2005 California Health and Safety Code Sections 124900-124945 Article 2. Primary Care

124900.  (a) (1) The State Department of Health Services shall
select primary care clinics that are licensed under paragraph (1) or
(2) of subdivision (a) of Section 1204, or are exempt from licensure
under subdivision (c) of Section 1206, to be reimbursed for
delivering medical services, including preventive health care, and
smoking prevention and cessation health education, to program
beneficiaries.
   (2) Except as provided for in paragraph (3), in order to be
eligible to receive funds under this article a clinic shall meet all
of the following conditions, at a minimum:
   (A) Provide medical diagnosis and treatment.
   (B) Provide medical support services of patients in all stages of
illness.
   (C) Provide communication of information about diagnosis,
treatment, prevention, and prognosis.
   (D) Provide maintenance of patients with chronic illness.
   (E) Provide prevention of disability and disease through
detection, education, persuasion, and preventive treatment.
   (F) Meet one or both of the following conditions:
   (i) Are located in an area federally designated as a medically
underserved area or medically underserved population.
   (ii) Are clinics that are able to demonstrate that at least 50
percent of the patients served are persons with incomes at or below
200 percent of the federal poverty level.
   (3) Notwithstanding the requirements of paragraph (2), all clinics
that received funds under this article in the 1997-98 fiscal year
shall continue to be eligible to receive funds under this article.
   (b) As a part of the award process for funding pursuant to this
article, the department shall take into account the availability of
primary care services in the various geographic areas of the state.
The department shall determine which areas within the state have
populations which have clear and compelling difficulty in obtaining
access to primary care.  The department shall consider proposals from
new and existing eligible providers to extend clinic services to
these populations.
   (c) Each primary care clinic applying for funds pursuant to this
article shall demonstrate that the funds shall be used to expand
medical services, including preventive health care, and smoking
prevention and cessation health education, for program beneficiaries
above the level of services provided in the 1988 calendar year or in
the year prior to the first year a clinic receives funds under this
article if the clinic did not receive funds in the 1989 calendar
year.
   (d) (1) The department, in consultation with clinics funded under
this article, shall develop a formula for allocation of funds
available.  It is the intent of the Legislature that the funds
allocated pursuant to this article promote stability for those
clinics participating in programs under this article as part of the
state's health care safety net and at the same time be distributed in
a manner that best promotes access to health care to uninsured
populations.
   (2) The formula shall be based on both of the following:
   (A) A hold harmless for clinics funded in the 1997-98 fiscal year
to continue to reimburse them for some portion of their uncompensated
care.
   (B) Demonstrated unmet need by both new and existing clinics, as
reflected in their levels of uncompensated care reported to the
department.  For purposes of this article, "uncompensated care" means
clinic patient visits for persons with incomes at or below 200
percent of the federal poverty level for which there is no
encounter-based third-party reimbursement which includes, but is not
limited to, unpaid expanded access to primary care claims and other
unreimbursed visits as verified by the department according to
subparagraph (A) of paragraph (5).
   (3) In the 1998-99 fiscal year, the department shall allocate
funds for a three-year period as follows:
   (A) If the funds available for the purposes of this article are
equal to or less than the prior fiscal year, clinics that received
funding in the prior fiscal year shall receive 90 percent of their
prior fiscal year allocation, subject to available funds, provided
that funding award is substantiated by the clinics' reported levels
of uncompensated care.  The remaining funds beyond 90 percent shall
be awarded in the following order:
   (i) First priority shall be given to clinics that participated in
the program in prior fiscal years, withdrew from the program due to
financial considerations, were subsequently categorized as "new
applicants" when they reapplied to the program, and received a
significantly reduced allocation as a result.  These clinics shall be
awarded 90 percent of their allocation prior to their withdrawal
from the program, subject to available funds, provided that award
level is substantiated by the clinics' reported levels of
uncompensated care.
   (ii) Second priority shall be given to those clinics that received
program funds in the prior year and continue to meet the minimum
requirements for funding under this article.  In implementing this
priority, the department shall allocate funds to all eligible
previously funded clinics on a proportionate basis, based on their
reported levels of uncompensated care, which may include, but is not
limited to, unpaid expanded access to primary care claims and other
unreimbursed patient visits, as verified by the department according
to subparagraph (A) of paragraph (5).
   (B) If funds available for the purposes of this article are equal
to or less than the prior fiscal year, only those clinics that
received program funds in the prior fiscal year may be awarded funds.
  Funds shall be awarded in the same priority order as specified in
clauses (i) and (ii) of subparagraph (A).
   (C) If funds available for purposes of this article are greater
than the prior fiscal year, clinics that received funds in the prior
fiscal year shall be awarded 100 percent of their prior fiscal year
allocation, provided that funding award level is substantiated by the
clinics' reported levels of uncompensated care.  Remaining funds
shall be awarded in the following priority order:
   (i) First priority shall be given to clinics that participated in
the program in prior fiscal years, withdrew from the program due to
financial considerations, were subsequently categorized as "new
applicants" when they reapplied to the program, and received a
significantly reduced allocation as a result.  These clinics shall be
awarded 100 percent of their allocation prior to their withdrawal
from the program, provided that award level is substantiated by the
clinics' reported levels of uncompensated care.
   (ii) Second priority shall be given to new and existing applicants
that meet the minimum requirements for funding under this article.
In implementing this priority, the department shall allocate funds to
all eligible previously funded clinics on a proportionate basis,
based on their reported levels of uncompensated care, which may
include, but is not limited to, unpaid expanded access to primary
care claims and other unreimbursed patient visits, as verified by the
department, according to subparagraph (A) of paragraph (5).
   (4) In the 2001-02 fiscal year, and subsequent fiscal years, the
department shall allocate available funds, for a three-year period,
as follows:
   (A) Clinics that received funding in the prior fiscal year shall
receive 90 percent of their prior fiscal year allocation, subject to
available funds, provided that the funding award is substantiated by
the clinics' reported levels of uncompensated care.
   (B) The remaining funds beyond 90 percent shall be awarded to new
and existing applicants based on the clinics' reported levels of
uncompensated care as verified by the department according to
subparagraph (B) of paragraph (5).  The department shall seek input
from stakeholders to discuss any adjustments to award levels that the
department deems reasonable such as including base amounts for new
applicant clinics.
   (C) New applicants shall be awarded funds pursuant to this
subdivision if they meet the minimum requirements for funding under
this article based on the clinics' reported levels of uncompensated
care as verified by the department according to subparagraph (B) of
paragraph (5).  New applicants include applicants for any new site
expansions by existing applicants.
   (D) The department shall confer with clinic representatives to
develop a funding formula for the program implemented pursuant to
this paragraph to use for allocations for the 2004-05 fiscal year and
subsequent fiscal years.
   (E) This paragraph shall become inoperative on July 1, 2004.
   (5) In assessing reported levels of uncompensated care, the
department shall utilize the most recent data available from the
Office of Statewide Health Planning and Development's (OSHPD)
completed analysis of the "Annual Report of Primary Care Clinics."
   (A) In the 1998-99 to 2000-01 fiscal years, inclusive, clinics
shall submit updated data regarding the clinics' levels of
uncompensated care to the department with their initial application,
and for each of the two remaining years in the three-year application
period.  The department shall compare the clinics' updated
uncompensated care data to the OSHPD uncompensated care data for that
clinic for the same reporting period.  Discrepancies in
uncompensated care data for any particular clinic shall be resolved
to the satisfaction of the department prior to the award of funds to
that clinic.
   (B) In the 2001-02 fiscal year, and subsequent fiscal years,
clinics may not submit updated data regarding the clinics' levels of
uncompensated care.  The department shall utilize the most recent
data available from OSHPD's completed analysis of the "Annual Report
of Primary Care Clinics."
   (C) If the funds allocated to the program are less than the prior
year, the department shall allocate available funds to existing
program providers only.
   (6) The department shall establish a base funding level, subject
to available funds, of no less than thirty-five thousand dollars
($35,000) for frontier clinics and Native American reservation-based
clinics.  For purposes of this article, "frontier clinics" means
clinics located in a medical services study area with a population of
fewer than 11 persons per square mile.
   (7) The department shall develop, in consultation with clinics
funded pursuant to this article, a formula for reallocation of unused
funds to other participating clinics to reimburse for uncompensated
care.  The department shall allocate the unused funds to other
participating clinics to reimburse for uncompensated care.
   (e) In applying for funds, eligible clinics shall submit a single
application per clinic corporation.  Applicants with multiple sites
shall apply for all eligible clinics, and shall report to the
department the allocation of funds among their corporate sites in the
prior year.  A corporation may only claim reimbursement for services
provided at a program-eligible clinic site identified in the
corporate entity's application for funds, and approved for funding by
the department.  A corporation may increase or decrease the number
of its program-eligible clinic sites on an annual basis, at the time
of the annual application update for the subsequent fiscal years of
any multiple-year application period.
   (f) Grant allocations pursuant to this article shall be based on
the formula developed by the department, notwithstanding a merger of
one of more licensed primary care clinics participating in the
program.
   (g) A clinic that is eligible for the program in every other
respect, but that provides dental services only, rather than the full
range of primary care medical services, shall only be eligible to
receive funds under this article on an exception basis.  A
dental-only provider's application shall include a Memorandum of
Understanding (MOU) with a primary care clinic funded under this
article.  The MOU shall include medical protocols for making
referrals by the primary care clinic to the dental clinic and from
the dental clinic to the primary care clinic, and ensure that case
management services are provided and that the patient is being
provided comprehensive primary care as defined in subdivision (a).
   (h) (1) For purposes of this article, an outpatient visit shall
include diagnosis and medical treatment services, including the
associated pharmacy, X-ray, and laboratory services, and prevention
health and case management services that are needed as a result of
the outpatient visit.  For a new patient, an outpatient visit shall
also include a health assessment encompassing an assessment of
smoking behavior and the patient's need for appropriate health
education specific to related tobacco use and exposure.
   (2) "Case management" includes, for this purpose, the management
of all physician services, both primary and specialty, and
arrangements for hospitalization, postdischarge care, and followup
care.
   (i) (1) Payment shall be on a per-visit basis at a rate that is
determined by the department to be appropriate for an outpatient
visit as defined in this section, and shall be not less than
seventy-one dollars and fifty cents ($71.50).
   (2) In developing a statewide uniform rate for an outpatient visit
as defined in this article, the department shall consider existing
rates of payments for comparable outpatient visits.  The department
shall review the outpatient visit rate on an annual basis.
   (j) Not later than May 1 of each year, the department shall adopt
and provide each licensed primary care clinic with a schedule for
programs under this article, including the date for notification of
availability of funds, the deadline for the submission of a completed
application, and an anticipated contract award date for successful
applicants.
   (k) In administering the program created pursuant to this article,
the department shall utilize the Medi-Cal program statutes and
regulations pertaining to program participation standards, medical
and administrative recordkeeping, the ability of the department to
monitor and audit clinic records pertaining to program services
rendered to program beneficiaries and take recoupments or recovery
actions consistent with monitoring and audit findings, and the
provider's appeal rights.  Each primary care clinic applying for
program participation shall certify that it will abide by these
statutes and regulations and other program requirements set forth in
this article.
124905.  For purposes of this article, a "program beneficiary" is
any person whose income level is at or below 200 percent of the
federal poverty level as adjusted annually.  Program beneficiaries
shall not be required to provide any copayment for services that are
funded pursuant to this article, except that clinics may charge
beneficiaries on a sliding fee scale for services, but no beneficiary
shall be denied services because of an inability to pay.  The
department shall annually adjust this income standard to reflect any
changes in the federal poverty level.  Payment pursuant to this
article shall be made only for services for which payment will not be
made through any private or public third-party reimbursement.
124906.  A program applicant's uncompensated care shall be
determined by, and based on, the number of visits for patients whose
income level is at or below 200 percent of the federal poverty level,
and whose health care costs are not reimbursed by any
encounter-based third-party payer, which includes, but is not limited
to, unpaid expanded access to primary care claims or other
unreimbursed visits, as verified by the department according to
subparagraph (A) of paragraph (5) of subdivision (d) of Section
124900.
124910.  (a) (1) Except as provided in paragraph (3) of subdivision
(a) of Section 124900, each licensed primary care clinic, as
specified in subdivision (a) of Section 124900, applying for funds
under this article, shall demonstrate in its application that it
meets all of the following conditions, at a minimum:
   (A) Provides medical diagnosis and treatment.
   (B) Provides medical support services of patients in all stages of
illness.
   (C) Provides communication of information about diagnosis,
treatment, prevention, and prognosis.
   (D) Provides maintenance of patients with chronic illness.
   (E) Provides prevention of disability and disease through
detection, education, persuasion, and preventive treatment.
   (F) Meets one or both of the following conditions:
   (i) Is located in an area federally designated as a medically
underserved area or medically underserved population.
   (ii) Is a clinic in which at least 50 percent of the patients
served are persons with incomes at or below 200 percent of the
federal poverty level.
   (2) Any applicant who has applied for and received a federal or
state designation for serving a medically underserved area or
population shall be deemed to meet the requirements of subdivision
(a) of Section 124900.
   (b) Each applicant shall also demonstrate to the satisfaction of
the department that the proposed services supplement, and do not
supplant, those primary care services to program beneficiaries that
are funded by any county, state, or federal program.
   (c) Each applicant shall demonstrate that it is an active Medi-Cal
provider by having a Medi-Cal provider number and diligently billing
the Medi-Cal program for services rendered to Medi-Cal eligible
patients during the past three months.  This subdivision shall not
apply to clinics that are not currently Medi-Cal providers, and were
funded participants pursuant to this article during the 1993-94
fiscal year.
   (d) Each application shall be evaluated by the state department
prior to funding to determine all of the following:
   (1) The number of program beneficiaries who are in the service
area of the applicant, and the number of visits, the scope of primary
care services, and the proposed total budget for outpatient visits
provided to beneficiaries under this article.  The applicant shall
provide its most recently audited financial statement to verify
budget information.
   (2) The applicant's ability to deliver basic primary care to
program beneficiaries.
   (3) A description of the applicant's operational quality assurance
program.
   (4) The applicant's use of protocols for the most common diseases
in the population served under this article.
124911.  (a) Commencing in the 1998-99 fiscal year, the department
shall release a request for allocation of funds for a period of three
succeeding fiscal years.  The request for allocation shall include
specifications for the clinics to submit uniform data on
uncompensated patient visits.
   (b) Annual funding awards for a clinic provider in the second and
third fiscal years of a three-year funding period shall be contingent
upon the clinic's satisfactory performance under the program, and
upon the availability of sufficient funds appropriated by the annual
Budget Act.
124915.  Services funded pursuant to this article shall be limited
to the extent that funds are appropriated for this purpose.
124920.  (a) The department shall utilize existing contractual
claims processing services in order to promote efficiency and to
maximize use of funds.
   (b) The department shall certify which primary care clinics are
selected to participate in the program for each specific fiscal year,
and how much in program funds each selected primary care clinic will
be allocated each fiscal year.
   (c) The department shall make an advance payment for funds
appropriated for services provided under this article to the selected
primary care clinics in an amount not to exceed 25 percent of a
clinic's allocation for visits provided to program beneficiaries.
These advance payments may only be made during the 1994-95 fiscal
year.
   (d) In the event the department's contractual claims processing
service is not ready to accept and timely adjudicate program claims
by August 15, 1994, the department shall reimburse clinic billings in
excess of the advance payment until such time as the contractual
claims processing mechanism is viable.
   (e) The department shall pay claims from selected primary care
clinics up to each clinic's annual allocation, adjusted for advance
payments made under subdivision (c) and claims reimbursement made
under subdivision (d).  Once a clinic has exhausted its annual
allocation, the state shall stop paying its program claims.
   (f) The department may adjust any selected primary care clinic's
allocation to take into account:
   (1) An increase in program funds appropriated for the fiscal year.
   (2) A decrease in program funds appropriated for the fiscal year.
   (3) A clinic's projected inability to fully spend its allocation
within the fiscal year.
   (4) Surplus funds reallocated from other selected primary care
clinics.
   (g) The department shall notify all affected primary care clinics
in writing prior to adjusting selected primary care clinics'
allocations.
   (h) Cessation of program payments under subdivision (e) or
adjustment of selected primary care clinic's allocations under
subdivision (f) shall not be subject to the Medi-Cal appeals process
referenced in subdivision (g) of Section 124900.
   (i) A clinic's allocation under this article shall not be reduced
solely because the clinic has engaged in supplemental fundraising
drives and activities, the proceeds of which have been used to defray
the costs of services to the uninsured.
124925.  The department shall submit a report on its activities
under this article to the Legislature no later than January 1, 1991,
and annually thereafter.
124927.  Final payment adjustments reflecting advance payments
pursuant to this article shall be made pursuant to a plan of
financial adjustment that is approved by the state department and
submitted to the Controller.
124930.  (a) For any condition detected as part of a child health
and disability prevention screen for any child eligible for services
under Section 104395, if the child was screened by the clinic or upon
referral by a child health and disability prevention program
provider, unless the child is eligible to receive care with no share
of cost under the Medi-Cal program, is covered under another publicly
funded program, or the services are payable under private coverage,
a clinic shall, as a condition of receiving funds under this article,
do all of the following:
   (1) Insofar as the clinic directly provides these services for
other patients, provide medically necessary followup treatment,
including prescription drugs.
   (2) Insofar as the clinic does not provide treatment for the
condition, arrange for the treatment to be provided.
   (b) (1) If any child requires treatment the clinic does not
provide, the clinic shall arrange for the treatment to be provided,
and the name of that provider shall be noted in the patient's medical
record.
   (2) The clinic shall contact the provider or the patient or his or
her guardian, or both, within 30 days after the arrangement for the
provision of treatment is made, and shall determine if the provider
has provided appropriate care, and shall note the results in the
patient's medical record.
   (3) If the clinic is not able to determine, within 30 days after
the arrangement for the provision of treatment is made, whether the
needed treatment was provided, the clinic shall provide written
notice to the county child health and disability prevention program
director, and shall also provide a copy to the state director of the
program.
   (c) (1) For the 1994-95 and 1995-96 fiscal years, inclusive, the
state department may establish a reimbursement program for referral
case management services required pursuant to subdivision (b),
provided to a child pursuant to subdivision (a).
   (2) The department may utilize funds appropriated for the purposes
of this article for reimbursements under paragraph (1).
124940.  The use of funds granted pursuant to this article for use
by school-based clinics shall be limited to those school-based
clinics that were licensed and in operation before January 1, 1990.
124945.  Any entity or provider that receives funds pursuant to this
article shall expend those funds in accordance with the requirements
of Article 2 (commencing with Section 30121) of Chapter 2 of Part 13
of Division 2 of the Revenue and Taxation Code.