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.
Prepaid PlansMedi-cal At-risk Fiscal Intermediaries
Section § 14499.7
This law allows a government department to hire financial agents to handle payments for certain benefits. These contracts can be awarded through competitive bidding or without bidding, giving flexibility in choosing the best fiscal intermediary.
fiscal intermediaries benefits payments contracting
Section § 14499.71
This law section defines what a 'fiscal intermediary' is for the purposes of a certain article. It describes a fiscal intermediary as a company that handles payments for services provided to Medi-Cal recipients in exchange for receiving a fee, like a premium or subscription fee. This company also takes on financial risk and must be licensed under a specific California health care law.
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 the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).
fiscal intermediary Medi-Cal services premium payment
Section § 14499.73
This law section outlines the requirements for a fiscal intermediary in a Medi-Cal contract. The intermediary must ensure there are enough primary and supportive specialty care doctors available. Additionally, they need to have a system to manage and report information about the costs of different healthcare services provided to Medi-Cal recipients.
A contract entered into under this article shall provide that a fiscal intermediary meets both of the following criteria:
(a)CA Welfare & Institutions Code § 14499.73(a) The fiscal intermediary shall provide or arrange for an adequate number of primary care physicians and supportive specialty care physicians.
(b)CA Welfare & Institutions Code § 14499.73(b) The fiscal intermediary shall implement a management and information reporting system in order to determine the costs of each type of health care service rendered to Medi-Cal recipients.
fiscal intermediary Medi-Cal contract primary care physicians
Section § 14499.74
This law section explains how California determines payment rates, called capitated rates, for companies managing Medi-Cal services. In the first year, these rates are based on past data about Medi-Cal users in the area. After the first year, rates are based on Medi-Cal spending in similar regions. The rates must not exceed what would be paid if services were provided directly under the traditional fee-for-service Medi-Cal system.
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 is being, served by the fiscal intermediary. During the remaining years of the contract with the fiscal intermediary, the department shall utilize data concerning Medi-Cal expenditures for delivery of services based on the fee-for-service experience in comparable geographic areas. The capitated rates shall not exceed the total per capita amount (including the cost of adjustments to provide actuarial equivalence) which would be payable for all services and requirements covered under the fiscal intermediary contract adopted pursuant to this article if all those services and requirements were to be furnished to Medi-Cal beneficiaries under the fee-for-service Medi-Cal program provided for by Chapter 7 (commencing with Section 14000).
capitated rates fiscal intermediary Medi-Cal recipients
Section § 14499.75
This law allows financial agents, known as fiscal intermediaries, to make contracts with service providers who are qualified to offer services even if those services were charged individually. Essentially, if a provider could normally offer a service and get paid per task, they can still do so through a fiscal intermediary.
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.
fiscal intermediary contract service provision
Section § 14499.77
This law says that for Medi-Cal recipients living in a specific area, the fiscal intermediary will pay for their services, unless the department specifically excludes certain services. However, those services must be given by providers who have agreements with the fiscal intermediary unless the intermediary permits otherwise.
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 into agreements with the fiscal intermediary, unless authorized by the fiscal intermediary.
Medi-Cal recipients fiscal intermediary service payment
