SECTIONS 14094-14094.3 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 14094-14094.3

14094. For purposes of this article "CCS" means California Children'
s Services.

14094.1. (a) The director shall investigate and to the extent
feasible require any managed care contractor serving children with
conditions eligible under the CCS program, to maintain and follow
standards of care established by the program, including use of
paneled providers and CCS approved special care centers and to 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.
(b) The director shall investigate and to the extent feasible
require any managed care contractor serving children with conditions
eligible under the CCS program, to report expenditures and savings
separately for CCS covered services and CCS eligible children.
(c) (1) 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.
(2) Notwithstanding paragraph (1), a managed care pilot project
may, if approval is obtained from the state CCS program director,
utilize an alternative rate structure for CCS eligible children.

14094.2. (a) This article is not intended, 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.
(b) In order to ensure that 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.

14094.3. (a) Notwithstanding this article or Section 14093.05 or
14094.1, CCS covered services shall not be incorporated into any
Medi-Cal managed care contract entered into after August 1, 1994,
pursuant to Article 2.7 (commencing with Section 14087.3), Article
2.8 (commencing with Section 14087.5), Article 2.9 (commencing with
Section 14088), Article 2.91 (commencing with Section 14089), Article
2.95 (commencing with Section 14092); or either Article 2
(commencing with Section 14200), or Article 7 (commencing with
Section 14490) of Chapter 8, until January 1, 2012, except for
contracts entered into for county organized health systems or
Regional Health Authority in the Counties of San Mateo, Santa
Barbara, Solano, Yolo, Marin, and Napa.
(b) Notwithstanding any other provision of this chapter, providers
serving children under the CCS program who are enrolled with a
Medi-Cal managed care contractor but who are not enrolled in a pilot
project pursuant to subdivision (c) shall continue to submit billing
for CCS covered services on a fee-for-service basis until CCS covered
services are incorporated into the Medi-Cal managed care contracts
described in subdivision (a).
(c) (1) The department may authorize a pilot project in Solano
County in which reimbursement for conditions eligible under the CCS
program may be reimbursed on a capitated basis pursuant to Section
14093.05, and provided all CCS program's guidelines, standards, and
regulations are adhered to, and CCS program's case management is
utilized.
(2) During the time period described in subdivision (a), the
department may approve, implement, and evaluate limited pilot
projects under the CCS program to test alternative managed care
models tailored to the special health care needs of children under
the CCS program. The pilot projects may include, but need not be
limited to, coverage of different geographic areas, focusing on
certain subpopulations, and the employment of different payment and
incentive models. Pilot project proposals from CCS program-approved
providers shall be given preference. All pilot projects shall utilize
CCS program-approved standards and providers pursuant to Section
14094.1.
(d) (1) The department shall submit to the appropriate committees
of the Legislature an evaluation of pilot projects established
pursuant to subdivision (c) based on at least one full year of
operation.
(2) The evaluation required by paragraph (1) shall address the
impact of the pilot projects on outcomes as set forth in paragraph
(4) and, in addition, shall do both of the following:
(A) Examine the barriers, if any, to incorporating CCS covered
services into the Medi-Cal managed care contracts described in
subdivision (a).
(B) Compare different pilot project models with the
fee-for-service system. The evaluation shall identify, to the extent
possible, those factors that make pilot projects most effective in
meeting the special needs of children with CCS eligible conditions.
(3) CCS covered services shall not be incorporated into the
Medi-Cal managed care contracts described in subdivision (a) before
the evaluation process has been completed.
(4) The pilot projects shall be evaluated to determine whether:
(A) All children enrolled with a Medi-Cal managed care contractor
described in subdivision (a) identified as having a CCS eligible
condition are referred in a timely fashion for appropriate health
care.
(B) All children in the CCS program have access to coordinated
care that includes primary care services in their own community.
(C) CCS program standards are adhered to.
(e) For purposes of this section, CCS covered services include all
program benefits administered by the program specified in Section
123840 of the Health and Safety Code regardless of the funding
source.
(f) Nothing in this section shall be construed to exclude or
restrict CCS eligible children from enrollment with a managed care
contractor, or from receiving from the managed care contractor with
which they are enrolled primary and other health care unrelated to
the treatment of the CCS eligible condition.