SECTIONS 14092-14092.35 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 14092-14092.35

14092. It is the purpose of this article to ensure that the
Medi-Cal program is operated in the most cost-effective and efficient
manner possible by assuring that beneficiaries have early and
ongoing access to identified sources of quality primary care who have
agreed to accept Medi-Cal patients. In so doing, it is intended to
optimally realize the quality of care and health care financing
benefits demonstrated by the experience of successful commercial
managed care plans when patients affiliate with a single, specified
primary care provider and management of patient care is placed within
the control of the responsible primary care provider.

14092.05. For purposes of this article "primary care provider" is
defined as set forth in paragraph (1) of subdivision (a) of Section
14088.

14092.1. The department shall seek all federal waivers necessary to
allow federal financial participation in expenditures under this
article.

14092.15. The director shall investigate and may to the extent
feasible require that:
(a) Primary care providers specify their capacity to accept
Medi-Cal Patients and obtain a primary care provider project code
under which fee-for-service Medi-Cal beneficiaries may enroll with
the provider as their exclusive primary care source.
(b) Each primary care provider accept and enroll fee-for-service
beneficiaries up to the provider's specified capacity.
(c) Any managed care contractor serving children with conditions
eligible under the California Children's Services program shall
maintain and follow standards of care established by the program,
including use of paneled providers and CCS approved special care
centers and shall follow treatment plans approved by the program,
including specified services and providers of services. If there are
insufficient paneled providers willing to enter into contracts with
the managed care contractor, the program shall seek to establish new
paneled providers willing to contract. If a paneled provider cannot
be found, the managed care contractor shall seek program approval to
use a specific nonpaneled provider with appropriate qualifications.
(d) Any managed care contractor serving children with conditions
eligible under the CCS program shall report expenditures and savings
separately for CCS covered services and CCS eligible children. If the
managed care contractor is paid according to a capitated or
risk-based payment methodology, there shall be a separate actuarially
sound rate for CCS-eligible children.
(e) This article is not intended to and shall not be interpreted
to permit any reduction in benefits or eligibility levels under the
CCS program. Any medically necessary service not available under the
managed care contracts authorized under this article shall remain the
responsibility of the state and county.
(f) To assure CCS benefits are provided to enrollees with a
CCS-eligible condition according to CCS program standards, there
shall be oversight by the state and local CCS program agencies for
both services covered and not covered by the managed care contract.
(g) Beneficiaries enroll with or are assigned to a primary care
provider who will be the exclusive source of fee-for-service primary
care for the beneficiary. However, enrollment under this article
shall be subordinated to any legal requirement that a beneficiary
enroll in a Medi-Cal managed care plan contracting under this chapter
or (Chapter 8 (commencing with Section 14200)).

14092.2. The director may establish policy and procedures that
assure that outpatient physician's services, and any other Medi-Cal
services the director may designate, provided by a source other than
the primary care provider with whom a beneficiary is enrolled under
this article, shall not be covered under the Medi-Cal program unless
they are provided on an emergency basis or authorized by the
responsible primary care provider.

14092.25. In areas where a Medi-Cal beneficiary has the opportunity
to enroll in a Medi-Cal managed care plan or to enroll with a
primary care provider under this article, the director may require a
beneficiary who is certified pursuant to subdivision (c) of Section
14016.5 that he or she has an established relationship with a
provider, to enroll in a managed care plan, a pilot project, or a
primary care provider under this article, if the beneficiary relies
on care provided by hospital emergency departments for nonemergency
care.

14092.3. In implementing this article, the director has discretion
to extend administrative or reimbursement flexibilities to
participating primary care providers.

14092.35. To the extent that this article proves to be effective in
reducing the cost of uncoordinated primary care delivered in the
hospital emergency room or the costs of duplicative, unnecessary, or
avoidable services, program savings may be shared with primary care
providers who enroll beneficiaries under this article.