(a)The purpose of this article is to ensure that the Medi-Cal program shall be operated in the most cost-effective and efficient manner possible with the optimum number of Medi-Cal providers, and shall ensure quality of care and known access to services.
(b)For the purposes of this article, the following definitions shall apply:
(1)“Primary care provider” means either of the following:
(A)
(i)Any internist, general practitioner, obstetrician-gynecologist, pediatrician, family physician and surgeon, nonphysician medical practitioner, or
any primary care clinic, rural health clinic, community clinic or hospital outpatient clinic currently enrolled in the Medi-Cal program, which agrees to provide case management to Medi-Cal beneficiaries.
(ii)For purposes of this subparagraph, “fam
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(a)
The purpose of this article is to ensure that the Medi-Cal program shall be operated in the most cost-effective and efficient manner possible with the optimum number of Medi-Cal providers, and shall ensure quality of care and known access to services.
(b)
For the purposes of this article, the following definitions shall apply:
(1)
“Primary care provider” means either of the following:
(A)
(i)
Any internist, general practitioner, obstetrician-gynecologist, pediatrician, family physician and surgeon, nonphysician medical practitioner, or
any primary care clinic, rural health clinic, community clinic or hospital outpatient clinic currently enrolled in the Medi-Cal program, which agrees to provide case management to Medi-Cal beneficiaries.
(ii)
For purposes of this subparagraph, “family physician” means a primary care physician and surgeon who renders continued comprehensive and preventative health care services to individuals and families, and who has received specialized training in an approved family medicine residency for three years after graduation from an accredited medical school.
(B)
A county or other political subdivision that employs, operates, or contracts with, any of the primary care providers listed in
subparagraph (A), and that agrees to use that primary care provider for the purposes of contracting under this article.
(2)
“Primary care case management” means responsibility for the provision of referral, consultation, ordering of therapy, admission to hospitals, followup care, and prepayment approval of referred services.
(3)
“Designation form” or “form” means a form supplied by the department to be executed by a Medi-Cal beneficiary and a primary care provider or other entity eligible pursuant to this article who has entered into a contract with the department pursuant to this article, setting forth the beneficiary’s choice of contractor and an agreement to be limited by the case management decisions of that contractor and the contractor’s agreement to be responsible for
that beneficiary’s case management and medical care, as specified in this article.
(4)
“Emergency services” means health care services rendered by an eligible Medi-Cal provider to a Medi-Cal beneficiary for those health services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions which if not immediately diagnosed and treated could lead to disability or death.
(5)
“Modified primary care case management” means primary care case management wherein capitated services are limited to primary care practitioner office visits only.
(6)
“Service area” means an area designated by either a single federal Postal ZIP Code or by two or more Postal ZIP Codes that are
contiguous.
(c)
For purposes of Medi-Cal managed care plans, as defined in subdivision (m) of Section 14016.5, “nonphysician medical practitioner” means a physician assistant performing services under physician and surgeon supervision in compliance with Chapter 7.7 (commencing with Section 3500) of Division 2 of the Business and Professions Code, a certified nurse-midwife performing services under physician and surgeon supervision in compliance with Article 2.5 (commencing with Section 2746) of Chapter 6 of Division 2 of the Business and Professions Code, or a nurse practitioner performing services in collaboration with a physician and surgeon pursuant to Chapter 6 (commencing with Section 2700) of Division 2 of the Business and Professions Code.