The Medi-Cal Benefits Program offers a standardized list of health care benefits that are managed by a specific department. Regardless of other rules in this chapter, health care services will only include the benefits mentioned in this section and in Section 14021.

This law section outlines the limits on hearing aid benefits under the Medi-Cal program in California. It sets a maximum coverage amount, or 'benefit cap,' for hearing aid benefits at $1,510 per beneficiary each fiscal year. This cap is subject to voter approval in the November 2024 election; if not approved, it will still be no less than $1,510 but adjustable by the department annually. Certain groups, like pregnant women and those in specific care programs, are exempt from this cap.

Additionally, managed care plans must adjust payments to account for these benefit caps, except for certain networks. The implementation of these rules depends on federal approval and will follow a specific timeline. The law allows for guideline issuance without further regulation procedures.

This law outlines certain optional medical services that are not typically covered under California's Medi-Cal program due to funding changes. However, there are exceptions where some services can be covered.

Initially excluded services included adult dental care, except for specific medically necessary situations, audiology and speech therapy, chiropractic services, optometric care, podiatric services, and incontinence supplies. Some exclusions, like adult dental and optometric services, were later restored depending on federal approvals and budget decisions.

Pregnancy-related services and care for conditions that could complicate pregnancy remain covered, as do services for young beneficiaries or those in long-term care facilities. Finally, implementation of this law hinges on federal law compatibility and funding.

This section explains that if a healthcare provider increases charges to the Medi-Cal program due to a preventable condition they caused, those charges won't be reimbursed. This applies to different healthcare delivery systems like fee-for-service and managed care. If a preventable issue existed before treatment, this doesn't apply. Providers need to report these preventable conditions, and if they received money for such charges, they must pay it back. Providers also can't charge patients for costs related to these preventable conditions. The law allows the state department to implement and adjust these rules, and emergency regulations are expected to be in place until finalized. Finally, the law will only be fully enacted if it doesn't risk losing federal funding.

This law allows the director to specify that certain Medi-Cal benefits are only available through a managed care plan in areas where these plans have the capacity to take more members. If people want those benefits, they must enroll in a managed care plan if they are eligible and live in the area covered by that plan. Even when managed care plans reach capacity, the director can arrange for benefits to be delivered in other ways, like through contracts or on a fee-for-service basis.

Managed care plans can use their own standards for determining medical necessity and reviewing utilization of services. The law also clarifies that managed care plans are not required to contract with any particular service provider. Finally, the department will seek federal waivers to ensure federal funding is available under these arrangements.

This legal section outlines the range of healthcare benefits provided under the Medi-Cal program. It covers outpatient services like various therapies and acupuncture, inpatient services including emergency medical care, nursing facility services, and the purchase of prescribed drugs with specific conditions. Benefits extend to services like home health care, prosthetics, family planning, and transportation needed for medical access. The section also details provisions for dental services, hospice care, and specialized medical treatments like rapid genome sequencing for infants. It specifies financial participation conditions, federal approvals needed, and outlines various waivers or special service considerations.

Congregate living health facilities in California can provide covered services to individuals with AIDS, subject to certain usage controls. The state decides the payment rates for these services, and it may audit how the services are given. However, these services are only available if federal Medicaid funds are available to support them.

This law outlines how community and free clinics in California can bill and receive payments for drugs and supplies under the Medi-Cal and Family PACT Waiver Programs. It specifies that these clinics should charge the lesser of their cost or their regular public price and defines what 'cost' includes, such as the drug's purchase price and a small dispensing fee.

Some clinics, especially those serving low-income patients or charging minimal fees, are exempt from certain payment reductions. Additionally, federally qualified health centers and rural health clinics have the option to receive reimbursements based on a fee-for-service model.

Finally, if a clinic chooses not to use discounted drugs for Medi-Cal patients under the 340B Drug Program, it must notify the relevant federal office.

This law clarifies that a 'surgical center' is a clinic licensed under a specific health code. It also states that the director is responsible for determining how much these centers are paid for their services.

This law is about providing a specific alternative benefit package to certain individuals who are newly eligible for Medi-Cal under new income standards. From January 1, 2014, this package must match the benefits of full-scope Medi-Cal except it won't cover long-term services unless required. However, long-term services will be available to those who meet asset requirements for Medi-Cal.

Long-term services include nursing and equivalent care, home-based services, and personal care. The law allows the department to seek necessary approvals to implement these changes and communicate through various documents. It mandates that these changes are effective only if the federal government supports them financially and approves the necessary conditions.

This California law specifies that from January 1, 2014, certain mental health and substance use disorder services are covered under Medi-Cal as essential health benefits. These include services adopted by the state and approved federally. Mental health services, including certain behavioral health treatments, are provided to individuals through specific programs. The law also encourages seeking necessary federal approvals to implement these changes, and it relies on the availability of federal funding.

This law states that hospitals can't get paid for certain services unless they have a special permit or approval. Specifically, if a hospital needs a special permit or extra service approval under Section 1256.1 of the Health and Safety Code, they must get these from the State Department of Health Services first to receive reimbursement for those services.

This law states that services provided by a certified nurse-midwife are covered, as specified by federal law, but are also subject to certain use and management guidelines.

This section requires a department to send copies of their reports to the state legislature's finance and policy committees. These reports are about their evaluations of the Family PACT program, which is part of a waiver from federal health regulations.

This law outlines that services provided by local educational agencies (LEAs), such as health evaluations, medical transportation, and therapy services, are covered by Medi-Cal if federal financial participation is available. Services must be prescribed or supervised by a physician and not expand the existing professional health care practices. Local educational agencies must contract with the department to provide these services and prefer using existing health service providers rather than duplicating services.

Covered services include nursing, therapy services, mental health counseling, and speech pathology, among others. LEAs may opt to provide some or all of these services. The law ensures these services can be billed to Medi-Cal even if provided free to the community, and outlines how LEAs can pursue reimbursement from third parties. The law requires annual public accounting of funds from federal Medicaid to local educational agencies.

This law ensures that external prostheses (like those made from silicon), prosthetic implants, and reconstructive surgery needed after a mastectomy are considered medically necessary and will be covered. A mastectomy is defined here as the removal of part or all of the breast based on medical necessity determined by a licensed doctor.

The law also makes sure that initial and follow-up prosthetic devices are provided according to the doctor’s prescription.

This law ensures that people in Medi-Cal managed care plans can choose any qualified provider they want for family planning services. The managed care plan can't limit their choice. "Qualified providers" are licensed providers who offer family planning services and are part of Medi-Cal. These providers can be outside of the beneficiary's specific plan or network.

Moreover, managed care plans must pay these out-of-plan or out-of-network providers at the standard fee-for-service rate. If federal approval is necessary for this law's implementation, it will move forward only once that approval is obtained.

This law covers rehabilitative services for patients with physical or cognitive impairments from strokes or brain injuries. It applies if there's potential for improvement or prevention of degeneration. Rehabilitation can occur in hospitals, rehabilitation clinics, adult day health care centers, or at home. These services are considered medically necessary if there is a likelihood of recovery. The term 'brain injury' includes damage from events like trauma, infection, or lack of oxygen, excluding age-related degeneration. The law does not limit the department's ability to review how these services are used.

This law requires that by July 1, 2024, biomarker testing will be a covered benefit for Medi-Cal beneficiaries, provided it's medically necessary. Biomarker testing is used to diagnose, treat, manage, or monitor diseases and conditions. Coverage is granted if the test is FDA approved, recommended by Medicare, or supported by clinical guidelines and scientific studies.

The law doesn't mandate testing for screenings unless specified and directs that testing should limit disruptions in care. Restricted or denied testing can be contested through grievance processes. Implementation depends on federal funding and approvals.

Biomarker testing involves analyzing biological samples for indicators of health conditions, including gene mutations or proteins, and covers various testing methods. There are additional guidelines for cancer patients in certain stages covered by Medi-Cal.

This law states that pediatric day health care is a covered benefit in California under specific conditions. It is provided by licensed facilities and excludes long-term inpatient care or family respite care. Services can be offered any time but must not exceed the total authorized hours, capped at 23 hours per day.

The department must set emergency regulations and reimbursement rates, effective from October 1, 1997, ensuring efficiency and quality. Coverage is only available if it doesn't increase net program costs and if federal funding supports it. Requests for pediatric day health care won't be approved if the patient is currently an inpatient or if the costs are higher than other medically appropriate care levels.

This law states that from July 1, 2024, pharmacogenomic testing will be a benefit covered by the Medi-Cal program, meaning it will help determine how a person's genetics affect their response to medications. The coverage will follow certain guidelines and regulations to ensure it is used properly.

However, this coverage depends on receiving necessary approvals from federal authorities and does not risk losing federal funding. The department can provide guidance on implementing this section through various communications without needing additional regulatory procedures.

This law states that services from community paramedicine programs, triage to alternate destination programs, and mobile integrated health programs are covered by Medi-Cal. The state will work with these programs to set rates for services. However, these provisions will only be implemented if federal waivers and financial participation are secured, and the state has appropriated funds for this purpose. Definitions for these programs are provided, highlighting their roles in supporting emergency medical services and offering alternative destinations for patient care.

This law defines 'rehabilitation services' as services designed to help individuals with physical or cognitive impairments improve or recover their ability to move, take care of themselves, and live independently.

Starting January 1, 1988, this law mandates that mammograms, whether for screening or diagnosing breast issues, must be covered if a doctor recommends it. This coverage is only required if allowed by federal law.

This law states that, starting January 1, 1991, annual cervical cancer tests are covered by the state's benefits program, as long as they are referred by a patient's physician and meet federal guidelines.

This law allows California to offer "community supported living arrangements" as a benefit through federal Medicaid, but only if federal funding is available. These services aim to help individuals live in community settings rather than institutions.

The state must consult with its Department of Developmental Services to apply for and maintain any necessary federal waivers. If approved, regional centers will use their existing funds to match federal dollars, with no new funds from California's General Fund.

The state is responsible for setting standards to protect the health and safety of those using the services. The law also requires the collection of cost data to compare expenses before and after implementation.

This section becomes inactive if federal approvals or funding cease, or if California opts out of participating in the program.

This law requires the establishment of an advisory working group to update, amend, or create tools and protocols to screen children for trauma under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. The group includes various mental health and child welfare experts and must review current tools used in the Medi-Cal program, like the Staying Healthy Assessment and others, to determine their effectiveness and appropriateness.

The group was to be convened by May 1, 2018, and report its findings and recommendations by May 1, 2019. The findings needing legislative funding won't be implemented until such funding is approved. The protocols should be reviewed every five years or as requested.

Trainee instructions are given without needing regulatory action, and the section is subject to federal financial participation not being jeopardized. 'Trauma' here means any harmful or threatening event with lasting negative effects on a child's well-being.

This law establishes a program providing 24/7 continuous skilled nursing care to individuals with developmental disabilities through Medi-Cal. The care must be offered in approved facilities with at least one nurse present 24/7, including eight hours under direct supervision of a registered nurse. The services are based on federal waivers or Medi-Cal State Plan amendments.

The program prioritizes care in the least restrictive, home-like settings. To qualify, both the person needing the care and the facility must meet specific federal and state criteria. The program cannot exceed established federal cost limits.

Facilities must comply with all waiver terms, and the state can contract out services without standard bidding processes. The program only begins once federal approval of the waiver or plan amendment is secured and officially declared by the Director of Health Care Services.

This law requires the department to explore the possibility of modifying the Medicaid State Plan to offer targeted case management services to two groups of women: those abusing substances during pregnancy and those who have given birth to infants affected by drugs or alcohol. These women might be identified through various channels such as self-referral or public health programs.

The services offered would include assessing their needs, creating a coordinated health and treatment plan, and providing case management to access medical, social, and educational services. The law outlines specific programs and services for referrals, such as child health programs, supplementary food assistance, drug detox programs, and support for in-home services, transport, and crisis intervention.

This section explains the types of dental materials that are included as dental restorative options, specifically composite resin, glass ionomer cement, resin ionomer cement, and amalgam.

Dentists can recommend other materials besides the standard option, amalgam, after discussing with the patient what might be best for them.

Even if a dentist uses a different material, they can still receive payment as if they had used amalgam.

This law section explains how orthodontic treatments under the Medi-Cal program are paid for. Generally, payments for the active and retentive phases of orthodontic care are made every three months. This is based on how long the treatment is expected to take. However, once an updated dental coding system from the American Dental Association is adopted, the payment approach for the retentive phase will change.

The law went into effect on July 1, 2008.

This law mandates that by April 1, 2023, and until June 30, 2025, California's Department of Health Care Services must set up a workgroup to look into how doula services are being provided under Medi-Cal. This group will include various stakeholders like doulas, healthcare providers, and community advocates. They will focus on ensuring these services are available to those who want them, improving payment processes, and promoting awareness among eligible individuals.

By July 1, 2025, the department needs to report the number of Medi-Cal users receiving doula services, broken down by different demographics, and identify barriers to accessing these services. The report should also compare birth outcomes between those who use doula services and those who don't. The law is set to expire on January 1, 2026, but the department may continue the workgroup and reporting if deemed necessary.

This law states that emergency medical services and care are covered benefits, meaning that treatment for emergencies is included under medical benefits, even when psychiatric conditions are involved. Whether a person needs emergency care voluntarily or is detained under mental health evaluation laws, the care is still covered. Medi-Cal managed care plans must pay for these emergency services, but once someone is admitted for inpatient psychiatric care, specialty mental health services aren't part of this coverage.

It doesn't change coverage for people on regular Medi-Cal, and the Department can issue instructions on this law before formal regulations are established. Emergency services mean both the costs of doctors and the facilities used. This law's goal is to clarify existing Medi-Cal benefits, not to expand them, and it aligns with federal laws only if federal funds are available for it.

This law requires the California State Department of Health Care Services to establish a subacute care program by July 1, 1983, to make efficient use of limited Medi-Cal funds and provide necessary services to patients in health facilities who meet subacute care criteria. The subacute care can be provided by any qualifying facility with an agreement with the department.

The department will decide how reimbursement rates are calculated, which could include set daily rates or customized rates for individual patient needs. Funds for reimbursement are contingent on annual budget availability.

The department may form agreements with health facilities meeting subacute care standards based on individual patient assessments, and set criteria for care levels and utilization.

Pediatric subacute services are specifically for those under 21 using medical technology to compensate for vital bodily function loss. Medical necessity is determined by specific dependencies on medical technologies or interventions, such as mechanical ventilation, tube feeding, or skilled nursing care.

This determination is used to assess the potential transfer of a patient from an acute to a subacute care setting.

This law requires the development of a program to test providing assisted living benefits to eligible individuals under Medi-Cal, needing a waiver of federal law. The program aims to help individuals remain in a home-like environment with necessary medical and personal care, offering services not covered under the standard state plan, like medicine management and case management.

Eligibility is for those approved for Medi-Cal who could be placed in a nursing facility. Participants must be fully informed and choose to participate. The program will test two service methods: providing benefits through licensed residential care facilities and publicly funded senior housing, with independent agencies managing services.

Initial participation is limited for evaluation, which will assess participant satisfaction, effectiveness, and costs, to potentially save government funds. The waiver program will proceed only if it does not incur extra costs and funds are available. The department can contract service providers without competitive bidding.

This California law directs the state’s health department to apply for a federal waiver to test a disease management program for Medi-Cal beneficiaries. The program is designed to support people with certain chronic diseases by promoting health care adherence and improving their living conditions, including education and lifestyle changes. Eligibility is limited to those aged, blind, or disabled, or those over 21 not in managed care, and diagnosed with specific chronic diseases. The program's effectiveness, cost savings, and participant satisfaction will be evaluated, and results will inform potential statewide expansion. Implementation depends on federal funds, and the department can contract out services if necessary. The waiver will only be developed and implemented if funding is available, and it won't proceed if federal funding is denied or discontinued.

If a healthcare facility's subacute care services contract is ending or not being renewed, the department must inform the facility 30 days in advance. After notification, they will guide the facility on safely transferring patients, aiming to minimize trauma and ensure compliance with relevant transfer and discharge laws. Before any transfers, the facility should maintain the required subacute service levels and staffing, receiving appropriate payments for these services. If they don't meet staffing laws, pay reverts to a lower nursing facility rate. After a contract ends, new admissions won't get subacute payment rates unless a new contract is obtained. Facilities can only receive certain subacute payments if patients return within specified 'bed-hold' times.

This law requires health facilities with a subacute services provider contract to follow specific rules for transferring and discharging patients. If a facility changes its license status or operations, it must adhere to both state and federal patient transfer and discharge laws. These include certain sections of the Health and Safety Code and federal regulations. Patients and their representatives have the right to appeal any transfers or discharges, and facilities must notify them in writing in a way they understand.

This law states that human milk and products derived from it, provided by a certified mothers’ milk bank, are considered a covered service. This means Medicaid will cover the cost for human milk provided by these banks.

Mothers' milk banks are non-profit organizations that collect, process, and distribute human milk donated by volunteers. They must follow specific standards set by the Human Milk Banking Association of North America.

This California law ensures that outpatient rehabilitation services, such as physical therapy and counseling, are available under specific conditions. These services are crucial for elderly people to help them stay independent and live at home. The law specifically mentions stroke centers, which can offer group therapy and training, as eligible providers. To receive payment from Medicare, these centers must be officially certified and meet certain legal standards. Importantly, there should be no discrimination against elderly patients when providing these services.

This section makes community health worker services a covered benefit under Medi-Cal. Community health workers act as intermediaries between health services and the community, helping people access care and ensuring services are culturally sensitive. They may include Promotores and other nonlicensed health workers. Medi-Cal must inform enrollees about these services, providers, and how to get referrals. The services must meet cultural and language needs.

Medi-Cal plans are required to inform providers about this benefit and by July 1, 2025, establish billing procedures for services during emergency department visits and outpatient follow-ups. The state will guide these procedures and engage stakeholders for input. Implementation depends on federal financial support and approvals and can be adjusted through policy guidelines without new regulations.

This section states that midwifery services offered by a licensed midwife are included as a covered service, but only if federal funding is available and certain use restrictions are followed.

This section states that services provided by a certified nurse practitioner are covered under this chapter as allowed by federal law and may be subject to usage restrictions. Nurse practitioners who are nationally board certified in a recognized specialty can independently bill Medi-Cal for their services, and they will receive payment directly.

This law ensures that mothers and newborns have at least 48 hours of hospital care after a normal vaginal delivery, and 96 hours after a C-section. If the doctor and the mother agree, they can leave the hospital earlier, but then a follow-up doctor visit is essential within 48 hours of going home. This visit should help with newborn care, breastfeeding guidance, and health checks, and the mother should know her options for having this visit at home or a nearby facility. The doctor will decide the best location for this visit by considering the family’s transportation needs and any other social or environmental risks.

This section covers targeted case management (TCM) services under Medi-Cal starting from January 1, 1995. Local agencies can provide or contract for TCM services, which are designed to help Medi-Cal beneficiaries access various needed services like medical and social support. However, these agencies are not required to offer TCM services.

Local agencies planning to offer these services must have systems to monitor performance, prevent service duplication, and ensure care coordination. They need to track costs and report them for federal Medicaid reimbursement, adhering to federal guidelines.

Different vulnerable groups are eligible, such as high-risk individuals, non-English speakers, and those with substance abuse issues. The law also provides for federal audits, requiring local agencies to share any financial liabilities arising from disallowed claims. Local funds used for these services should not create new funding obligations beyond what's federally required.

This law states that any regulations that help implement or detail subdivision (z) of Section 14132 are not required to follow the usual procedures outlined in Chapter 3.5 of the Government Code.

This law allows the Director of Health Services to recover costs from anyone who is legally or contractually obligated to pay for targeted case management services provided to eligible Medi-Cal beneficiaries.

This law allows local government agencies and educational groups in California to choose to participate in programs that help manage administrative tasks for the Medi-Cal program. These programs help with getting the proper funds from the federal government for Medicaid activities.

Agencies need to sign contracts and show proof of expenses to be eligible for reimbursement, and they can work with private or public partners to do so. If any agency's claims are found unsupported or fail to meet federal criteria, the state can reject them. Moreover, agencies must cover any costs if their claims are penalized in federal audits. Local agencies must also pay an annual fee for participating, which funds process administration. Native American tribes and school agencies have specific procedures and responsibilities outlined for their participation.

The law ensures state compliance and maximizes available federal funding through technical support. It also includes guidelines for nonemergency transport of eligible individuals to healthcare services under Medi-Cal, emphasizing accountability and accuracy in claims.

This section refers to targeted case management services that are covered as benefits for specific groups under California law. These services are meant for people served by programs managed by the State Department of Developmental Services and also include individuals receiving services under another specific law, Section 14021.3. The Director has the discretion to include more programs if deemed appropriate.

This law allows for targeted case management services to be offered to pregnant and parenting adolescents and their children once federal financial help is approved. The services depend on available funding and the state budget process. The department must limit these services to the funds available and can redirect money from existing adolescent programs to make the federal matching funds work.

The legislature intends for any additional federal funds to expand current programs rather than replace existing money. Decisions about whether to continue, grow, or stop the program depend on the program's effectiveness, cost, and the potential for additional federal funds. The Department must submit necessary changes by June 30, 1993, for federal approval.

This law states that for speech pathologists or audiologists to be reimbursed under the Medi-Cal program, they must be licensed either by California’s specific examining committee or a comparable agency in another state where they work. Additionally, licensed professionals can use and be reimbursed for the services of personnel completing certain requirements under the state professional code.

Medi-Cal will cover behavioral health treatment (BHT) for people under 21, but only if the federal government requires it and provides funding. BHT includes services like applied behavior analysis to help kids with developmental disorders or autism function better.

The state will only implement this if it gets federal approval, the budget covers it, and there's community input. Special services may help some kids who lose Medi-Cal BHT coverage enroll in health insurance. The state will use quick communication methods to guide this process and must adopt formal regulations by July 1, 2017.

They can enter into contracts to get expertise without following usual state bidding rules. They'll also make sure any changes to federal agreements are public and consider community feedback before proceeding. This plan depends on federal money and approvals being secured.

This law requires the California Department of Health to obtain federal approval to offer mobile crisis intervention services for Medi-Cal beneficiaries during mental health or substance use crises. These services will be available through the Medi-Cal behavioral health system. The department must follow federal guidelines to receive enhanced funding and establish standards and guidelines for these services and their providers.

They also need to monitor compliance with these requirements. The department can engage in contracts to support the implementation of this program. Assuming federal approval, the program will start from January 1, 2023, and run for five years.

This law allows California to use a program called the Health Services Initiative (HSI) under the Children’s Health Insurance Program (CHIP) to provide vision services to low-income children across the state through a mobile optometric office. This can only happen if federal funding is approved, and such funding must not exceed 3% of the federal budget designated for non-Medicaid or health insurance costs. The program is set to be in place by January 1, 2025, or later if federal approvals take longer.

The law creates a special fund called the Vision Services CHIP-HSI Special Fund to hold money for these vision services, and the funds can be used only upon legislative approval. The funding for this program must come from sources other than the state's general fund, like private gifts or grants. Finally, the state department can use letters or similar instructions to start this program without formal regulations until specific regulations are developed.

California law includes coverage for reconstructive surgery when it's needed to improve function or achieve a normal appearance due to abnormalities or injuries. Importantly, this law clearly distinguishes reconstructive surgery from cosmetic surgery, which is aimed at voluntarily changing appearance and is not covered. Only qualified medical professionals can deny coverage for reconstructive procedures. The law also allows for a review process to ensure the most appropriate procedure is selected and outlines possible grounds for denial, such as minimal improvement or lack of prior approval.

This law states that anyone providing orthotic or prosthetic services must be certified by recognized boards, either the Board for Orthotist Certification or the American Board of Certification in Orthotics and Prosthetics.

This requirement is in place until the director of the department officially declares that they've adopted regulations mandating this certification. Once that declaration is made, this specific section will no longer be in effect.

This law states that organ transplant surgeries for both donors and recipients are covered by the Medi-Cal program as long as the patient is eligible for full-scope benefits and the procedure is performed in an approved medical facility. These surgeries must undergo certain checks known as utilization controls to ensure appropriate use. Additionally, the department has the power to implement or interpret the section using different types of documentation without further regulatory steps. This section does not apply to Section 14133.8.

If someone on Medi-Cal gets an organ transplant, they can receive medication to prevent organ rejection for up to two years. However, this coverage stops if they get Medicare or private insurance that covers these medications during that time.

The health department can explain or implement this rule through letters or notices without needing to go through a formal legislative process.

This section of the law requires the relevant department to establish guidelines for approving which medical facilities can receive payment for organ transplant surgeries through Medi-Cal, California's Medicaid program.

The department has the authority to implement and clarify these organ transplant standards using less formal methods like letters or bulletins, rather than going through a more extensive regulatory process.

This law talks about telehealth in California, especially in relation to the Medi-Cal program. Telehealth allows patients to get health care services remotely without needing to meet health providers in-person. Health providers can still get paid for telehealth services as they do for in-person services, based on certain reimbursement policies. Importantly, there's no need to show a reason why an in-person visit isn’t possible to use telehealth, and there are no restrictions on where these telehealth services can take place. However, telehealth must be deemed appropriate by the healthcare provider, and they aren't forced to use it if they think an in-person visit is better. The Department of Health can issue guidelines on how this works through letters and bulletins without following the usual regulatory process.

This law allows psychiatrists to get reimbursed by Medi-Cal for providing services through telehealth, as specified in the Medicaid state plan.

This California law sets up a trial project within the Medi-Cal program to provide pediatric palliative care services for children under 21 years old. This project will explore whether these services should be permanently offered. The services are designed to meet the unique needs of children and may include hospice care that can be given alongside treatments aimed at curing an illness.

The project requires federal approval, and healthcare providers must meet certain criteria to participate. The program’s outcomes will be reported to the state legislature to assess its benefits and costs. Importantly, this effort won’t reduce any current benefits or affect eligibility for other services under the Medi-Cal or California Children’s Services programs.

This section of the California Welfare and Institutions Code aims to ensure that palliative care is part of the services offered under Medi-Cal. Palliative care is comprehensive support for patients with serious illnesses, focusing on improving quality of life by easing symptoms, pain, and stress. The law outlines that palliative care should be for all ages and stages of serious illness and could include hospice services alongside curative treatments when appropriate. The law requires establishing standards for Medi-Cal managed care plans to offer these services and emphasizes the need for these services to be cost-neutral to the state's General Fund.

Additionally, authorized providers must be licensed hospice or home health agencies with Medi-Cal contracts. The law also ensures it won't reduce or eliminate other Medi-Cal benefits, and Medi-Cal beneficiaries will still receive all eligible services concurrently. The department can implement these provisions through various non-regulatory means and must inform stakeholders about implementing instructions.

Individuals who started receiving hospice or palliative care services before they turned 21 can continue receiving these services even after reaching that age. To continue hospice care, a physician must certify eligibility under a certain federal law. For palliative care, the individual's treating healthcare provider must determine eligibility. The state will seek federal approvals if necessary and will only implement this if it gets those approvals and federal funding is available.

This law allows rural hospitals in California to participate in a two-year pilot project where they manage their own authorization for inpatient treatment under Medi-Cal. These hospitals must make an agreement with the department to ensure treatments are appropriate and stay in the project for at least one year unless removed for non-compliance.

The department will review 25% of the treated patients every six months to make sure the hospital isn't overcharging. If overcharging occurs, the department will adjust payments accordingly. If a hospital has too many unapproved treatments, actions like audits or training may occur, and participation could be revoked.

If revoked hospitals improve and limit unapproved treatments, they can be reintroduced after three months. The project will be evaluated six months after its first year to decide if it should continue. Payments might be adjusted every two weeks based on claims, necessitating federal approval. Only federally approved funds beyond the General Fund will support this initiative.

This law makes it possible for people on Medi-Cal who have Alzheimer's, cognitive issues, or life-threatening medication allergies to get free ID bracelets. The bracelets must come from a place that has a 24/7 toll-free hotline for emergencies. A licensed doctor must say the person needs this bracelet, and the state has to ensure there are at least two providers for the bracelets. The state will cover the cost only if the federal government helps pay.

This law is about providing complex rehabilitation technology to patients with significant physical impairments or functional limitations under the Medi-Cal program in California. It defines key terms like 'complex needs patient' and 'complex rehabilitation technology,' which includes customized equipment like wheelchairs and other assistive devices.

Providers must meet specific standards, employ qualified professionals, ensure the availability of parts and technicians, and provide information for maintenance and repair. Patients need evaluations by both a healthcare professional and a rehabilitation technology professional before getting certain equipment. There are guidelines for prescribing power wheelchairs or scooters, which require a medical assessment and certification of necessity. The department may implement additional controls and must obtain federal approval for these provisions.

This law says that starting May 1, 2014, Medi-Cal will cover the cost of prescribed nutritional products that are taken through a tube or similar method. The coverage is based on a specific list of approved products and usage rules. The California Department of Health Care Services will share details with providers using bulletins or similar announcements, without going through a full regulatory process. This can only be done if it's allowed under federal law, and the department will also apply to get federal funds for this coverage.

This section outlines dental benefits for Medi-Cal beneficiaries based on age groups and funding availability. Adults 21 and over are entitled to one dental cleaning and an initial exam per year, plus medically necessary crowns on back teeth according to specific criteria. Meanwhile, those under 21 receive coverage for two cleanings and exams annually. Furthermore, crowns made from certain materials are reimbursable the same as stainless steel crowns. The Medi-Cal Dental Manual of Criteria lists all covered benefits, aligning with dental associations' guidelines. Pre-treatment X-rays are required to prevent fraud in dental fillings claims, except for young children and individuals with developmental disabilities. Any policy changes can be communicated without formal regulatory action, and the implementation depends on federal approval and funding.

This law says that starting May 1, 2014, certain dental services for people age 21 and over are covered under Medi-Cal if they pass federal approval. Services include examinations, x-rays, cleanings, fluoride treatments, fillings, crowns, root canals, and complete dentures, along with emergency procedures related to these services. However, these benefits will only be implemented as allowed by federal law. The Department of Health Care Services doesn't need to make new regulations to put this into effect; they can use existing communications like bulletins. They must also seek federal approval and financial support for these services.

This section of the law requires the department to run a dental outreach and education program for people who use Medi-Cal, which is a California health care program. This program is only required if there's enough funding available. It aims to educate Medi-Cal users about the availability of dental care, recommended dental care frequencies, how to access Medi-Cal dental services, avoid scams, and get help with dental problems.

Special focus is on underserved groups and parents of children. The program's components include adding dental information to ongoing outreach and advertising, mailing educational materials, and displaying consumer protection materials at dental service locations. The department should work with dental professionals, community groups, and media experts to make the program effective.

This law requires that facilities defined by specific Health and Safety Code sections must be reimbursed by Medi-Cal for services provided to beneficiaries who have developmental disabilities and were living in certain licensed care facilities as of July 1, 2000. These payments will continue as long as the individual remains in such a facility.

The law also maintains existing reimbursement requirements and time limits. It mandates that the state seek additional federal financial support and any necessary federal approvals. If federal funds are unavailable, the services will still be funded by the state's General Fund.

This law states that California's Medi-Cal program can include services provided by the Programs of All-Inclusive Care for the Elderly (PACE) if approved by federal Medicaid authorities. To qualify, beneficiaries must meet the criteria for needing nursing facility services according to Medi-Cal standards.

The specific services covered under PACE are detailed in the federal regulations at 42 C.F.R. 460.92.

This section outlines the provision of personal care services as a covered benefit for certain Medicaid-eligible individuals in California, contingent upon federal financial participation. Personal care services are comprehensive and include help with daily activities like bathing, grooming, dressing, and medical tasks, but they must be provided in the home by a qualified person and authorized by social services. The law requires federal approval for implementing these services, and financial constraints are tied to the historical state appropriation levels from the early 1990s.

Specifically, funds must not surpass those established in prior fiscal years, with adjustments for caseload growth. The law also details reimbursement rates for service providers, encouraging counties to use their funds to access federal matching grants under certain conditions.

There are specific eligibility rules, particularly excluding services to residents of licensed facilities and only covering individuals with serious conditions that require such in-home care. If any part of this section is invalidated by a court, the entire section becomes inoperative. The law aims to ensure Medicaid services for both categorically and medically needy individuals while managing state and federal budget constraints.

This law section requires that before setting new payment rates for Medi-Cal personal care service providers, counties must review and ensure these rates align with their budgets. They need to confirm they can afford their share of any cost increases. This certification must be included when the rates are submitted to the relevant department.

Waiver personal care services are special care services offered to people eligible for nursing services under specific waivers. These services help people stay in their homes instead of moving to nursing facilities. To receive these services, individuals must have an approved waiver, doctor's orders, and they must personally consent or have a decisionmaker consent for them. The services must be necessary to keep them safe at home and not replace other authorized services.

The state will notify local administrators when someone qualifies, and these administrators will then check what other services they are eligible for. Services can be provided by certified home health agencies or personal care service providers, and payments will be handled as per existing systems. The statute will only be implemented if it doesn't increase state expenses and has federal approval.

This law requires Medi-Cal to cover the usual patient care costs for cancer patients participating in qualifying clinical trials if recommended by their doctor and if the trial could potentially benefit them. Routine costs include typical healthcare services, monitoring, and care related to the investigational treatment, but not unapproved drugs, non-medical expenses, data-only services, or standard trial sponsor free services.

The clinical trial must be recognized for its role in addressing serious diseases. Coverage may be limited to California facilities unless the trial isn't available there. Implementing this law depends on federal approval and financial participation.

This law section clarifies rights and procedures related to moving residents from nursing facilities or hospitals into the community under specific conditions. It defines 'facility residents' as those residing in nursing homes paid by Medi-Cal or waiting for transfer from hospitals. For those still in hospital care, the law requires quick processing of applications to support their transition to community living.

It introduces a waiver that supports services like community transition expenses up to $5,000, including essentials like furnishings and utilities, and involves services to help individuals improve skills needed to live in the community. Certain caregivers can get exemptions allowing them to work extended hours if they meet conditions, like living with their patient or continuous caregiving for over two years, or when language barriers exist.

Providers can apply for these exemptions, and decisions must be communicated within 30 days. This law is only active if budget-neutral conditions are maintained and if supported financially by federal Medicaid services.

This law outlines the reimbursement process for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) for medical services, specifying they are paid per visit. It includes provisions for adjusting payment rates based on changes in services offered, and allows for adjustments related to costs of new facilities or services. The law addresses billing for telehealth services, detailing how visits can include various health professionals and modes of interaction, like audio-only or video calls, and how these can affect billing rates.

There are specific rules for altering the rate when the scope of services changes and for extraordinary circumstances. The law allows for billing adjustments when FQHCs or RHCs provide services like Drug Medi-Cal and specialty mental health services under special agreements. Processes for seeking adjustments are defined, including documentation requirements and timelines for requests.

The department retains discretion over supplemental payments and rate adjustments, and any changes are generally subject to federal approval. The law also allows for FQHCs and RHCs to appeal disputes in rate setting and service changes. It sets an expiration date for the provisions on July 1, 2026.

This section outlines how federally qualified health centers (FQHCs) and rural health clinics (RHCs) in California receive funding and reimbursement for health services, including adjustments based on service changes. Medicare Economic Index affects per-visit rates, and clinics can request rate adjustments if services change. Reimbursement details for extraordinary circumstances and telehealth services are also provided. Scope-of-service changes can affect reimbursement rates, and these changes must be submitted annually. FQHCs and RHCs can also seek supplemental payments under specific extraordinary circumstances.

Additionally, the section allows billing for services related to mental health and Drug Medi-Cal if applicable conditions are met, while excluding their costs from general per-visit rates. It includes procedures for establishing new facility rates and adjustments if clinics or services relocate or expand. The section mandates federal approval for funding conditions and outlines the need for communication with stakeholders before implementing changes. It becomes fully operative in 2026.

This section highlights the deadlines for federally qualified health centers (FQHCs) or rural health clinics to file scope-of-service change requests. Generally, these requests must be submitted within 150 days after the start of the clinic's fiscal year, following the year when the change happened. However, certain FQHCs that meet specific criteria outlined in another section can be considered timely if they meet additional requirements.

This law outlines the transition from cost-based reimbursement to a prospective payment system (PPS) for federally qualified health centers (FQHCs) in Los Angeles County that were part of a past waiver demonstration project. From July 1, 2005, these centers will adopt a PPS rate based on past per-visit rate data or a base rate adjusted according to specified rules.

FQHCs must report changes only for services up to June 30, 2005, without needing new cost reports. All relevant paperwork for scope-of-service changes must be filed by July 1, 2006. The department will then calculate a rate adjustment, retroactive to July 1, 2005, and will seek necessary federal approvals to implement these changes without regulatory action, if funding allows.

This law section is about the timeline and process for dealing with claims for reimbursement. Once a claim is received, the department has 150 days to finalize it. After finalization, payment should be made within 30 days. If there's a dispute over the amounts, then it follows a different process outlined in another section. Changes to the scope of these claims must be finalized within 90 days and paid within 30 days of finalization.

This law section allows Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to request rate adjustments for changes in their services that happened in the fiscal year ending in 2004. As long as these requests are submitted within 90 days after the end of a specific 150-day period, they are considered filed on time. This applies to changes occurring between January 1, 2001, and the end of the 2003 fiscal year.

This law ensures that Medi-Cal recipients aged 65 or older can receive an annual cognitive health assessment if they're not already eligible for a similar assessment through Medicare. Doctors can only get paid for these assessments if they use specific tools recommended by the state. The assessments should help detect signs of Alzheimer's or dementia, following recognized standards. By early 2024, the state must review and publicize information on these assessments. The law can be implemented through various instructions without additional regulatory procedures, but it depends on federal approval and funding.

This law specifies that, under federal law, developmental screenings must be offered as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for children up to three years old.

Medi-Cal managed care plans are responsible for ensuring that these screenings follow specific schedules and tools recommended by the American Academy of Pediatrics.

Providers must use complete and validated developmental screening tools according to recommended guidelines.

The law also clarifies that it does not change other EPSDT benefits or blood lead screening obligations for children on Medi-Cal.

This law allows healthcare services to be provided remotely without requiring the patient to be physically present at the clinic during or shortly after a state of emergency. This applies to community clinics and other Medi-Cal providers.

The term 'enrolled community clinic' includes various types of clinics, such as federally recognized tribal clinics and federally qualified health centers (FQHCs). Also, the term 'immediately following' a state of emergency can be up to 90 days but may be extended in special cases.

Telehealth and telephonic services provided during this period are reimbursable if federal approvals and funds are obtained. The law ensures that telehealth services extend to the patient's home, temporary shelters, or other locations within the emergency area.

Finally, the department can issue guidelines without regulatory actions, provided federal permissions and funding are secured.

This law requires that by July 1, 2020, guidelines be published online to help community clinics and other Medi-Cal providers get reimbursed for services during a state of emergency. The guidance explains how to file claims for telehealth services, even if they're offered outside a clinic, like in a patient's home.

Medi-Cal plans must ensure their payment processors follow all laws and guidance. It identifies which services can be given over the phone and which need video or other tech, and lists the equipment that can be used and reimbursed. Plus, it outlines how claims should be paid promptly, even allowing for easier billing processes.

The law also explains terms like "telehealth" and "asynchronous store and forward" and mandates seeking federal approvals when needed. Finally, the department can provide updates without regulatory actions and must enact formal regulations by January 1, 2024.

This law defines how telehealth services should be handled within the California Medi-Cal program. It specifies that in-person meetings between healthcare providers and patients are not necessary for covered services that can be conducted through telehealth, like video calls, phone conversations, or remote monitoring, as long as they meet specific care standards. By January 2024, these services will need to be offered both by video and audio platforms, with exceptions allowed in some scenarios.

Healthcare providers must inform patients about their right to choose in-person visits and the voluntary nature of using telehealth, documenting that this information has been communicated. New patient relationships can be established via video interactions but have restrictions for other telehealth methods, except in certain conditions.

The law ensures payments for virtual services are equal to those for in-person ones, provided they fulfill the required standards. It also emphasizes maintaining privacy and security for patient data in line with federal laws. Any implementation is subject to federal approval, and the section is effective from January 1, 2023, or when federal approvals are obtained.

This law section is about how counties or the Department of Health Care Services in California should handle Telehealth services under the Drug Medi-Cal Treatment Program. It says that certified providers can offer medically necessary services through video or audio calls but with certain rules.

Providers cannot start new patient relationships using certain virtual methods unless there's an exception stated elsewhere. All services must follow privacy laws like HIPAA. The law will only take effect if federal approvals and funding are in place, and official regulations are expected by July 1, 2024. Meanwhile, guidelines may be provided informally before regulations are fully adopted.

Starting July 1, 2022, Medi-Cal will cover dyadic behavioral health visits, which focus on the mental and developmental health of children using a family-centered approach. These services, available during medical visits, are designed to support children's social-emotional health, developmental parenting, and maternal mental health by providing screenings and referrals for issues like behavioral health problems, food insecurity, and housing instability.

The implementation of these services depends on obtaining federal approval and ensuring federal funding is secure. The health department can administer this section through various communication methods without further regulatory steps.

This California law states that you don't need prior approval to get prosthetic devices or have them repaired or replaced if the cost is under $500. The same goes for orthotic devices if the cost is under $250. This policy started on March 1, 1994, but only if a certain report showed it was cost-effective or if the report wasn't submitted by the end of 1993. However, if it's found that skipping prior approval leads to overuse, the requirement could be reinstated with 30 days' notice to a specific legislative committee.

This law states that day care habilitative services are specifically available for pregnant and postpartum women who have been exposed to alcohol or drugs. It also mentions that these services may be provided if required by federal law. Importantly, this provision became effective on July 1, 2013.

This law requires the creation of performance measures to ensure that California's dental fee-for-service program offers quality care and access to services. The department must consult with various stakeholders before finalizing these measures, which will evaluate aspects such as utilization, access, and effectiveness of care for both children and adults.

The law outlines specific metrics, including the number of dental visits, preventive services, and treatment services, as well as ratios like sealant to restoration and filling to preventive services. Data on these measures must be posted online and updated regularly.

The department can update these measures based on feedback and comparisons with other programs. Reports on complaints and grievances regarding dental services must also be publicly available, and annual utilization data must be published, detailing service provision down to the provider level.

This section outlines the responsibilities of licensed intermediate care facilities for individuals with developmental disabilities in arranging and financing day treatment and transportation services as part of an individual's program plan. These services are coordinated through regional centers, and the facilities must reimburse the regional center for these costs. The State Department of Developmental Services will reimburse the facilities, including additional fees for administrative costs. If a facility fails to pay within 30 days, the debt may be collected in several ways, like lump sum payments or offsets against government payments.

Furthermore, the state aims to secure federal funds to help cover these costs, and if such funds aren't available, the General Fund will cover them. The implementation of this section is contingent on federal approval, and changes may be made to align with federal requirements.

This law discusses California's plan to expand the In-Home Supportive Services (IHSS) program through a Medicaid waiver called the IHSS Plus waiver. The goal is to offer IHSS as a Medi-Cal benefit, leveraging federal funding where available.

The waiver aims to keep existing IHSS eligibility and operational requirements but gives the director flexibility to adjust these terms to secure federal approval. When implemented, eligible individuals will access IHSS through the waiver instead of the standard program, with benefits limited by the waiver's terms and federal funding availability.

The law specifies that services can't be offered to residents of licensed care facilities and ensures reimbursement rates are consistent with those of the existing IHSS program. The department can implement this section outside the usual regulatory process and issue emergency regulations temporarily.

In case of conflicts between the waiver and state regulations, the waiver takes precedence for covered services. Certain sections of the IHSS program remain unchanged, and the director must report any significant adjustments required to obtain the waiver.

This law outlines the implementation of the IHSS Plus option, a program that adds self-directed personal assistance services as a Medi-Cal benefit under the state's Medicaid plan. It requires approval from federal authorities and aims to align with the existing In-Home Supportive Services (IHSS) program. However, adjustments to eligibility and benefits can be made to meet federal requirements.

Once the IHSS Plus option is available, those eligible for it cannot receive overlapping services from the traditional IHSS program. Additionally, the IHSS Plus benefits are not available to residents of certain health and care facilities. The reimbursement rates for the IHSS Plus option will match those of the existing IHSS program in each county.

The implementation of this option bypasses traditional regulatory processes, with the department authorized to issue guidelines via letters instead of formal regulations, which can stay effective up to 18 months. The department cannot alter specific existing IHSS provisions, maintaining consistency with current safeguards. Notification to the Legislature is required upon federal approval of changes.

This law allows personal care services, which are typically provided at home, to also be used at a recipient's workplace if two conditions are met. First, the services must already be approved for home use and should help the individual obtain, keep, or return to work, without replacing employer obligations under the Americans with Disabilities Act. Second, any work-related personal care hours must not exceed the total hours already authorized for home use, meaning no extra hours can be added just for work purposes.

The California Department of Health Care Services must evaluate if it's cost-effective to offer home and community-based services under a specific federal option. These services would include help with daily living activities for people needing assistance, like the elderly and those with disabilities. The department will work with other state agencies to make this decision. If it decides this option is cost-effective, the department must create a council, primarily comprising people with disabilities and elderly individuals, to help develop the program.

The department can use informal methods like letters to implement decisions until official regulations are made, and services can be administered by different state departments. They must also adopt emergency regulations within two years of federal approval, which are considered crucial for immediate public welfare and don't need to be reviewed by the Office of Administrative Law.

This law explains that services provided by physician assistants are covered under certain health care programs, as long as federal law allows and certain rules are followed. If a service is covered when done by a doctor, it's also covered if done by a physician assistant, provided they stay within their professional limits.

Additionally, supervising doctors are not required to follow more strict rules for reviewing or signing off on a physician assistant's work than what is already mandated by existing professional codes and regulations.

This law explains that certain pharmacist services are covered under the Medi-Cal program, provided they're approved by federal authorities. These services include providing travel medications, naloxone, self-administered contraception, immunizations, tobacco cessation support, and specific prophylaxes. Pharmacist services are reimbursed at 85% of the rate for doctors, except for certain management services related to specialty drugs.

Pharmacists must be enrolled as providers before offering reimbursable services. The law also allows the department to establish guidelines without formal regulation processes initially but requires regulations by July 2021, and they must report progress semiannually.

This section of the law sets up a system for reimbursing pharmacists for providing medication therapy management (MTM) services when dealing with certain specialty drugs. It requires pharmacies to enter into a contract with the department to be eligible for these reimbursements. The program is supported by annual funding and is intended to enhance existing Medi-Cal payments for pharmacists aiding patients who might struggle with their medication plans. The department will establish protocols, reimbursement rates, and eligibility criteria for these services. Federal approval and cooperation are needed to implement this program, and it will kick in from July 1, 2021, or when federal approvals are in place, whichever is later. The law also clarifies that it should not limit any pharmacist services currently allowed by law.

This section establishes that the county or a designated public authority is considered the employer for negotiating wages and benefits for people providing waiver personal care services. These workers are included in an established bargaining unit for in-home supportive services.

People receiving services can still hire, fire, and oversee their caregivers. The terms of employment, including pay and benefits, must be equal to those in local IHSS programs. Eligibility for benefits depends on the total hours worked across both IHSS and waiver services.

The law is only put into action if federal approvals and financial support are in place.

This law states that if federal funds aren't available, certain health-related services must be paid for using state funds. It covers services specified in related sections of other Health and Safety Codes.

This law outlines how California's Department of Health Care Services can manage the renewal and operation of the Nursing Facility/Acute Hospital Transition and Diversion Waiver. It allows the director to work with care management contractors to provide services and support for individuals transitioning from medical facilities or needing long-term care. The care management contractors must handle personal needs assessments, arrange required services, and coordinate care to prevent unnecessary hospital visits. They also need to ensure cost neutrality and can expand service slots with federal approval. Additionally, contractors must be financially stable, or the director can terminate their contracts. Finally, the law allows for expedited contract processing and requires federal approval to ensure cost neutrality for funding.