1, 1997.
24007.5. The program formulary shall include all federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are authorized by the Medi-Cal program.
24009. Family planning services are confidential. All information
about personal facts and circumstances obtained by the provider shall
be treated as privileged communications, shall be held confidential,
and shall not be divulged without the individual's written consent,
except as required by law or as may be necessary to provide emergency
services to the individual or as required by the department to
administer this program. Information may be disclosed in summary,
statistical, or other form that does not identify particular
individuals.
24011. (a) Providers shall submit claims for reimbursement for
services provided on or after January 1, 1997, or receipt of notice
from the department, whichever is later, and covered by this program,
to the fiscal intermediary of the department for payment. Charges
and individual information shall be submitted on the form or in the
format specified by the department for the state-only family planning
program, and providers shall be reimbursed at the rates established
for those services by the department.
(b) The department shall use existing contractual claims
processing services in order to promote efficiency and to maximize
use of funds.
(c) Claims for state-only family planning services provided
through prescription, including laboratory and pharmaceutical, shall
be reimbursed in a manner determined by the department. Eligible
individuals shall not be charged for any state-only family planning
laboratory or pharmaceutical services.
(d) Claims for method-related complications requiring approved
treatment authorization requests shall be reimbursed regardless of
category of medical service.
24013. (a) Notwithstanding any other provision of law, the
department may adopt any procedures as are necessary for the review
of a grievance or complaint concerning the processing of claims or
payment of moneys alleged by a provider of services to be payable by
reason of any of the provisions of this division.
(b) Any applicant for, or recipient of, services under the
state-only family planning program shall have a right to a hearing
conducted by the department regarding the person's eligibility or
receipt of services. A proposed decision from the administrative law
judge shall be submitted to the State Director of Health Services for
adoption, modification, or rehearing. The decision of the director
shall be final. A person shall not have a right to contest changes
made to the eligibility standards or benefits of the state-only
family planning program.
24015. The department may adopt emergency regulations as necessary
to implement and administer this chapter in accordance with Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code. The initial adoption of any emergency
regulations following January 1, 1997, shall be deemed to be an
emergency and necessary for immediate preservation of the public
peace, health and safety, or general welfare. Emergency regulations
adopted pursuant to this act shall remain in effect no more than 180
days.
24017. The program shall be exempt from the requirements of Chapter
7 (commencing with Section 11700) of Part 1 of Division 3 of Title 2
of the Government Code and Chapter 3 (commencing with Section 12100)
of Division 2 of Part 2 of the Public Contract Code as those
requirements apply to the use of contractual claims processing
services by the department.
24021. The department shall conduct an evaluation of the
effectiveness and efficiency of the program, including expanded
access and reduction of unintended pregnancies, and shall report to
the Legislature by no later than January 1, 2000. The department may
use local assistance funds allocated to the State-Only Family
Planning Program for the evaluation of the program.
24023. It is the intent of the Legislature that the State
Department of Health Services shall, effective March 1, 1997, conduct
no other general statewide program for the provision of
comprehensive clinical family planning services as referenced in
Chapter 8.5 (commencing with Section 14500) of Part 3 of Division 9,
while the State-Only Family Planning Program authorized by this
division is in effect. For the purpose of avoiding a disruption of
services, to the extent the implementation of the State-Only Family
Planning Program does not occur on or before March 1, 1997, the
Director of Health Services may extend the general statewide program
for the provision of comprehensive clinical family planning services
as referenced in Chapter 8.5 (commencing with Section 14500) of Part
3 of Division 9. This extension shall be made only upon notification
to the Chairperson of the Joint Legislative Budget Committee and the
chairperson of the committee in each house that considers
appropriations and under no condition shall extend beyond 120 days.
24027. The State-Only Family Planning Program established under
this division is hereby reenacted and continued in existence in order
to continue to provide comprehensive, clinical family planning
services to those persons who are not eligible to receive these
services under the Family Planning, Access, Care, and Treatment
(Family PACT) Waiver Program established pursuant to subdivision (aa)
of Section 14132, and to those persons who are not eligible to
receive family planning services pursuant to subdivision (n) of
Section 14132 without a share of cost.
24000. There is established in the State Department of Health
Services the State-Only Family Planning Program to provide
comprehensive clinical family planning services to low-income men and
women. This division shall be known and may be cited as the
State-Only Family Planning Program.
24001. (a) (1) For purposes of this division, "family planning"
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, natural family planning,
abstinence methods and basic, limited fertility management. 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. Family planning shall not
include abortion, pregnancy testing solely for the purposes of
referral for abortion or services ancillary to abortions, not
including contraceptives, or pregnancy care that is not incident to
the diagnosis of pregnancy.
(2) Family planning services for males shall be expanded to
include laboratory tests for sexually transmitted infections and
comprehensive physical examinations. Within 60 days of approval of
the Family Planning, Access, Care, and Treatment (Family PACT) Waiver
Program, provided for pursuant to subdivision (aa) of Section 14132,
the department shall seek to amend the waiver to add this expansion.
The implementation of this paragraph shall be dependent upon federal
approval and receipt of federal financial participation.
(b) For purposes of this division, "department" means the State
Department of Health Services.
24003. (a) A person shall be eligible to receive services pursuant
to this chapter provided that the following conditions are met:
(1) The person is a resident of California.
(2) The person has a family income at or below 200 percent of the
federal poverty level.
(3) The person has no other source of health care coverage unless
the use of that health care coverage would create a barrier to access
because of confidentiality.
(4) The person is not otherwise eligible for existing Medi-Cal
services without a share of cost.
(b) Notwithstanding any other provision of law, the provision of
family planning services shall not require the consent of anyone
other than the person who is to receive the services.
(c) Eligibility shall be determined at point of service by the
provider. The provider shall obtain information on the individual's
family size, income, and health care coverage and then, based on that
information, determine if the individual meets the eligibility
criteria specified in subdivision (a). All individuals who meet the
eligibility requirements shall be certified by the provider as
eligible for services under the program. A Medi-Cal share of cost
shall not be used to deny access to family planning services under
the program. The department may require the collection on a voluntary
basis or the use of the individual's social security number, or
both. No services shall be denied to a client if a social security
number is not provided.
(d) Eligibility shall be based on the individual's
self-declaration of gross annual or monthly income, family size, and
other source of health care coverage, signed under penalty of perjury
at each annual eligibility certification. No asset information shall
be used to determine eligibility.
(e) The department may establish a copayment system for services
provided pursuant to this chapter that is based upon the income level
of the individual and the cost of the service provided. No
individual whose documented family income is at or below 100 percent
of the federal poverty level shall be subject to copayment. The
copayment fee shall not be used to deny access to family planning
services. State reimbursement to the provider shall be offset by that
amount of the copayment collected from the eligible individual. The
department shall notify providers on an annual basis of the copayment
fee schedule.
24003.2. The basic preventive health services covered under this
program shall include measles, mumps, and rubella vaccines for women
of reproductive age. Within 60 days of approval of the Family
Planning, Access, Care, and Treatment (Family PACT) Waiver Program,
provided for pursuant to subdivision (aa) of Section 14132, the
department shall seek to amend the waiver to add this expansion. The
implementation of this section shall be dependent upon federal
approval and receipt of federal financial participation.
24003.5. Any male or female of reproductive age who is not at risk
for pregnancy and is eligible for the program shall have available
the scope of benefits provided by the program. Within 60 days of
approval of the Family Planning, Access, Care, and Treatment (Family
PACT) Waiver Program, provided for pursuant to subdivision (aa) of
Section 14132, the department shall seek to amend the waiver to add
this expansion. The implementation of this section shall be dependent
upon federal approval and receipt of federal financial
participation.
24005. (a) This section shall apply to the Family Planning Access
Care and Treatment Waiver program identified in subdivision (aa) of
Section 14132 and this program.
(b) Only licensed medical personnel with family planning skills,
knowledge, and competency may provide the full range of family
planning medical services covered in this program.
(c) Medi-Cal enrolled providers, as determined by the department,
shall be eligible to provide family planning services under the
program when these services are within their scope of practice and
licensure. Those clinical providers electing to participate in the
program and approved by the department shall provide the full scope
of family planning education, counseling, and medical services
specified for the program, either directly or by referral, consistent
with standards of care issued by the department.
(d) The department shall require providers to enter into clinical
agreements with the department to ensure compliance with standards
and requirements to maintain the fiscal integrity of the program.
Provider applicants, providers, and persons with an ownership or
control interest, as defined in federal medicaid regulations, shall
be required to submit to the department their social security numbers
to the full extent allowed under federal law. All state and federal
statutes and regulations pertaining to the audit or examination of
Medi-Cal providers shall apply to this program.
(e) Clinical provider agreements shall be signed by the provider
under penalty of perjury. The department may screen applicants at the
initial application and at any reapplication pursuant to
requirements developed by the department to determine provider
suitability for the program.
(f) The department may complete a background check on clinical
provider applicants for the purpose of verifying the accuracy of
information provided to the department for purposes of enrolling in
the program and in order to prevent fraud and abuse. The background
check may include, but not be limited to, unannounced onsite
inspection prior to enrollment, review of business records, and data
searches. If discrepancies are found to exist during the
preenrollment period, the department may conduct additional
inspections prior to enrollment. Failure to remediate significant
discrepancies as prescribed by the director may result in denial of
the application for enrollment. Providers that do not provide
services consistent with the standards of care or that do not comply
with the department's rules related to the fiscal integrity of the
program may be disenrolled as a provider from the program at the sole
discretion of the department.
(g) The department shall not enroll any applicant who, within the
previous 10 years:
(1) Has been convicted of any felony or misdemeanor that involves
fraud or abuse in any government program, that relates to neglect or
abuse of a patient in connection with the delivery of a health care
item or service, or that is in connection with the interference with,
or obstruction of, any investigation into health care related fraud
or abuse.
(2) Has been found liable for fraud or abuse in any civil
proceeding, or that has entered into a settlement in lieu of
conviction for fraud or abuse in any government program.
(h) In addition, the department may deny enrollment to any
applicant that, at the time of application, is under investigation by
the department or any local, state, or federal government law
enforcement agency for fraud or abuse. The department shall not deny
enrollment to an otherwise qualified applicant whose felony or
misdemeanor charges did not result in a conviction solely on the
basis of the prior charges. If it is discovered that a provider is
under investigation by the department or any local, state, or federal
government law enforcement agency for fraud or abuse, that provider
shall be subject to immediate disenrollment from the program.
(i) (1) The program shall disenroll as a program provider any
individual who, or any entity that, has a license, certificate, or
other approval to provide health care, which is revoked or suspended
by a federal, California, or other state's licensing, certification,
or other approval authority, has otherwise lost that license,
certificate, or approval, or has surrendered that license,
certificate, or approval while a disciplinary hearing on the license,
certificate, or approval was pending. The disenrollment shall be
effective on the date the license, certificate, or approval is
revoked, lost, or surrendered.
(2) A provider shall be subject to disenrollment if the provider
submits claims for payment for the services, goods, supplies, or
merchandise provided, directly or indirectly, to a program
beneficiary, by an individual or entity that has been previously
suspended, excluded, or otherwise made ineligible to receive,
directly or indirectly, reimbursement from the program or from the
Medi-Cal program and the individual has previously been listed on
either the Suspended and Ineligible Provider List, which is published
by the department, to identify suspended and otherwise ineligible
providers or any list published by the federal Office of the
Inspector General regarding the suspension or exclusion of
individuals or entities from the federal Medicare and medicaid
programs, to identify suspended, excluded, or otherwise ineligible
providers.
(3) The department shall deactivate, immediately and without prior
notice, the provider numbers used by a provider to obtain
reimbursement from the program when warrants or documents mailed to a
provider's mailing address, its pay to address, or its service
address, if any, are returned by the United States Postal Service as
not deliverable or when a provider has not submitted a claim for
reimbursement from the program for one year. Prior to taking this
action, the department shall use due diligence in attempting to
contact the provider at its last known telephone number and to
ascertain if the return by the United States Postal Service is by
mistake and shall use due diligence in attempting to contact the
provider by telephone or in writing to ascertain whether the provider
wishes to continue to participate in the Medi-Cal program. If
deactivation pursuant to this section occurs, the provider shall meet
the requirements for reapplication as specified in regulation.
(4) For purposes of this subdivision:
(A) "Mailing address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which it wishes to receive general program
correspondence.
(B) "Pay to address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which it wishes to receive warrants.
(C) "Service address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which the provider will provide services to program
beneficiaries.
(j) Subject to Article 4 (commencing with Section 19130) of
Chapter 5 of Division 5 of Title 2 of the Government Code, the
department may enter into contracts to secure consultant services or
information technology including, but not limited to, software, data,
or analytical techniques or methodologies for the purpose of fraud
or abuse detection and prevention. Contracts under this section shall
be exempt from the Public Contract Code.
(k) Enrolled providers shall attend specific orientation approved
by the department in comprehensive family planning services. Enrolled
providers who insert IUDs or contraceptive implants shall have
received prior clinical training specific to these procedures.
(l) Upon receipt of reliable evidence that would be admissible
under the administrative adjudication provisions of Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code, of fraud or willful misrepresentation by a
provider under the program or commencement of a suspension under
Section 14123, the department may do any of the following:
(1) Collect any State-Only Family Planning program or Family
Planning Access Care and Treatment Waiver program overpayment
identified through an audit or examination, or any portion thereof
from any provider. Notwithstanding Section 100171 of the Health and
Safety Code, a provider may appeal the collection of overpayments
under this section pursuant to procedures established in Article 5.3
(commencing with Section 14170) of Part 3 of Division 9. Overpayments
collected under this section shall not be returned to the provider
during the pendency of any appeal and may be offset to satisfy audit
or appeal findings, if the findings are against the provider.
Overpayments shall be returned to a provider with interest if
findings are in favor of the provider.
(2) Withhold payment for any goods or services, or any portion
thereof, from any State-Only Family Planning program or Family
Planning Access Care and Treatment Waiver program provider. The
department shall notify the provider within five days of any
withholding of payment under this section. The notice shall do all of
the following:
(A) State that payments are being withheld in accordance with this
paragraph and that the withholding is for a temporary period and
will not continue after it is determined that the evidence of fraud
or willful misrepresentation is insufficient or when legal
proceedings relating to the alleged fraud or willful
misrepresentation are completed.
(B) Cite the circumstances under which the withholding of the
payments will be terminated.
(C) Specify, when appropriate, the type or types of claimed
payments being withheld.
(D) Inform the provider of the right to submit written evidence
that is evidence that would be admissible under the administrative
adjudication provisions of Chapter 5 (commencing with Section 11500)
of Part 1 of Division 3 of Title 2 of the Government Code, for
consideration by the department.
(3) Notwithstanding Section 100171 of the Health and Safety Code,
a provider may appeal a withholding of payment under this section
pursuant to Section 14043.65. Payments withheld under this section
shall not be returned to the provider during the pendency of any
appeal and may be offset to satisfy audit or appeal findings.
(m) As used in this section:
(1) "Abuse" means either of the following:
(A) Practices that are inconsistent with sound fiscal or business
practices and result in unnecessary cost to the medicaid program, the
Medicare program, the Medi-Cal program, including the Family
Planning Access Care and Treatment Waiver program, identified in
subdivision (aa) of Section 14132, another state's medicaid program,
or the State-Only Family Planning program, or other health care
programs operated, or financed in whole or in part, by the federal
government or any state or local agency in this state or any other
state.
(B) Practices that are inconsistent with sound medical practices
and result in reimbursement, by any of the programs referred to in
subparagraph (A) or other health care programs operated, or financed
in whole or in part, by the federal government or any state or local
agency in this state or any other state, for services that are
unnecessary or for substandard items or services that fail to meet
professionally recognized standards for health care.
(2) "Fraud" means an intentional deception or misrepresentation
made by a person with the knowledge that the deception could result
in some unauthorized benefit to himself or herself or some other
person. It includes any act that constitutes fraud under applicable
federal or state law.
(3) "Provider" means any individual, partnership, group,
association, corporation, institution, or entity, and the officers,
directors, owners, managing employees, or agents of any partnership,
group, association, corporation, institution, or entity, that
provides services, goods, supplies, or merchandise, directly or
indirectly, to a beneficiary and that has been enrolled in the
program.
(4) "Convicted" means any of the following:
(A) A judgment of conviction has been entered against an
individual or entity by a federal, state, or local court, regardless
of whether there is a post-trial motion or an appeal pending or the
judgment of conviction or other record relating to the criminal
conduct has been expunged or otherwise removed.
(B) A federal, state, or local court has made a finding of guilt
against an individual or entity.
(C) A federal, state, or local court has accepted a plea of guilty
or nolo contendere by an individual or entity.
(D) An individual or entity has entered into participation in a
first offender, deferred adjudication, or other program or
arrangement where judgment of conviction has been withheld.
(5) "Professionally recognized standards of health care" means
statewide or national standards of care, whether in writing or not,
that professional peers of the individual or entity whose provision
of care is an issue, recognize as applying to those peers practicing
or providing care within a state. When the United States Department
of Health and Human Services has declared a treatment modality not to
be safe and effective, practitioners that employ that treatment
modality shall be deemed not to meet professionally recognized
standards of health care. This definition shall not be construed to
mean that all other treatments meet professionally recognized
standards of care.
(6) "Unnecessary or substandard items or services" means those
that are either of the following:
(A) Substantially in excess of the provider's usual charges or
costs for the items or services.
(B) Furnished, or caused to be furnished, to patients, whether or
not covered by Medicare, medicaid, or any of the state health care
programs to which the definitions of applicant and provider apply,
and which are substantially in excess of the patient's needs, or of a
quality that fails to meet professionally recognized standards of
health care. The department's determination that the items or
services furnished were excessive or of unacceptable quality shall be
made on the basis of information, including sanction reports, from
the following sources:
(i) The professional review organization for the area served by
the individual or entity.
(ii) State or local licensing or certification authorities.
(iii) Fiscal agents or contractors, or private insurance
companies.
(iv) State or local professional societies.
(v) Any other sources deemed appropriate by the department.
(7) "Enrolled or enrollment in the program" means authorized under
any and all processes by the department or its agents or contractors
to receive, directly or indirectly, reimbursement for the provision
of services, goods, supplies, or merchandise to a program
beneficiary.
(n) In lieu of, or in addition to, the imposition of any other
sanctions available, including the imposition of a civil penalty
under Sections 14123.2 or 14171.6, the program may impose on
providers any or all of the penalties pursuant to Section 14123.25,
in accordance with the provisions of that section. In addition,
program providers shall be subject to the penalties contained in
Section 14107.
(o) (1) Notwithstanding any other provision of law, every primary
supplier of pharmaceuticals, medical equipment, or supplies shall
maintain accounting records to demonstrate the manufacture, assembly,
purchase, or acquisition and subsequent sale, of any
pharmaceuticals, medical equipment, or supplies, to providers.
Accounting records shall include, but not be limited to, inventory
records, general ledgers, financial statements, purchase and sales
journals, and invoices, prescription records, bills of lading, and
delivery records.
(2) For purposes of this subdivision, the term "primary supplier"
means any manufacturer, principal labeler, assembler, wholesaler, or
retailer.
(3) Accounting records maintained pursuant to paragraph (1) shall
be subject to audit or examination by the department or its agents.
The audit or examination may include, but is not limited to,
verification of what was claimed by the provider. These accounting
records shall be maintained for three years from the date of sale or
the date of service.
(p) Each provider of health care services rendered to any program
beneficiary shall keep and maintain records of each service rendered,
the beneficiary to whom rendered, the date, and such additional
information as the department may by regulation require. Records
required to be kept and maintained pursuant to this subdivision shall
be retained by the provider for a period of three years from the
date the service was rendered.
(q) A program provider applicant or a program provider shall
furnish information or copies of records and documentation requested
by the department. Failure to comply with the department's request
shall be grounds for denial of the application or automatic
disenrollment of the provider.
(r) A program provider may assign signature authority for
transmission of claims to a billing agent subject to Sections 14040,
14040.1, and 14040.5.
(s) Moneys payable or rights existing under this division shall be
subject to any claim, lien, or offset of the State of California,
and any claim of the United States of America made pursuant to
federal statute, but shall not otherwise be subject to enforcement of
a money judgment or other legal process, and no transfer or
assignment, at law or in equity, of any right of a provider of health
care to any payment shall be enforceable against the state, a fiscal
intermediary, or carrier.
24007. (a) The department shall determine the scope of benefits for
the program, which shall include, but is not limited to, the
following:
(1) Family planning related services and male and female
sterilization. Family planning services for men and women include
emergency and complication services directly related to the
contraceptive method and followup, consultation and referral
services, as indicated, which may require treatment authorization
requests.
(2) All United States Department of Health and Human Services,
Federal Drug Administration-approved birth control methods, devices,
and supplies that are in keeping with current standards of practice
and from which the individual may choose.
(3) Culturally and linguistically appropriate health education and
counseling services, including informed consent; psychosocial and
medical aspects of contraception, sexuality, fertility, pregnancy,
and parenthood; infertility; reproductive health care; preconceptual
and nutrition counseling; prevention and treatment of sexually
transmitted infection; use of contraceptive methods, devices, and
supplies; possible contraceptive consequences and followup;
interpersonal communication and negotiation of relationships to
assist individuals and couples in effective contraceptive method use
and planning families.
(4) A comprehensive health history, updated at 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.
(5) A complete physical examination on initial and subsequent
periodic visits.
(b) Benefits under this program shall be effective in 30 days
after notice to providers, but not sooner than January 1, 1997.
24007.5. The program formulary shall include all federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are authorized by the Medi-Cal program.
24009. Family planning services are confidential. All information
about personal facts and circumstances obtained by the provider shall
be treated as privileged communications, shall be held confidential,
and shall not be divulged without the individual's written consent,
except as required by law or as may be necessary to provide emergency
services to the individual or as required by the department to
administer this program. Information may be disclosed in summary,
statistical, or other form that does not identify particular
individuals.
24011. (a) Providers shall submit claims for reimbursement for
services provided on or after January 1, 1997, or receipt of notice
from the department, whichever is later, and covered by this program,
to the fiscal intermediary of the department for payment. Charges
and individual information shall be submitted on the form or in the
format specified by the department for the state-only family planning
program, and providers shall be reimbursed at the rates established
for those services by the department.
(b) The department shall use existing contractual claims
processing services in order to promote efficiency and to maximize
use of funds.
(c) Claims for state-only family planning services provided
through prescription, including laboratory and pharmaceutical, shall
be reimbursed in a manner determined by the department. Eligible
individuals shall not be charged for any state-only family planning
laboratory or pharmaceutical services.
(d) Claims for method-related complications requiring approved
treatment authorization requests shall be reimbursed regardless of
category of medical service.
24013. (a) Notwithstanding any other provision of law, the
department may adopt any procedures as are necessary for the review
of a grievance or complaint concerning the processing of claims or
payment of moneys alleged by a provider of services to be payable by
reason of any of the provisions of this division.
(b) Any applicant for, or recipient of, services under the
state-only family planning program shall have a right to a hearing
conducted by the department regarding the person's eligibility or
receipt of services. A proposed decision from the administrative law
judge shall be submitted to the State Director of Health Services for
adoption, modification, or rehearing. The decision of the director
shall be final. A person shall not have a right to contest changes
made to the eligibility standards or benefits of the state-only
family planning program.
24015. The department may adopt emergency regulations as necessary
to implement and administer this chapter in accordance with Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code. The initial adoption of any emergency
regulations following January 1, 1997, shall be deemed to be an
emergency and necessary for immediate preservation of the public
peace, health and safety, or general welfare. Emergency regulations
adopted pursuant to this act shall remain in effect no more than 180
days.
24017. The program shall be exempt from the requirements of Chapter
7 (commencing with Section 11700) of Part 1 of Division 3 of Title 2
of the Government Code and Chapter 3 (commencing with Section 12100)
of Division 2 of Part 2 of the Public Contract Code as those
requirements apply to the use of contractual claims processing
services by the department.
24021. The department shall conduct an evaluation of the
effectiveness and efficiency of the program, including expanded
access and reduction of unintended pregnancies, and shall report to
the Legislature by no later than January 1, 2000. The department may
use local assistance funds allocated to the State-Only Family
Planning Program for the evaluation of the program.
24023. It is the intent of the Legislature that the State
Department of Health Services shall, effective March 1, 1997, conduct
no other general statewide program for the provision of
comprehensive clinical family planning services as referenced in
Chapter 8.5 (commencing with Section 14500) of Part 3 of Division 9,
while the State-Only Family Planning Program authorized by this
division is in effect. For the purpose of avoiding a disruption of
services, to the extent the implementation of the State-Only Family
Planning Program does not occur on or before March 1, 1997, the
Director of Health Services may extend the general statewide program
for the provision of comprehensive clinical family planning services
as referenced in Chapter 8.5 (commencing with Section 14500) of Part
3 of Division 9. This extension shall be made only upon notification
to the Chairperson of the Joint Legislative Budget Committee and the
chairperson of the committee in each house that considers
appropriations and under no condition shall extend beyond 120 days.
24027. The State-Only Family Planning Program established under
this division is hereby reenacted and continued in existence in order
to continue to provide comprehensive, clinical family planning
services to those persons who are not eligible to receive these
services under the Family Planning, Access, Care, and Treatment
(Family PACT) Waiver Program established pursuant to subdivision (aa)
of Section 14132, and to those persons who are not eligible to
receive family planning services pursuant to subdivision (n) of
Section 14132 without a share of cost.
24000. There is established in the State Department of Health
Services the State-Only Family Planning Program to provide
comprehensive clinical family planning services to low-income men and
women. This division shall be known and may be cited as the
State-Only Family Planning Program.
24001. (a) (1) For purposes of this division, "family planning"
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, natural family planning,
abstinence methods and basic, limited fertility management. 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. Family planning shall not
include abortion, pregnancy testing solely for the purposes of
referral for abortion or services ancillary to abortions, not
including contraceptives, or pregnancy care that is not incident to
the diagnosis of pregnancy.
(2) Family planning services for males shall be expanded to
include laboratory tests for sexually transmitted infections and
comprehensive physical examinations. Within 60 days of approval of
the Family Planning, Access, Care, and Treatment (Family PACT) Waiver
Program, provided for pursuant to subdivision (aa) of Section 14132,
the department shall seek to amend the waiver to add this expansion.
The implementation of this paragraph shall be dependent upon federal
approval and receipt of federal financial participation.
(b) For purposes of this division, "department" means the State
Department of Health Services.
24003. (a) A person shall be eligible to receive services pursuant
to this chapter provided that the following conditions are met:
(1) The person is a resident of California.
(2) The person has a family income at or below 200 percent of the
federal poverty level.
(3) The person has no other source of health care coverage unless
the use of that health care coverage would create a barrier to access
because of confidentiality.
(4) The person is not otherwise eligible for existing Medi-Cal
services without a share of cost.
(b) Notwithstanding any other provision of law, the provision of
family planning services shall not require the consent of anyone
other than the person who is to receive the services.
(c) Eligibility shall be determined at point of service by the
provider. The provider shall obtain information on the individual's
family size, income, and health care coverage and then, based on that
information, determine if the individual meets the eligibility
criteria specified in subdivision (a). All individuals who meet the
eligibility requirements shall be certified by the provider as
eligible for services under the program. A Medi-Cal share of cost
shall not be used to deny access to family planning services under
the program. The department may require the collection on a voluntary
basis or the use of the individual's social security number, or
both. No services shall be denied to a client if a social security
number is not provided.
(d) Eligibility shall be based on the individual's
self-declaration of gross annual or monthly income, family size, and
other source of health care coverage, signed under penalty of perjury
at each annual eligibility certification. No asset information shall
be used to determine eligibility.
(e) The department may establish a copayment system for services
provided pursuant to this chapter that is based upon the income level
of the individual and the cost of the service provided. No
individual whose documented family income is at or below 100 percent
of the federal poverty level shall be subject to copayment. The
copayment fee shall not be used to deny access to family planning
services. State reimbursement to the provider shall be offset by that
amount of the copayment collected from the eligible individual. The
department shall notify providers on an annual basis of the copayment
fee schedule.
24003.2. The basic preventive health services covered under this
program shall include measles, mumps, and rubella vaccines for women
of reproductive age. Within 60 days of approval of the Family
Planning, Access, Care, and Treatment (Family PACT) Waiver Program,
provided for pursuant to subdivision (aa) of Section 14132, the
department shall seek to amend the waiver to add this expansion. The
implementation of this section shall be dependent upon federal
approval and receipt of federal financial participation.
24003.5. Any male or female of reproductive age who is not at risk
for pregnancy and is eligible for the program shall have available
the scope of benefits provided by the program. Within 60 days of
approval of the Family Planning, Access, Care, and Treatment (Family
PACT) Waiver Program, provided for pursuant to subdivision (aa) of
Section 14132, the department shall seek to amend the waiver to add
this expansion. The implementation of this section shall be dependent
upon federal approval and receipt of federal financial
participation.
24005. (a) This section shall apply to the Family Planning Access
Care and Treatment Waiver program identified in subdivision (aa) of
Section 14132 and this program.
(b) Only licensed medical personnel with family planning skills,
knowledge, and competency may provide the full range of family
planning medical services covered in this program.
(c) Medi-Cal enrolled providers, as determined by the department,
shall be eligible to provide family planning services under the
program when these services are within their scope of practice and
licensure. Those clinical providers electing to participate in the
program and approved by the department shall provide the full scope
of family planning education, counseling, and medical services
specified for the program, either directly or by referral, consistent
with standards of care issued by the department.
(d) The department shall require providers to enter into clinical
agreements with the department to ensure compliance with standards
and requirements to maintain the fiscal integrity of the program.
Provider applicants, providers, and persons with an ownership or
control interest, as defined in federal medicaid regulations, shall
be required to submit to the department their social security numbers
to the full extent allowed under federal law. All state and federal
statutes and regulations pertaining to the audit or examination of
Medi-Cal providers shall apply to this program.
(e) Clinical provider agreements shall be signed by the provider
under penalty of perjury. The department may screen applicants at the
initial application and at any reapplication pursuant to
requirements developed by the department to determine provider
suitability for the program.
(f) The department may complete a background check on clinical
provider applicants for the purpose of verifying the accuracy of
information provided to the department for purposes of enrolling in
the program and in order to prevent fraud and abuse. The background
check may include, but not be limited to, unannounced onsite
inspection prior to enrollment, review of business records, and data
searches. If discrepancies are found to exist during the
preenrollment period, the department may conduct additional
inspections prior to enrollment. Failure to remediate significant
discrepancies as prescribed by the director may result in denial of
the application for enrollment. Providers that do not provide
services consistent with the standards of care or that do not comply
with the department's rules related to the fiscal integrity of the
program may be disenrolled as a provider from the program at the sole
discretion of the department.
(g) The department shall not enroll any applicant who, within the
previous 10 years:
(1) Has been convicted of any felony or misdemeanor that involves
fraud or abuse in any government program, that relates to neglect or
abuse of a patient in connection with the delivery of a health care
item or service, or that is in connection with the interference with,
or obstruction of, any investigation into health care related fraud
or abuse.
(2) Has been found liable for fraud or abuse in any civil
proceeding, or that has entered into a settlement in lieu of
conviction for fraud or abuse in any government program.
(h) In addition, the department may deny enrollment to any
applicant that, at the time of application, is under investigation by
the department or any local, state, or federal government law
enforcement agency for fraud or abuse. The department shall not deny
enrollment to an otherwise qualified applicant whose felony or
misdemeanor charges did not result in a conviction solely on the
basis of the prior charges. If it is discovered that a provider is
under investigation by the department or any local, state, or federal
government law enforcement agency for fraud or abuse, that provider
shall be subject to immediate disenrollment from the program.
(i) (1) The program shall disenroll as a program provider any
individual who, or any entity that, has a license, certificate, or
other approval to provide health care, which is revoked or suspended
by a federal, California, or other state's licensing, certification,
or other approval authority, has otherwise lost that license,
certificate, or approval, or has surrendered that license,
certificate, or approval while a disciplinary hearing on the license,
certificate, or approval was pending. The disenrollment shall be
effective on the date the license, certificate, or approval is
revoked, lost, or surrendered.
(2) A provider shall be subject to disenrollment if the provider
submits claims for payment for the services, goods, supplies, or
merchandise provided, directly or indirectly, to a program
beneficiary, by an individual or entity that has been previously
suspended, excluded, or otherwise made ineligible to receive,
directly or indirectly, reimbursement from the program or from the
Medi-Cal program and the individual has previously been listed on
either the Suspended and Ineligible Provider List, which is published
by the department, to identify suspended and otherwise ineligible
providers or any list published by the federal Office of the
Inspector General regarding the suspension or exclusion of
individuals or entities from the federal Medicare and medicaid
programs, to identify suspended, excluded, or otherwise ineligible
providers.
(3) The department shall deactivate, immediately and without prior
notice, the provider numbers used by a provider to obtain
reimbursement from the program when warrants or documents mailed to a
provider's mailing address, its pay to address, or its service
address, if any, are returned by the United States Postal Service as
not deliverable or when a provider has not submitted a claim for
reimbursement from the program for one year. Prior to taking this
action, the department shall use due diligence in attempting to
contact the provider at its last known telephone number and to
ascertain if the return by the United States Postal Service is by
mistake and shall use due diligence in attempting to contact the
provider by telephone or in writing to ascertain whether the provider
wishes to continue to participate in the Medi-Cal program. If
deactivation pursuant to this section occurs, the provider shall meet
the requirements for reapplication as specified in regulation.
(4) For purposes of this subdivision:
(A) "Mailing address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which it wishes to receive general program
correspondence.
(B) "Pay to address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which it wishes to receive warrants.
(C) "Service address" means the address that the provider has
identified to the department in its application for enrollment as the
address at which the provider will provide services to program
beneficiaries.
(j) Subject to Article 4 (commencing with Section 19130) of
Chapter 5 of Division 5 of Title 2 of the Government Code, the
department may enter into contracts to secure consultant services or
information technology including, but not limited to, software, data,
or analytical techniques or methodologies for the purpose of fraud
or abuse detection and prevention. Contracts under this section shall
be exempt from the Public Contract Code.
(k) Enrolled providers shall attend specific orientation approved
by the department in comprehensive family planning services. Enrolled
providers who insert IUDs or contraceptive implants shall have
received prior clinical training specific to these procedures.
(l) Upon receipt of reliable evidence that would be admissible
under the administrative adjudication provisions of Chapter 5
(commencing with Section 11500) of Part 1 of Division 3 of Title 2 of
the Government Code, of fraud or willful misrepresentation by a
provider under the program or commencement of a suspension under
Section 14123, the department may do any of the following:
(1) Collect any State-Only Family Planning program or Family
Planning Access Care and Treatment Waiver program overpayment
identified through an audit or examination, or any portion thereof
from any provider. Notwithstanding Section 100171 of the Health and
Safety Code, a provider may appeal the collection of overpayments
under this section pursuant to procedures established in Article 5.3
(commencing with Section 14170) of Part 3 of Division 9. Overpayments
collected under this section shall not be returned to the provider
during the pendency of any appeal and may be offset to satisfy audit
or appeal findings, if the findings are against the provider.
Overpayments shall be returned to a provider with interest if
findings are in favor of the provider.
(2) Withhold payment for any goods or services, or any portion
thereof, from any State-Only Family Planning program or Family
Planning Access Care and Treatment Waiver program provider. The
department shall notify the provider within five days of any
withholding of payment under this section. The notice shall do all of
the following:
(A) State that payments are being withheld in accordance with this
paragraph and that the withholding is for a temporary period and
will not continue after it is determined that the evidence of fraud
or willful misrepresentation is insufficient or when legal
proceedings relating to the alleged fraud or willful
misrepresentation are completed.
(B) Cite the circumstances under which the withholding of the
payments will be terminated.
(C) Specify, when appropriate, the type or types of claimed
payments being withheld.
(D) Inform the provider of the right to submit written evidence
that is evidence that would be admissible under the administrative
adjudication provisions of Chapter 5 (commencing with Section 11500)
of Part 1 of Division 3 of Title 2 of the Government Code, for
consideration by the department.
(3) Notwithstanding Section 100171 of the Health and Safety Code,
a provider may appeal a withholding of payment under this section
pursuant to Section 14043.65. Payments withheld under this section
shall not be returned to the provider during the pendency of any
appeal and may be offset to satisfy audit or appeal findings.
(m) As used in this section:
(1) "Abuse" means either of the following:
(A) Practices that are inconsistent with sound fiscal or business
practices and result in unnecessary cost to the medicaid program, the
Medicare program, the Medi-Cal program, including the Family
Planning Access Care and Treatment Waiver program, identified in
subdivision (aa) of Section 14132, another state's medicaid program,
or the State-Only Family Planning program, or other health care
programs operated, or financed in whole or in part, by the federal
government or any state or local agency in this state or any other
state.
(B) Practices that are inconsistent with sound medical practices
and result in reimbursement, by any of the programs referred to in
subparagraph (A) or other health care programs operated, or financed
in whole or in part, by the federal government or any state or local
agency in this state or any other state, for services that are
unnecessary or for substandard items or services that fail to meet
professionally recognized standards for health care.
(2) "Fraud" means an intentional deception or misrepresentation
made by a person with the knowledge that the deception could result
in some unauthorized benefit to himself or herself or some other
person. It includes any act that constitutes fraud under applicable
federal or state law.
(3) "Provider" means any individual, partnership, group,
association, corporation, institution, or entity, and the officers,
directors, owners, managing employees, or agents of any partnership,
group, association, corporation, institution, or entity, that
provides services, goods, supplies, or merchandise, directly or
indirectly, to a beneficiary and that has been enrolled in the
program.
(4) "Convicted" means any of the following:
(A) A judgment of conviction has been entered against an
individual or entity by a federal, state, or local court, regardless
of whether there is a post-trial motion or an appeal pending or the
judgment of conviction or other record relating to the criminal
conduct has been expunged or otherwise removed.
(B) A federal, state, or local court has made a finding of guilt
against an individual or entity.
(C) A federal, state, or local court has accepted a plea of guilty
or nolo contendere by an individual or entity.
(D) An individual or entity has entered into participation in a
first offender, deferred adjudication, or other program or
arrangement where judgment of conviction has been withheld.
(5) "Professionally recognized standards of health care" means
statewide or national standards of care, whether in writing or not,
that professional peers of the individual or entity whose provision
of care is an issue, recognize as applying to those peers practicing
or providing care within a state. When the United States Department
of Health and Human Services has declared a treatment modality not to
be safe and effective, practitioners that employ that treatment
modality shall be deemed not to meet professionally recognized
standards of health care. This definition shall not be construed to
mean that all other treatments meet professionally recognized
standards of care.
(6) "Unnecessary or substandard items or services" means those
that are either of the following:
(A) Substantially in excess of the provider's usual charges or
costs for the items or services.
(B) Furnished, or caused to be furnished, to patients, whether or
not covered by Medicare, medicaid, or any of the state health care
programs to which the definitions of applicant and provider apply,
and which are substantially in excess of the patient's needs, or of a
quality that fails to meet professionally recognized standards of
health care. The department's determination that the items or
services furnished were excessive or of unacceptable quality shall be
made on the basis of information, including sanction reports, from
the following sources:
(i) The professional review organization for the area served by
the individual or entity.
(ii) State or local licensing or certification authorities.
(iii) Fiscal agents or contractors, or private insurance
companies.
(iv) State or local professional societies.
(v) Any other sources deemed appropriate by the department.
(7) "Enrolled or enrollment in the program" means authorized under
any and all processes by the department or its agents or contractors
to receive, directly or indirectly, reimbursement for the provision
of services, goods, supplies, or merchandise to a program
beneficiary.
(n) In lieu of, or in addition to, the imposition of any other
sanctions available, including the imposition of a civil penalty
under Sections 14123.2 or 14171.6, the program may impose on
providers any or all of the penalties pursuant to Section 14123.25,
in accordance with the provisions of that section. In addition,
program providers shall be subject to the penalties contained in
Section 14107.
(o) (1) Notwithstanding any other provision of law, every primary
supplier of pharmaceuticals, medical equipment, or supplies shall
maintain accounting records to demonstrate the manufacture, assembly,
purchase, or acquisition and subsequent sale, of any
pharmaceuticals, medical equipment, or supplies, to providers.
Accounting records shall include, but not be limited to, inventory
records, general ledgers, financial statements, purchase and sales
journals, and invoices, prescription records, bills of lading, and
delivery records.
(2) For purposes of this subdivision, the term "primary supplier"
means any manufacturer, principal labeler, assembler, wholesaler, or
retailer.
(3) Accounting records maintained pursuant to paragraph (1) shall
be subject to audit or examination by the department or its agents.
The audit or examination may include, but is not limited to,
verification of what was claimed by the provider. These accounting
records shall be maintained for three years from the date of sale or
the date of service.
(p) Each provider of health care services rendered to any program
beneficiary shall keep and maintain records of each service rendered,
the beneficiary to whom rendered, the date, and such additional
information as the department may by regulation require. Records
required to be kept and maintained pursuant to this subdivision shall
be retained by the provider for a period of three years from the
date the service was rendered.
(q) A program provider applicant or a program provider shall
furnish information or copies of records and documentation requested
by the department. Failure to comply with the department's request
shall be grounds for denial of the application or automatic
disenrollment of the provider.
(r) A program provider may assign signature authority for
transmission of claims to a billing agent subject to Sections 14040,
14040.1, and 14040.5.
(s) Moneys payable or rights existing under this division shall be
subject to any claim, lien, or offset of the State of California,
and any claim of the United States of America made pursuant to
federal statute, but shall not otherwise be subject to enforcement of
a money judgment or other legal process, and no transfer or
assignment, at law or in equity, of any right of a provider of health
care to any payment shall be enforceable against the state, a fiscal
intermediary, or carrier.
24007. (a) The department shall determine the scope of benefits for
the program, which shall include, but is not limited to, the
following:
(1) Family planning related services and male and female
sterilization. Family planning services for men and women include
emergency and complication services directly related to the
contraceptive method and followup, consultation and referral
services, as indicated, which may require treatment authorization
requests.
(2) All United States Department of Health and Human Services,
Federal Drug Administration-approved birth control methods, devices,
and supplies that are in keeping with current standards of practice
and from which the individual may choose.
(3) Culturally and linguistically appropriate health education and
counseling services, including informed consent; psychosocial and
medical aspects of contraception, sexuality, fertility, pregnancy,
and parenthood; infertility; reproductive health care; preconceptual
and nutrition counseling; prevention and treatment of sexually
transmitted infection; use of contraceptive methods, devices, and
supplies; possible contraceptive consequences and followup;
interpersonal communication and negotiation of relationships to
assist individuals and couples in effective contraceptive method use
and planning families.
(4) A comprehensive health history, updated at 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.
(5) A complete physical examination on initial and subsequent
periodic visits.
(b) Benefits under this program shall be effective in 30 days
after notice to providers, but not sooner than January 1, 1997.
24007.5. The program formulary shall include all federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are authorized by the Medi-Cal program.
24009. Family planning services are confidential. All information
about personal facts and circumstances obtained by the provider shall
be treated as privileged communications, shall be held confidential,
and shall not be divulged without the individual's written consent,
except as required by law or as may be necessary to provide emergency
services to the individual or as required by the department to
administer this program. Information may be disclosed in summary,
statistical, or other form that does not identify particular
individuals.
24011. (a) Providers shall submit claims for reimbursement for
services provided on or after January 1, 1997, or receipt of notice
from the department, whichever is later, and covered by this program,
to the fiscal intermediary of the department for payment. Charges
and individual information shall be submitted on the form or in the
format specified by the department for the state-only family planning
program, and providers shall be reimbursed at the rates established
for those services by the department.
(b) The department shall use existing contractual claims
processing services in order to promote efficiency and to maximize
use of funds.
(c) Claims for state-only family planning services provided
through prescription, including laboratory and pharmaceutical, shall
be reimbursed in a manner determined by the department. Eligible
individuals shall not be charged for any state-only family planning
laboratory or pharmaceutical services.
(d) Claims for method-related complications requiring approved
treatment authorization requests shall be reimbursed regardless of
category of medical service.
24013. (a) Notwithstanding any other provision of law, the
department may adopt any procedures as are necessary for the review
of a grievance or complaint concerning the processing of claims or
payment of moneys alleged by a provider of services to be payable by
reason of any of the provisions of this division.
(b) Any applicant for, or recipient of, services under the
state-only family planning program shall have a right to a hearing
conducted by the department regarding the person's eligibility or
receipt of services. A proposed decision from the administrative law
judge shall be submitted to the State Director of Health Services for
adoption, modification, or rehearing. The decision of the director
shall be final. A person shall not have a right to contest changes
made to the eligibility standards or benefits of the state-only
family planning program.
24015. The department may adopt emergency regulations as necessary
to implement and administer this chapter in accordance with Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code. The initial adoption of any emergency
regulations following January 1, 1997, shall be deemed to be an
emergency and necessary for immediate preservation of the public
peace, health and safety, or general welfare. Emergency regulations
adopted pursuant to this act shall remain in effect no more than 180
days.
24017. The program shall be exempt from the requirements of Chapter
7 (commencing with Section 11700) of Part 1 of Division 3 of Title 2
of the Government Code and Chapter 3 (commencing with Section 12100)
of Division 2 of Part 2 of the Public Contract Code as those
requirements apply to the use of contractual claims processing
services by the department.
24021. The department shall conduct an evaluation of the
effectiveness and efficiency of the program, including expanded
access and reduction of unintended pregnancies, and shall report to
the Legislature by no later than January 1, 2000. The department may
use local assistance funds allocated to the State-Only Family
Planning Program for the evaluation of the program.
24023. It is the intent of the Legislature that the State
Department of Health Services shall, effective March 1, 1997, conduct
no other general statewide program for the provision of
comprehensive clinical family planning services as referenced in
Chapter 8.5 (commencing with Section 14500) of Part 3 of Division 9,
while the State-Only Family Planning Program authorized by this
division is in effect. For the purpose of avoiding a disruption of
services, to the extent the implementation of the State-Only Family
Planning Program does not occur on or before March 1, 1997, the
Director of Health Services may extend the general statewide program
for the provision of comprehensive clinical family planning services
as referenced in Chapter 8.5 (commencing with Section 14500) of Part
3 of Division 9. This extension shall be made only upon notification
to the Chairperson of the Joint Legislative Budget Committee and the
chairperson of the committee in each house that considers
appropriations and under no condition shall extend beyond 120 days.
24027. The State-Only Family Planning Program established under
this division is hereby reenacted and continued in existence in order
to continue to provide comprehensive, clinical family planning
services to those persons who are not eligible to receive these
services under the Family Planning, Access, Care, and Treatment
(Family PACT) Waiver Program established pursuant to subdivision (aa)
of Section 14132, and to those persons who are not eligible to
receive family planning services pursuant to subdivision (n) of
Section 14132 without a share of cost.
