SECTIONS 14075-14080.5 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 14075-14080.5

14075. The Legislature intends that Medi-Cal recipients have
reasonable access to medical care services and especially to primary
and maternity care services. In order to obtain such access, the
Legislature intends that, to the extent feasible and permitted by
federal law, physicians be reimbursed equally statewide for
comparable services, at a rate sufficient to provide Medi-Cal
recipients with such reasonable access, and also intends that higher
rates be paid, relatively, for providing primary and maternity care
services.

14076. As used in this article:
(a) "Medically underserved area" means a county, standard
metropolitan statistical area, or other area within the state in
which the director determines that Medi-Cal recipients do not have
access to an adequate number of physicians.
(b) "Primary care services" means those general medical services,
as determined by the director, which are not performed on an
emergency, referral, or consulting basis.
(c) "Maternity care services" are prenatal, postnatal, perinatal,
and neonatal services.

14077. Notwithstanding any other provisions of this chapter the
director shall establish, within 15 days of the effective date of
this act a statewide, uniform schedule for reimbursing physician
services to Medi-Cal patients provided on or after July 1, 1976;
except that, the director may establish physician reimbursement rates
higher than the statewide rates for; (a) areas which the director
determines to be medically underserved: and (b) other problems of
equity in payment levels which adversely affect the accessibility of
physician services to Medi-Cal recipients. Nothing in this section
shall be construed to prevent the director from adopting physician
reimbursement rates for primary care services and maternity care
services which are relatively higher than the rates paid for other
types of physician services.

14078. The director shall establish, at the time he or she
establishes the statewide rate for physician services required by
Section 14077, a level of reimbursement for physician services which
represents at least an average increase over the statewide average
amounts paid under the Medi-Cal program for the three-month period
ending February 29, 1976, of 9.5 percent for all physician services
except primary care services and maternity care services; of 20
percent for primary care services; and of 30 percent for maternity
care services.

14079. The director annually shall review the reimbursement levels
for physician and dental services under Medi-Cal, and shall revise
periodically the rates of reimbursement to physicians and dentists to
ensure the reasonable access of Medi-Cal beneficiaries to physician
and dental services.
This annual review, as it relates to rates for physician services,
shall take into account at least the following factors:
(a) Annual cost increases for physicians as reflected by the
Consumer Price Index.
(b) Physician reimbursement levels of medicare, Blue Shield, and
other third-party payors.
(c) Prevailing customary physician charges within the state and in
various geographical areas.
(d) Procedures reflected by the current Relative Value Studies
(RVS).
(e) Characteristics of the current population of Medi-Cal
beneficiaries and the medical services needed.

14079.5. Rates of reimbursement established pursuant to this
chapter shall make no distinction based on whether a particular
service is provided by a physician or a dentist. The director shall
not reduce any rate of reimbursement for physician services in order
to comply with this section.

14080. (a) Notwithstanding any other provision of this chapter,
reimbursement to providers for dental services provided to
individuals 21 years of age or older at the time of services shall be
limited to not more than one thousand eight hundred dollars ($1,800)
per beneficiary in any calendar year, commencing January 1, 2006.
This limitation shall not apply to any of the following:
(1) Emergency dental services within the scope of covered dental
benefits defined as a dental condition manifesting itself by acute
symptoms of sufficient severity such that the absence of immediate
medical attention could reasonably be expected to result in placing
the health of the individual in serious jeopardy, serious impairment
to bodily functions, or serious dysfunction of any bodily organ or
part.
(2) Services that are federally mandated under Part 440
(commencing with Section 440.1) of Title 42 of the Code of Federal
Regulations, including pregnancy-related services and services for
other conditions that might complicate the pregnancy.
(3) Dentures.
(4) Maxillofacial and complex oral surgery.
(5) Maxillofacial services, including dental implants and
implant-retained prostheses.
(6) Services provided in long-term care facilities.
(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all-county letters, provider bulletins, or similar
instructions. No later than January 1, 2008, the department shall
adopt regulations in accordance with the requirements of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code.
(c) The department shall pursue any state plan amendment or other
federal approval necessary in order to effectuate this section. This
section shall be implemented only to the extent that federal
financial participation is available.

14080.5. Notwithstanding any other provision of this article, no
increase in the reimbursement levels for physician and dental
services under Medi-Cal shall be made for the period from July 1,
1982, to September 30, 1982, inclusive, except to the extent funds
may be provided therefor by the Budget Act of 1982.