(a)CA 福利和机构 Code § 10950(a) If any applicant for or recipient of public social services is dissatisfied with any action of the county department relating to his or her application for or receipt of public social services, if his or her application is not acted upon with reasonable promptness, or if any person who desires to apply for public social services is refused the opportunity to submit a signed application therefor, and is dissatisfied with that refusal, he or she shall, in person or through an authorized representative, without the necessity of filing a claim with the board of supervisors, upon filing a request with the State Department of Social Services or the State Department of Health Care Services, whichever department administers the public social service, be accorded an opportunity for a state hearing.
(b)Copy CA 福利和机构 Code § 10950(b)
(1)Copy CA 福利和机构 Code § 10950(b)(1) The requirements of Sections 100506.2 and 100506.4 of the Government Code apply to state hearings regarding eligibility for or enrollment in an insurance affordability program administered by the State Department of Health Care Services to the extent that those sections conflict with the state hearing requirements under this chapter.
(2)CA 福利和机构 Code § 10950(b)(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, 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. Notwithstanding Section 10231.5 of the Government Code, beginning July 1, 2015, the department shall provide a semiannual status report to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(3)CA 福利和机构 Code § 10950(b)(3) This subdivision shall be implemented only to the extent it does not conflict with federal law.
(c)CA 福利和机构 Code § 10950(c) Priority in setting and deciding cases shall be given in those cases in which aid is not being provided pending the outcome of the hearing. This priority shall not be construed to permit or excuse the failure to render decisions within the time allowed under federal and state law.
(d)CA 福利和机构 Code § 10950(d) Notwithstanding any other provision of this code, there is no right to a state hearing when either (1) state or federal law requires
automatic grant adjustments for classes of recipients unless the reason for an individual request is incorrect grant computation, or (2) the sole issue is a federal or state law requiring an automatic change in services or medical assistance which adversely affects some or all recipients.
(e)CA 福利和机构 Code § 10950(e) For the purposes of administering health care services and medical assistance, the Director of Health Care Services shall have those powers and duties conferred on the Director of Social Services by this chapter to conduct state hearings in order to secure approval of a state plan under applicable federal law.
(f)CA 福利和机构 Code § 10950(f) The Director of Health Care Services may contract with the State Department of Social Services for the provisions of state hearings in accordance with this chapter.
(g)CA 福利和机构 Code § 10950(g) For purposes of this chapter, the following terms
have the following meanings:
(1)CA 福利和机构 Code § 10950(g)(1) “Adverse benefit determination” means, in the case of a Medi-Cal managed care plan, any of the following:
(A)CA 福利和机构 Code § 10950(g)(1)(A) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.
(B)CA 福利和机构 Code § 10950(g)(1)(B) The reduction, suspension, or termination of a previously authorized service.
(C)CA 福利和机构 Code § 10950(g)(1)(C) The denial, in whole or in part, of payment for a service.
(D)CA 福利和机构 Code § 10950(g)(1)(D) The failure to provide services in a timely manner, as described in Section 14197.
(E)CA 福利和机构 Code § 10950(g)(1)(E) The failure of a Medi-Cal
managed care plan to act within the timeframes provided in Section 438.408(b)(1) and Section 438.408(b)(2) of Title 42 of the Code of Federal Regulations regarding the standard resolution of grievances and appeals.
(F)CA 福利和机构 Code § 10950(g)(1)(F) For a resident of a rural area with only one Medi-Cal managed care plan, excluding a Medi-Cal managed care plan defined in subparagraphs (H) and (I) of paragraph (2), the denial of an enrollee’s request to exercise his or her right under Section 438.52(b)(2)(ii) of Title 42 of the Code of Federal Regulations to obtain services outside the network.
(G)CA 福利和机构 Code § 10950(g)(1)(G) The denial of an enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.
(2)CA 福利和机构 Code § 10950(g)(2) “Medi-Cal 管理式医疗计划”指任何与该部门签订合同,根据以下任何一项规定,为已注册的 Medi-Cal 受益人提供服务的个人、组织或实体:
(A)CA 福利和机构 Code § 10950(g)(2)(A) 第3部分第7章第2.7条(自第14087.3节起),包括根据第14087.46节制定的牙科管理式医疗计划。
(B)CA 福利和机构 Code § 10950(g)(2)(B) 第3部分第7章第2.8条(自第14087.5节起)。
(C)CA 福利和机构 Code § 10950(g)(2)(C) 第3部分第7章第2.81条(自第14087.96节起)。
(D)CA 福利和机构 Code § 10950(g)(2)(D) 第3部分第7章第2.82条(自第14087.98节起)。
(E)CA 福利和机构 Code § 10950(g)(2)(E) 第3部分第7章第2.9条(自第14088节起)。
(F)CA 福利和机构 Code § 10950(g)(2)(F) 第3部分第7章第2.91条(自第14089节起)。
(G)CA 福利和机构 Code § 10950(g)(2)(G) 第3部分第8章(自第14200节起),包括牙科管理式医疗计划。
(H)CA 福利和机构 Code § 10950(g)(2)(H) 第3部分第8.9章(自第14700节起)。
(I)CA 福利和机构 Code § 10950(g)(2)(I) 根据加州 Medi-Cal 2020 示范项目(编号 11-W-00193/9)授权的县级药物 Medi-Cal 有组织交付系统,该系统经联邦医疗保险和医疗补助服务中心批准,并在《特殊条款和条件》中描述。就本款而言,“特殊条款和条件”应具有第14184.10节(o)款中规定的相同含义。
(3)CA 福利和机构 Code § 10950(g)(3) “受助人”指公共社会服务的申请人或受助人,但不包括完全由县级资金资助的援助,或第3部分第3章第1条(自第12000节起)至第6条(自第12250节起)(含)项下的援助,以及第3部分第3章第8条(自第12350节起)项下的援助,或第6部分第6章(自第18350节起)项下开展的活动,并应包括任何经批准的收养父母,如《家庭法典》第8708节(a)款第(3)项所述,并且声称其仅因居住在部门管辖范围之外而被拒绝或延迟安置儿童进行收养。