Title WIC, California Welf. & Inst. Code

(a) The department shall share with the Department of Managed Health Care its findings from medical audits and monthly provider files of a Medi-Cal managed care plan that provides services to Medi-Cal beneficiaries pursuant to Chapter 7 (commencing with Section 14000) or this cha…

(a) For purposes of this section, Medi-Cal managed care plan means any prepaid health plan or Medi-Cal managed care plan contracting with the department to provide services to enrolled Medi-Cal beneficiaries under Chapter 7 (commencing with Section 14000) or this chapter, or Part…

(a) In addition to the reviews required or authorized by Section 14456, the department shall conduct periodic onsite visits or additional visits after a determination by the director of good cause by departmental representatives to include observation of the general operation of …

The prepaid health plan shall establish procedures for continuously reviewing the quality of care, performance of medical personnel, the utilization of services and facilities, and costs. Information derived from such review shall be made available to the department. (Amended by …

(a) The prepaid health plan shall maintain financial records and shall have an annual audit or additional audits after a determination by the director of good cause, performed by an independent certified public accountant. A prepaid health plan operated by a public entity shall h…

(a) As delegated by the federal government, the department has responsibility for monitoring the quality of all Medicaid services provided in the state. A key component of this monitoring function is the performance of annual, independent, external reviews of the quality of servi…

(a) The department shall establish a list of performance measures to ensure dental health plans meet quality criteria required by the department. The list shall specify the benchmarks used by the department to determine whether and the extent to which a dental health plan meets e…

(a) The department shall implement a Management Information System/Decision Support System (MIS/DSS) for the Medi-Cal Program, that shall integrate data from managed care plans to monitor and evaluate the quality of care provided to beneficiaries, including access to services, es…

(a) By no later than March 15, 2013, with annual updates thereafter, the department shall provide the fiscal and appropriate policy committees of the Legislature with either a comprehensive report or separate reports on dental managed care in the Counties of Sacramento and Los An…

A schedule of reviews, visits, and audits shall be jointly established by the Department of Managed Health Care or the Department of Insurance, as the case may be, and the State Department of Health Services. Nothing in Section 14456, 14457, or 14459 shall be construed to prohibi…

Upon request by the department, each prepaid health plan shall submit to the department a copy of any financial report submitted to any other public or private organization, if such report differs in content or format from any financial report already submitted to the department.…

In accordance with Section 14081.5, the provisions of Section 15459 of the Government Code shall not be applicable to a hospital, whether or not it negotiates to obtain a contract pursuant to Article 2.6 (commencing with Section 14081), if the hospital predominantly serves or wil…

(a) Except as otherwise provided in this chapter, each prepaid health plan shall be responsible for all of the costs of services rendered under the provisions of this chapter to any Medi-Cal beneficiary enrolled in the plan. (b) The department shall bear the costs of providing to…

(a) The department may negotiate and establish an individual administrative cost limit in its contracts with each prepaid health plan or Medi-Cal managed care plan contracting under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) providing s…

Relief granted to any person who is not entitled thereto under the provisions of this chapter shall constitute a debt of the recipient, to the amount of such relief, to the state and the county participating in the granting of such relief. Recovery may be had upon such debt out o…

If the spouse, parent, or adult child of any recipient of relief is financially able to contribute to the support of the recipient, such relative is liable to reimburse the state and county for relief granted to the recipient to the extent of his financial ability so to do. The b…

(a) No prepaid health plan or pilot program contract shall be approved or renewed by the department pursuant to this chapter if any state officer or state employee or his spouse or minor child has a substantial financial interest, as defined by Section 14478, in any of the follow…

The chief executive, sole proprietor, or managing partner of each prepaid health plan shall file with the department an annual statement disclosing any purchases or leases of services, equipment, supplies or real property by the plan from any entity in which any of the following …

(a) For purposes of this article, “state officer” means a United States Senator or Member of Congress representing California, the Governor, Lieutenant Governor, Secretary of State, Controller, Treasurer, Attorney General, State Superintendent of Public Instruction, a Member of t…

(a) As used in this chapter, “substantial financial interest” means the ownership of common stock, preferred stock, warrants, options, loans, partnership interests, debt instruments, or other ownership interest, if consisting of, or convertible to, equity investments in an entity…

(a) No prepaid health plan or pilot program contract shall be approved, renewed or continued by the department if a state officer or state employee is employed in a management or consultant position by the contractor or a subcontractor to the contractor within one year after the …

No prepaid health plan or pilot program contract with an existing or proposed contractor shall be approved or renewed if a state officer or state employee provides legal or management services to the contracting organization. For the purposes of this section no state officer or s…

No prepaid health plan or pilot program contract shall be approved or renewed if any state officer or state employee receives anything of value for the purpose of influencing or attempting to influence the negotiations for approval or renewal of the contract. (Amended by Stats. 1…

No prepaid health plan shall contract with any subcontractor other than the plan’s subsidiary corporation, its parent corporation, or another subsidiary of its parent corporation, or an affiliate of the prepaid health plan whose financial statements are consolidated with that of …

The provisions of this chapter providing for state payments to counties do not constitute appropriations of money from the State Treasury, and no provision of this chapter shall be construed to make an appropriation. No money shall be available for expenditure under this chapter …

(a) Until the rate of county expenditure for the direct and administrative costs of welfare activities under this chapter exceeds, on a fiscal year basis determined not less frequently than quarterly, eight one-hundredths of 1 percent (.08%) of the total assessed valuation of the…

During such time as grants-in-aid are provided or made available by the United States government for either direct costs or administrative costs of welfare activities under this chapter, or both, the State Treasurer shall transfer the sums so granted to the Relief Fund. Of such s…

The method of computing and paying the amounts provided for in Sections 18521 and 18522 for each quarter shall be as follows: (a) The department shall, prior to the beginning of each quarter, estimate the amount to be paid for such quarter to each county under the provisions of S…

Reports of payments of relief and of payments for the cost of administration thereof made under this chapter shall be presented by the respective counties at times and in the form prescribed by the department. Such reports shall be audited by the department and the State Controll…

In providing benefits under this chapter and Chapter 7 (commencing with Section 14000), the director shall aggressively seek the development of alternative forms of financing and delivering health care services. In carrying out the intent of this article, the director shall contr…

The director shall pursue the feasibility of establishing the following as pilot programs: (a) A capitated, risk-assuming contract with one or more regional fiscal intermediaries. (b) A capitated, risk-assuming contract with acute care hospitals within a county or region. (c) A c…

The director shall also consider programs which demonstrate an innovative and economical use of health personnel and are approved pursuant to Article 18 (commencing with Section 429.70), Chapter 2, Part 1, Division 1 of the Health and Safety Code. (Added by Stats. 1977, Ch. 1036.…

The director may enter into other contracts under this article which do one or more of the following: (a) Demonstrate an innovative and economical use of health personnel. (b) Emphasize preventive care. (c) Stress new methods for controlling utilization of services. (d) Stress ne…

In establishing pilot programs, the director may do the following: (a) Provide benefits based on class of recipient, class of benefit, geographical area, or any other reasonable classification. (b) Modify, to the extent permitted by federal law, the scope and duration of benefits…

(a) The department shall establish a pilot program to provide continuous skilled nursing care as a benefit of the Medi-Cal program, when those services are provided in accordance with an approved federal waiver meeting the requirements of subdivision (b). “Continuous skilled nurs…

(a) Alternate methods of payment for a pilot program may include, but shall not be limited to, a prospectively negotiated reimbursement rate, fee-for-service, retainer, capitation, or other basis. (b) In order to implement expeditiously the budgeting decisions of the Legislature,…

The director shall call a public hearing pursuant to Section 14300 prior to entering into or renewing a pilot program. The director shall make available to the public a statement of objectives, program proposal, pilot program contract, and other details regarding the pilot progra…

(a) (1) In carrying out the intent of this article, the director shall contract for the operation of one local pilot program. Special consideration shall be given to approving a program contracted through county government in Santa Barbara County. (2) Notwithstanding the limitati…

(a) The Santa Barbara Regional Health Authority may arrange with out-of-county Selective Provider Contracting Program hospitals that have negotiated hospital contracts and per diem rates under Article 5.1 (commencing with Section 14165) of Chapter 7, to provide medically justifie…

The department may contract with one or more fiscal intermediaries in order to pay for benefits authorized under this chapter and Chapter 7 (commencing with Section 14000). Contracts entered into pursuant to this article may be awarded on a bid or nonbid basis. (Added by Stats. 1…

For the purposes of this article, “fiscal intermediary” means an entity that agrees to pay for covered services provided to Medi-Cal eligibles in exchange for a premium, subscription charge, or capitation payment; to assume an underwriting risk; and is licensed by the Director of…

A contract entered into under this article shall provide that a fiscal intermediary meets both of the following criteria: (a) The fiscal intermediary shall provide or arrange for an adequate number of primary care physicians and supportive specialty care physicians. (b) The fisca…

In determining the capitated rates to be paid to a fiscal intermediary during the first year of contracting under this article, the department shall utilize an acceptable actuarial process and historical data concerning Medi-Cal recipients in the geographical area which will, or …

A fiscal intermediary may contract for the provision of services with any provider who would be eligible to provide services if services were to be provided on a fee-for-service basis without the use of a fiscal intermediary pursuant to this article. (Added by Stats. 1985, Ch. 15…

All services, except those specified for exclusion by the department, received by Medi-Cal recipients residing in the geographical area served by the fiscal intermediary shall be paid for by the fiscal intermediary. Services shall be provided only by providers which have entered …

For purposes of this article and Section 14454, “emergency services” shall have the same meaning as that established in Section 1317.1 of the Health and Safety Code for “emergency services and care.” (Added by Stats. 1992, Ch. 1052, Sec. 1. Effective January 1, 1993.)