(a)For the purposes of this section:
(1)“Eligible providers” means physicians, physician assistants, nurse practitioners, podiatrists, certified nurse midwives, licensed midwives, doula providers, psychologists, licensed professional clinical counselors, licensed clinical social workers, licensed marriage and family therapists, optometrists, audiologists, and community health workers.
(2)“Applicable professional services” means:
(A)Evaluation and management services associated with primary care and specialist office visits, preventative care services, and care management services.
(B)Maternal care services, including obstetric care services and doula services.
(C)Outpatient behavioral health services that are not the financial responsibility of county mental health plans operating pu
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(a)
For the purposes of this section:
(1)
“Eligible providers” means physicians, physician assistants, nurse practitioners, podiatrists, certified nurse midwives, licensed midwives, doula providers, psychologists, licensed professional clinical counselors, licensed clinical social workers, licensed marriage and family therapists, optometrists, audiologists, and community health workers.
(2)
“Applicable professional services” means:
(A)
Evaluation and management services associated with primary care and specialist office visits, preventative care services, and care management services.
(B)
Maternal care services, including obstetric care services and doula services.
(C)
Outpatient behavioral health services that are not the financial responsibility of county mental health plans operating pursuant to Chapter 8.9 (commencing with Section 14700).
(D)
Vaccine administration services, as specified by the department.
(E)
Vision services.
(F)
Community health worker services, as described in the approved Medi-Cal State Plan.
(G)
Evaluation and management services associated with emergency physician services.
(H)
Other services commonly provided by
primary care, specialist, and hospital-based emergency physician and non-physician health professionals as determined by the department.
(I)
Hearing aids and audiological services.
(3)
“Applicable professional services” do not include:
(A)
Abortion and family planning services.
(B)
Other allied health services, clinical laboratory services, radiology, and durable medical equipment.
(C)
Outpatient hospital facility services other than services described in subparagraphs (B) and (C) of paragraph (2).
(4)
“Applicable percentage” means:
(A)
With respect to the
applicable services listed in subparagraphs (A) and (B) of paragraph (2), 95 percent.
(B)
With respect to the applicable services listed in subparagraphs (C) to (E), inclusive, of paragraph (2), 87.5 percent.
(C)
With respect to the applicable services listed in subparagraph (F) of paragraph (2), 100 percent.
(D)
With respect to the applicable services listed in subparagraph (G) of paragraph (2), 90 percent.
(E)
With respect to the applicable services listed in subparagraphs (H) and (I) of paragraph (2), 80 percent.
(b)
Notwithstanding any other law, for dates of service no sooner than January 1, 2026, or on the effective date of any necessary federal approvals as required by subdivision
(d) of Section 14124.162, whichever is later, the department shall establish a geographically adjusted fee schedule for applicable services rendered by eligible providers consistent with the geographic localities utilized by the federal Medicare Program.
(c)
(1)
(A)
Notwithstanding any other law, for dates of service no sooner than January 1, 2025, or on the effective date of any necessary federal approvals as required by subdivision (d) of Section 14124.162, whichever is later, the reimbursement rates for eligible providers rendering the services described in subparagraph (G) of paragraph (2) of subdivision (a) shall be no less than the applicable percentage of the lowest maximum allowance established by the federal Medicare Program for the same or similar services in effect as of January 1 of the calendar year prior to the implementation of this subparagraph.
(B)
Notwithstanding any other law, for dates of service no sooner than January 1, 2026, or on the effective date of any necessary federal approvals as required by subdivision (d) of Section 14124.162, whichever is later, the reimbursement rates for eligible providers rendering the applicable professional services shall be no less than the applicable percentage of the applicable, geographically adjusted, maximum allowance established by the federal Medicare Program for the same or similar services in effect as of January 1 of the calendar year prior to the implementation of this subdivision for each geographic locality established by the Medicare Program.
(2)
The department shall develop and implement a methodology for establishing reimbursement rates or payments for services for which there is no maximum allowable rate established by the federal Medicare Program. The department shall
review this methodology annually and may, in its sole discretion, modify the methodology on a prospective basis.
(3)
The department shall annually review and, subject to appropriation by the Legislature, revise the reimbursement rates established in accordance with this subdivision based on changes to the applicable maximum allowable rate established by the federal Medicare Program for the same or similar services. Any revisions to the reimbursement rates shall be considered as part of the annual budget development process and subject to the provisions of subdivision (d) of Section 14124.162 and take effect beginning no sooner than January 1, 2026, and thereafter on each subsequent January 1 of the calendar year following the department's annual review.
(d)
Notwithstanding subdivision (b) of Section 14105.201, the following shall apply:
(1)
For contract periods during which subdivision (c) is implemented, each Medi-Cal managed care plan shall reimburse a network provider furnishing the services subject to subdivision (c) at least the amount the network provider would be paid for those services in the Medi-Cal fee-for-service delivery system, as set forth by the department in the approved Medi-Cal State Plan and guidance issued pursuant to subdivision (b) of Section 14124.162.
(2)
In any instance where a Medi-Cal managed care plan and network provider furnishing the services subject to subdivision (c) mutually agree to reimbursement on a basis other than per-service reimbursement, the Medi-Cal managed care plan shall account for the reimbursement amount required pursuant to paragraph (1) in determining the negotiated level of reimbursement and disclose to the network provider the value of any reimbursement increases
associated with the changes to Medi-Cal managed care program described in this section.
(3)
(A)
For the 2026 calendar year, the department shall require Medi-Cal managed care plans to demonstrate compliance with the requirements of paragraphs (1) and (2) in a form and manner specified by the department.
(B)
Subsequent to the 2026 calendar year, and subject to paragraph (2) of subdivision (j) of Section 14124.162, the department shall require Medi-Cal managed care plans to redemonstrate compliance with the requirements of paragraphs (1) and (2), in a form and manner specified by the department, no less than once every four years, or more frequently as deemed necessary by the department.
(C)
This paragraph does not limit the department’s authority to audit, monitor, or oversee a Medi-Cal managed
care plan’s compliance with applicable contractual, statutory, or other requirements.