§ 14093.05. — 14093.05. (Amended by Stats. 2023, Ch. 266, Sec. 2.)

California § 14093.05.

• Jurisdiction: California
• Code WIC: Welfare and Institutions Code - WIC
• Div. 9.: DIVISION 9. PUBLIC SOCIAL SERVICES
• Part 3.: PART 3. AID AND MEDICAL ASSISTANCE
• Ch. 7.: CHAPTER 7. Basic Health Care
• Art. 2.97.: ARTICLE 2.97. Managed Care Plan Contracts

Text

(a)
(1)
Except as otherwise authorized pursuant to this chapter, the director shall enter into contracts, under this chapter and Chapter 8 (commencing with Section 14200), with managed care plans licensed pursuant to 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), for the provision of medical benefits to all persons who are eligible to receive medical benefits under publicly supported programs. The
director may also amend existing Medi-Cal managed care contracts to include the provision of medical benefits to persons who are eligible to receive medical benefits under publicly supported programs. Contracts may be on an exclusive or nonexclusive basis.
(2)
Prior to issuing a new request for proposal or entering into new contracts pursuant to paragraph (1), the director shall provide an opportunity for interested stakeholders to provide input to inform the development of contract provisions.
(b)
Contractors pursuant to this article and participating providers acting pursuant to subcontracts with those contractors, shall agree to hold harmless the beneficiaries of the publicly supported programs if the
contract between the sponsoring government agency and the contractor does not ensure sufficient funding to cover program benefits.
(c)
Any managed care contractor serving children with conditions eligible under the California Children’s Services (CCS) program shall maintain and follow standards of care established by the program, including use of paneled providers and CCS-approved special care centers and shall 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.
(d)
(1)
Any managed care contractor serving children with conditions eligible under the CCS program shall report expenditures and savings separately for CCS-covered services and CCS-eligible children.
(2)
If the managed care contractor is paid according to a capitated or risk-based payment methodology, there shall be separate actuarially sound rates for CCS-eligible children.
(3)
Notwithstanding paragraph (2), 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.
(e)
This article is not intended
to 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.
(f)
To assure 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.
(g)
Any managed care contract that will affect the delivery of care to CCS-eligible children shall be approved by the state CCS program director prior to execution. The state CCS program shall continue to be responsible for selection of
CCS-paneled providers and monitoring of contractors to see that CCS state standards are maintained.

Legislative History

Amended by Stats. 2023, Ch. 266, Sec. 2. (AB 614) Effective January 1, 2024.