2007 California Welfare and Institutions Code Article 4. The Medi-cal Benefits Program

CA Codes (wic:14131-14138)

14131.  The Medi-Cal Benefits Program comprises a
department-administered uniform schedule of health care benefits.
Notwithstanding any other provision of this chapter, "health care
services" shall be limited to the benefits set forth in this article
and in Section 14021.



14131.15.  (a) In geographic areas in which Medi-Cal managed care
plans contracting under this chapter or Chapter 8 (commencing with
Section 14200) are operating with capacity to enroll additional
qualifying Medi-Cal beneficiaries, the director may, in the interest
of bringing managed care principles to bear on the quality, costs, or
utilization levels of the Medi-Cal program, designate any benefit or
service included in the Medi-Cal program, at state option under
federal medicaid rules, as a covered Medi-Cal benefit only when
provided by a Medi-Cal managed care plan to a Medi-Cal enrollee of
the plan.
   (b) Where benefits and services have been designated by the
director under subdivision (a), beneficiaries who are eligible to
enroll in and reside in the service area of a managed care plan, and
who desire coverage for such benefits and services, must enroll in a
Medi-Cal managed care plan to receive them and shall, to the maximum
extent permitted under federal law, remain enrolled in the plan.
   (c) When managed care capacity is reached in an area in which
Medi-Cal benefits have been designated under this section, the
director may provide for the delivery of designated benefits or
services to beneficiaries by contract to the extent permitted under
this chapter, on a fee-for-service basis or a combination of both.
   (d) Exercise of the director's discretion under this section shall
not preclude Medi-Cal managed care contractors from applying their
established medical necessity criteria, utilization control standards
and policies and utilization review procedures in delivering
designated services as permitted and controlled by Medi-Cal contract
and other state and federal regulatory standards.
   (e) Enactment of this section shall not impose any requirement on
a Medi-Cal managed care plan to negotiate or enter into a contract or
any other participation arrangement with any provider of a Medi-Cal
benefit or service designated under subdivision (a).
   (f) The department shall seek all federal waivers necessary to
allow for federal financial participation in expenditures under this
section.


14132.  The following is the schedule of benefits under this
chapter:
   (a) Outpatient services are covered as follows:
   Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
   (b) Inpatient hospital services, including, but not limited to,
physician and podiatric services, physical therapy and occupational
therapy, are covered subject to utilization controls.
   (c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.

   (d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
   (2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
   (3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers of Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
   (B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
   (e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and equipment
required for dialysis, are covered, subject to utilization controls.

   (f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
   (g) Blood and blood derivatives are covered.
   (h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
   (2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
   (A) Periodontal treatment is not a benefit.
   (B) Endodontic therapy is not a benefit except for vital
pulpotomy.
   (C) Laboratory processed crowns are not a benefit.
   (D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
   (E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
   (F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
   (3) Paragraph (2) shall become inoperative July 1, 1995.
   (i) Medical transportation is covered, subject to utilization
controls.
   (j) Home health care services are covered, subject to utilization
controls.
   (k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
   Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
   Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
   (l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
   (m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
   (n) Family planning services are covered, subject to utilization
controls.
   (o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
   (1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
   (2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
   (p) Adult day health care is covered in accordance with Chapter
8.7 (commencing with Section 14520).
   (q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.
   (2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and 1770
of the Business and Professions Code may be covered as long as they
are within the scope of Denti-Cal benefits and they are necessary
services provided by a registered dental hygienist in alternative
practice.
   (r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under Article 3
(commencing with Section 1480) of Chapter 2.5 of Division 2 of the
Health and Safety Code by a paramedic certified pursuant to that
article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.
   (2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming a
Medi-Cal provider.
   (3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
   (s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
   As used in this subdivision, in-home medical care services,
include, but are not limited to:
   (1) Level of care and cost of care evaluations.
   (2) Expenses, directly attributable to home care activities, for
materials.
   (3) Physician fees for home visits.
   (4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
   (5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
   (6) Medically related personal services.
   (7) Home nursing education.
   (8) Emergency maintenance repair.
   (9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
   (10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
   (11) Emergency and nonemergency medical transportation.
   (12) Medical supplies.
   (13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
   (14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
   (15) Special drugs and medications.
   (16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.

   (17) Therapy services.
   (18) Household appliances and household utensil costs directly
attributable to home care activities.
   (19) Modification of medical equipment for home use.
   (20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
   (21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
   Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
   (t) Home- and community-based services approved by the United
States Department of Health and Human Services may be covered to the
extent that federal financial participation is available for those
services under waivers granted in accordance with Section 1396n of
Title 42 of the United States Code. The director may seek waivers for
any or all home- and community-based services approvable under
Section 1396n of Title 42 of the United States Code. Coverage for
those services shall be limited by the terms, conditions, and
duration of the federal waivers.
   (u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
   The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
   (v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
   (w) Hospice service which is Medicare-certified hospice service is
covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are
incurred.
   (x) When a claim for treatment provided to a beneficiary includes
both services which are authorized and reimbursable under this
chapter, and services which are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
   (y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
   Services provided pursuant to a waiver obtained from the Secretary
of the United States Department of Health and Human Services
pursuant to this subdivision, and which are not otherwise included in
the Medi-Cal schedule of benefits, shall be available only to the
extent that federal financial participation for these services is
available in accordance with the waiver, and subject to the terms,
conditions, and duration of the waiver.  These services shall be
provided to individual beneficiaries in accordance with the client's
needs as identified in the plan of care, and subject to medical
necessity and applicable utilization control.
   The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
   (z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
   (aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Waiver Program.
   (2) The department shall seek a waiver for a program to provide
comprehensive clinical family planning services as described in
paragraph (8). The program shall be operated only in accordance with
the waiver and the statutes and regulations in paragraph (4) and
subject to the terms, conditions, and duration of the waiver. The
services shall be provided under the program only if the waiver is
approved by the federal Centers for Medicare and Medicaid Services in
accordance with Section 1396n of Title 42 of the United States Code
and only to the extent that federal financial participation is
available for the services.
   (3) Solely for the purposes of the waiver and notwithstanding any
other provision of law, the collection and use of an individual's
social security number shall be necessary only to the extent required
by federal law.
   (4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
   (5) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, without taking regulatory action, the
provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section by
means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement this
section and the approved waiver 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.  Beginning six months after the
effective date of the act adding this subdivision, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
   (6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) is no longer cost effective, this subdivision shall
become inoperative on the first day of the first month following the
issuance of a 30-day notification of that determination in writing by
the Department of Finance to the chairperson in each house that
considers appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
   (7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
   (8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
   (A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
   (B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
   (C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
   (i) Psychosocial and medical aspects of contraception.
   (ii) Sexuality.
   (iii) Fertility.
   (iv) Pregnancy.
   (v) Parenthood.
   (vi) Infertility.
   (vii) Reproductive health care.
   (viii) Preconception and nutrition counseling.
   (ix) Prevention and treatment of sexually transmitted infection.
   (x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
   (xi) Possible contraceptive consequences and followup.
   (xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
   (D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
   (E) A complete physical examination on initial and subsequent
periodic visits.
   (ab) Purchase of prescribed enteral formulae is covered, subject
to the Medi-Cal list of enteral formulae and utilization controls.
   (ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.



14132.01.  (a) Notwithstanding any other provision of law, a
community clinic or free clinic licensed pursuant to subdivision (a)
of Section 1204 of the Health and Safety Code or an intermittent
clinic operating pursuant to subdivision (h) of Section 1206 of the
Health and Safety Code, that has a valid license pursuant to Article
13 (commencing with Section 4180) of Chapter 9 of Division 2 of the
Business and Professions Code shall bill and be reimbursed, as
described in this section, for drugs and supplies covered under the
Medi-Cal program and Family PACT Waiver Program.
   (b) (1) A clinic described in subdivision (a) shall bill the
Medi-Cal program and Family PACT Waiver Program for drugs and
supplies covered under those programs at the lesser of cost or the
clinic's usual charge made to the general public.
   (2) For purposes of this section, "cost" means an aggregate amount
equivalent to the sum of the actual acquisition cost of a drug or
supply plus a clinic dispensing fee not to exceed twelve dollars
() per billing unit as identified in either the Family PACT
Policies, Procedures, and Billing Instructions Manual, or the
Medi-Cal Inpatient/Outpatient Provider Manual governing outpatient
clinic billing for drugs and supplies, as applicable. For purposes of
this section, "cost" for a take-home drug that is dispensed for use
by the patient within a specific timeframe of five or less days from
the date medically indicated means actual acquisition cost for that
drug plus a clinic dispensing fee, not to exceed seventeen dollars
() per prescription. Reimbursement shall be at the lesser of the
amount billed or the Medi-Cal reimbursement rate, and shall not
exceed the net cost of these drugs or supplies when provided by
retail pharmacies under the Medi-Cal program.
   (c) A clinic described in subdivision (a) that furnishes services
free of charge, or at a nominal charge, as defined in subsection (a)
of Section 413.13 of Title 42 of the Code of Federal Regulations, or
that can demonstrate to the department, upon request, that it serves
primarily low-income patients, and its customary practice is to
charge patients on the basis of their ability to pay, shall not be
subject to reimbursement reductions based on its usual charge to the
general public.
   (d) Federally qualified health centers and rural health clinics
that are clinics as described in subdivision (a) may bill and be
reimbursed as described in this section, upon electing to be
reimbursed for pharmaceutical goods and services on a fee-for-service
basis, as permitted by subdivision (k) of Section 14132.100.
   (e) A clinic that otherwise meets the qualifications set forth in
subdivision (a), that is eligible to, but that has elected not to,
utilize drugs purchased under the 340B Discount Drug Program for its
Medi-Cal patients, shall provide notification to the Health Resources
and Services Administration's Office of Pharmacy Affairs that it is
utilizing non-340B drugs for its Medi-Cal patients in the manner and
to the extent required by federal law.



14132.05.  The department shall provide the fiscal and appropriate
policy committees of the Legislature with a copy of their submittal
to the federal Health Care Financing Administration pertaining to any
evaluation completed regarding the Family PACT federal waiver
required by subdivision (aa) of Section 14132.



14132.06.  (a) Services specified in this section that are provided
by a local educational agency are covered Medi-Cal benefits, to the
extent federal financial participation is available, and subject to
utilization controls and standards adopted by the department, and
consistent with Medi-Cal requirements for physician prescription,
order, and supervision.
   (b) Any provider enrolled on or after January 1, 1993, to provide
services pursuant to this section may bill for those services
provided on or after January 1, 1993.
   (c) Nothing in this section shall be interpreted to expand the
current category of professional health care practitioners permitted
to directly bill the Medi-Cal program.
   (d) Nothing in this section is intended to increase the scope of
practice of any health professional providing services under this
section or Medi-Cal requirements for physician prescription, order,
and supervision.
   (e) (1) For the purposes of this section, the local educational
agency, as a condition of enrollment to provide services under this
section, shall be considered the provider of services. A local
educational agency provider, as a condition of enrollment to provide
services under this section, shall enter into, and maintain, a
contract with the department in accordance with guidelines contained
in regulations adopted by the director and published in Title 22 of
the California Code of Regulations.
   (2) Notwithstanding paragraph (1), a local educational agency
providing services pursuant to this section shall utilize current
safety net and traditional health care providers, when those
providers are accessible to specific schoolsites identified by the
local educational agency to participate in this program, rather than
adding duplicate capacity.
   (f) For the purposes of this section, covered services may include
all of the following local educational agency services:
   (1) Health and mental health evaluations and health and mental
health education.
   (2) Medical transportation.
   (3) Nursing services.
   (4) Occupational therapy.
   (5) Physical therapy.
   (6) Physician services.
   (7) Mental health and counseling services.
   (8) School health aide services.
   (9) Speech pathology services. These services may be provided by
either of the following:
   (A) A licensed speech pathologist.
   (B) A credentialed speech-language pathologist, to the extent
authorized by Chapter 5.3 (commencing with Section 2530) of Division
2 of the Business and Professions Code.
   (10) Audiology services.
   (11) Targeted case management services for children with an
individualized education plan (IEP) or an individualized family
service plan (IFSP).
   (g) Local educational agencies may, but need not, provide any or
all of the services specified in subdivision (f).
   (h) For the purposes of this section, "local educational agency"
means the governing body of any school district or community college
district, the county office of education, a state special school, a
California State University campus, or a University of California
campus.
   (i) Any local educational agency provider enrolled to provide
service pursuant to this section on January 1, 1995, may bill for
targeted case management services for children with an individualized
education plan (IEP) or an individualized family service plan
(IFSP), provided on or after January 1, 1995.
   (j) Notwithstanding any other provision of law, a community
college district, a California State University campus, or a
University of California campus, consistent with the requirements of
this section, may bill for services provided to any student,
regardless of age, who is a Medi-Cal recipient.



14132.1.  As used in this chapter "surgical center" means a surgical
clinic that is licensed under Section 1203 of the Health and Safety
Code.  Pursuant to Section 14105, the director  shall establish the
rates of payment for services provided by surgical centers.



14132.10.  (a) Pediatric day health care provided by a health
facility licensed under paragraph (11) of subdivision (a) of Section
1250.1 of the Health and Safety Code is a covered benefit under this
chapter subject to terms, conditions, and utilization controls
developed by the department.  Pediatric day care does not include
inpatient long-term care or family respite care.
   (b) The department shall publish emergency regulations for
pediatric day health care services by October 1, 1997.  These
regulations shall reimburse providers at a rate that shall be
determined by the department, consistent with efficiency, economy,
and quality of care until a new rate is determined on the basis of a
cost study conducted by the department.
   (c) Coverage for pediatric day health care services shall be
available only to the extent that no additional net program costs are
incurred.
   (d) The department shall not approve a request for authorization
of pediatric day health care when the beneficiary for whom the
authorization is requested is an inpatient in a licensed health care
facility.
   (e) The department shall not approve a request for authorization
of pediatric day care if the department determines that the total
cost incurred by the Medi-Cal program for providing pediatric day
health care services and all other medically necessary services to
the individual beneficiary is greater than the total cost incurred by
the Medi-Cal program in providing medically equivalent services at
the beneficiary's otherwise appropriate level of institutional or
home care.
   (f) Coverage for pediatric day health care services shall be
available only to the extent that federal financial participation in
the cost of providing these services is available pursuant to a
federally approved state plan amendment including those services as a
Medi-Cal program benefit.



14132.100.  (a) The federally qualified health center services
described in Section 1396d(a)(2)(C) of Title 42 of the United States
Code are covered benefits.
   (b) The rural health clinic services described in Section 1396d
(a)(2)(B) of Title 42 of the United States Code are covered benefits.

   (c) Federally qualified health center services and rural health
clinic services shall be reimbursed on a per-visit basis in
accordance with the definition of "visit" set forth in subdivision
(g).
   (d) Effective October 1, 2004, and on each October 1, thereafter,
until no longer required by federal law, federally qualified health
center (FQHC) and rural health clinic (RHC) per-visit rates shall be
increased by the Medicare Economic Index applicable to primary care
services in the manner provided for in Section 1396a(bb)(3)(A) of
Title 42 of the United States Code. Prior to January 1, 2004, FQHC
and RHC per-visit rates shall be adjusted by the Medicare Economic
Index in accordance with the methodology set forth in the state plan
in effect on October 1, 2001.
   (e) (1) An FQHC or RHC may apply for an adjustment to its
per-visit rate based on a change in the scope of services provided by
the FQHC or RHC. Rate changes based on a change in the scope of
services provided by an FQHC or RHC shall be evaluated in accordance
with Medicare reasonable cost principles, as set forth in Part 413
(commencing with Section 413.1) of Title 42 of the Code of Federal
Regulations, or its successor.
   (2) Subject to the conditions set forth in subparagraphs (A) to
(D), inclusive, of paragraph (3), a change in scope of service means
any of the following:
   (A) The addition of a new FQHC or RHC service that is not
incorporated in the baseline prospective payment system (PPS) rate,
or a deletion of an FQHC or RHC service that is incorporated in the
baseline PPS rate.
   (B) A change in service due to amended regulatory requirements or
rules.
   (C) A change in service resulting from relocating or remodeling an
FQHC or RHC.
   (D) A change in types of services due to a change in applicable
technology and medical practice utilized by the center or clinic.
   (E) An increase in service intensity attributable to changes in
the types of patients served, including, but not limited to,
populations with HIV or AIDS, or other chronic diseases, or homeless,
elderly, migrant, or other special populations.
   (F) Any changes in any of the services described in subdivision
(a) or (b), or in the provider mix of an FQHC or RHC or one of its
sites.
   (G) Changes in operating costs attributable to capital
expenditures associated with a modification of the scope of any of
the services described in subdivision (a) or (b), including new or
expanded service facilities, regulatory compliance, or changes in
technology or medical practices at the center or clinic.
   (H) Indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing
teaching services to interns and residents.
   (I) Any changes in the scope of a project approved by the federal
Health Resources and Service Administration (HRSA).
   (3) No change in costs shall, in and of itself, be considered a
scope-of-service change unless all of the following apply:
   (A) The increase or decrease in cost is attributable to an
increase or decrease in the scope of services defined in subdivisions
(a) and (b), as applicable.
   (B) The cost is allowable under Medicare reasonable cost
principles set forth in Part 413 (commencing with Section 413) of
Subchapter B of Chapter 4 of Title 42 of the Code of Federal
Regulations, or its successor.
   (C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination
thereof.
   (D) The net change in the FQHC's or RHC's rate equals or exceeds
1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs
that filed consolidated cost reports for multiple sites to establish
the initial prospective payment reimbursement rate, the 1.75-percent
threshold shall be applied to the average per-visit rate of all sites
for the purposes of calculating the cost associated with a
scope-of-service change. "Net change" means the per-visit rate change
attributable to the cumulative effect of all increases and decreases
for a particular fiscal year.
   (4) An FQHC or RHC may submit requests for scope-of-service
changes once per fiscal year, only within 90 days following the
beginning of the FQHC's or RHC's fiscal year. Any approved increase
or decrease in the provider's rate shall be retroactive to the
beginning of the FQHC's or RHC's fiscal year in which the request is
submitted.
   (5) An FQHC or RHC shall submit a scope-of-service rate change
request within 90 days of the beginning of any FQHC or RHC fiscal
year occurring after the effective date of this section, if, during
the FQHC's or RHC's prior fiscal year, the FQHC or RHC experienced a
decrease in the scope of services provided that the FQHC or RHC
either knew or should have known would have resulted in a
significantly lower per-visit rate. If an FQHC or RHC discontinues
providing onsite pharmacy or dental services, it shall submit a
scope-of-service rate change request within 90 days of the beginning
of the following fiscal year. The rate change shall be effective as
provided for in paragraph (4). As used in this paragraph,
"significantly lower" means an average per-visit rate decrease in
excess of 2.5 percent.
   (6) Notwithstanding paragraph (4), if the approved
scope-of-service change or changes were initially implemented on or
after the first day of an FQHC's or RHC's fiscal year ending in
calendar year 2001, but before the adoption and issuance of written
instructions for applying for a scope-of-service change, the adjusted
reimbursement rate for that scope-of-service change shall be made
retroactive to the date the scope-of-service change was initially
implemented. Scope-of-service changes under this paragraph shall be
required to be submitted within the later of 150 days after the
adoption and issuance of the written instructions by the department,
or 150 days after the end of the FQHC's or RHC's fiscal year ending
in 2003.
   (7) All references in this subdivision to "fiscal year" shall be
construed to be references to the fiscal year of the individual FQHC
or RHC, as the case may be.
   (f) (1) An FQHC or RHC may request a supplemental payment if
extraordinary circumstances beyond the control of the FQHC or RHC
occur after December 31, 2001, and PPS payments are insufficient due
to these extraordinary circumstances. Supplemental payments arising
from extraordinary circumstances under this subdivision shall be
solely and exclusively within the discretion of the department and
shall not be subject to subdivision (l). These supplemental payments
shall be determined separately from the scope-of-service adjustments
described in subdivision (e). Extraordinary circumstances include,
but are not limited to, acts of nature, changes in applicable
requirements in the Health and Safety Code, changes in applicable
licensure requirements, and changes in applicable rules or
regulations. Mere inflation of costs alone, absent extraordinary
circumstances, shall not be grounds for supplemental payment. If an
FQHC's or RHC's PPS rate is sufficient to cover its overall costs,
including those associated with the extraordinary circumstances, then
a supplemental payment is not warranted.
   (2) The department shall accept requests for supplemental payment
at any time throughout the prospective payment rate year.
   (3) Requests for supplemental payments shall be submitted in
writing to the department and shall set forth the reasons for the
request. Each request shall be accompanied by sufficient
documentation to enable the department to act upon the request.
Documentation shall include the data necessary to demonstrate that
the circumstances for which supplemental payment is requested meet
the requirements set forth in this section.  Documentation shall
include all of the following:
   (A) A presentation of data to demonstrate reasons for the FQHC's
or RHC's request for a supplemental payment.
   (B) Documentation showing the cost implications. The cost impact
shall be material and significant, two hundred thousand dollars
(0,000) or 1 percent of a facility's total costs, whichever is
less.
   (4) A request shall be submitted for each affected year.
   (5) Amounts granted for supplemental payment requests shall be
paid as lump-sum amounts for those years and not as revised PPS
rates, and shall be repaid by the FQHC or RHC to the extent that it
is not expended for the specified purposes.
   (6) The department shall notify the provider of the department's
discretionary decision in writing.
   (g) (1) An FQHC or RHC "visit" means a face-to-face encounter
between an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse midwife, clinical psychologist,
licensed clinical social worker, or a visiting nurse. For purposes of
this section, "physician" shall be interpreted in a manner
consistent with the Centers for Medicare and Medicaid Services'
Medicare Rural Health Clinic and Federally Qualified Health Center
Manual (Publication 27), or its successor, only to the extent that it
defines the professionals whose services are reimbursable on a
per-visit basis and not as to the types of services that these
professionals may render during these visits and shall include a
medical doctor, osteopath, podiatrist, dentist, optometrist, and
chiropractor. A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a comprehensive perinatal services
practitioner, as defined in Section 51179.1 of Title 22 of the
California Code of Regulations, providing comprehensive perinatal
services, a four-hour day of attendance at an adult day health care
center, and any other provider identified in the state plan's
definition of an FQHC or RHC visit.
   (2) (A) A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a dental hygienist or a dental
hygienist in alternative practice.
   (B) Notwithstanding subdivision (e), an FQHC or RHC that currently
includes the cost of the services of a dental hygienist in
alternative practice for the purposes of establishing its FQHC or RHC
rate shall apply for an adjustment to its per-visit rate, and, after
the rate adjustment has been approved by the department, shall bill
these services as a separate visit. However, multiple encounters with
dental professionals that take place on the same day shall
constitute a single visit. The department shall develop the
appropriate forms to determine which FQHC's or RHC rates shall be
adjusted and to facilitate the calculation of the adjusted rates. An
FQHC's or RHC's application for, or the department's approval of, a
rate adjustment pursuant to this subparagraph shall not constitute a
change in scope of service within the meaning of subdivision (e). An
FQHC or RHC that applies for an adjustment to its rate pursuant to
this subparagraph may continue to bill for all other FQHC or RHC
visits at its existing per-visit rate, subject to reconciliation,
until the rate adjustment for visits between an FQHC or RHC patient
and a dental hygienist or a dental hygienist in alternative practice
has been approved.  Any approved increase or decrease in the provider'
s rate shall be made within six months after the date of receipt of
the department's rate adjustment forms pursuant to this subparagraph
and shall be retroactive to the beginning of the fiscal year in which
the FQHC or RHC submits the request, but in no case shall the
effective date be earlier than January 1, 2008.
   (C) An FQHC or RHC that does not provide dental hygienist or
dental hygienist in alternative practice services, and later elects
to add these services, shall process the addition of these services
as a change in scope of service pursuant to subdivision (e).
   (h) If FQHC or RHC services are partially reimbursed by a
third-party payer, such as a managed care entity (as defined in
Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the
Medicare Program, or the Child Health and Disability Prevention
(CHDP) program, the department shall reimburse an FQHC or RHC for the
difference between its per-visit PPS rate and receipts from other
plans or programs on a contract-by-contract basis and not in the
aggregate, and may not include managed care financial incentive
payments that are required by federal law to be excluded from the
calculation.
   (i) (1) An entity that first qualifies as an FQHC or RHC in the
year 2001 or later, a newly licensed facility at a new location added
to an existing FQHC or RHC, and any entity that is an existing FQHC
or RHC that is relocated to a new site shall each have its
reimbursement rate established in accordance with one of the
following methods, as selected by the FQHC or RHC:
   (A) The rate may be calculated on a per-visit basis in an amount
that is equal to the average of the per-visit rates of three
comparable FQHCs or RHCs located in the same or adjacent area with a
similar caseload.
   (B) In the absence of three comparable FQHCs or RHCs with a
similar caseload, the rate may be calculated on a per-visit basis in
an amount that is equal to the average of the per-visit rates of
three comparable FQHCs or RHCs located in the same or an adjacent
service area, or in a reasonably similar geographic area with respect
to relevant social, health care, and economic characteristics.
   (C) At a new entity's one-time election, the department shall
establish a reimbursement rate, calculated on a per-visit basis, that
is equal to 100 percent of the projected allowable costs to the FQHC
or RHC of furnishing FQHC or RHC services during the first 12 months
of operation as an FQHC or RHC. After the first 12-month period, the
projected per-visit rate shall be increased by the Medicare Economic
Index then in effect. The projected allowable costs for the first 12
months shall be cost settled and the prospective payment
reimbursement rate shall be adjusted based on actual and allowable
cost per visit.
   (D) The department may adopt any further and additional methods of
setting reimbursement rates for newly qualified FQHCs or RHCs as are
consistent with Section 1396a(bb)(4) of Title 42 of the United
States Code.
   (2) In order for an FQHC or RHC to establish the comparability of
its caseload for purposes of subparagraph (A) or (B) of paragraph
(1), the department shall require that the FQHC or RHC submit its
most recent annual utilization report as submitted to the Office of
Statewide Health Planning and Development, unless the FQHC or RHC was
not required to file an annual utilization report. FQHCs or RHCs
that have experienced changes in their services or caseload
subsequent to the filing of the annual utilization report may submit
to the department a completed report in the format applicable to the
prior calendar year. FQHCs or RHCs that have not previously submitted
an annual utilization report shall submit to the department a
completed report in the format applicable to the prior calendar year.
The FQHC or RHC shall not be required to submit the annual
utilization report for the comparable FQHCs or RHCs to the
department, but shall be required to identify the comparable FQHCs or
RHCs.
   (3) The rate for any newly qualified entity set forth under this
subdivision shall be effective retroactively to the later of the date
that the entity was first qualified by the applicable federal agency
as an FQHC or RHC, the date a new facility at a new location was
added to an existing FQHC or RHC, or the date on which an existing
FQHC or RHC was relocated to a new site. The FQHC or RHC shall be
permitted to continue billing for Medi-Cal covered benefits on a
fee-for-service basis until it is informed of its enrollment as an
FQHC or RHC, and the department shall reconcile the difference
between the fee-for-service payments and the FQHC's or RHC's
prospective payment rate at that time.
   (j) Visits occurring at an intermittent clinic site, as defined in
subdivision (h) of Section 1206 of the Health and Safety Code, of an
existing FQHC or RHC, or in a mobile unit as defined by paragraph
(2) of subdivision (b) of Section 1765.105 of the Health and Safety
Code, shall be billed by and reimbursed at the same rate as the FQHC
or RHC establishing the intermittent clinic site or the mobile unit,
subject to the right of the FQHC or RHC to request a scope-of-service
adjustment to the rate.
   (k) An FQHC or RHC may elect to have pharmacy or dental services
reimbursed on a fee-for-service basis, utilizing the current fee
schedules established for those services. These costs shall be
adjusted out of the FQHC's or RHC's clinic base rate as
scope-of-service changes. An FQHC or RHC that reverses its election
under this subdivision shall revert to its prior rate, subject to an
increase to account for all MEI increases occurring during the
intervening time period, and subject to any increase or decrease
associated with applicable scope-of-services adjustments as provided
in subdivision (e).
   (l) FQHCs and RHCs may appeal a grievance or complaint concerning
ratesetting, scope-of-service changes, and settlement of cost report
audits, in the manner prescribed by Section 14171. The rights and
remedies provided under this subdivision are cumulative to the rights
and remedies available under all other provisions of law of this
state.
   (m) The department shall, by no later than March 30, 2008,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
   (n) The department shall implement this section only to the extent
that federal financial participation is obtained.



14132.101.  (a) Notwithstanding paragraphs (4) and (5) of
subdivision (e) of Section 14132.100, a scope-of-service change
request, whether mandatory or permissive, shall be timely when filed
within 150 days following the beginning of the federally qualified
health center's or rural health clinic's fiscal year following the
year in which the change occurred.
   (b) Notwithstanding subdivision (a), and notwithstanding
subdivision (e) of Section 14132.100, a federally qualified health
center described in Section 14132.102 shall be deemed to have filed a
scope-of-service change in a timely manner upon compliance with the
requirements set forth in subdivision (c) of Section 14132.102.



14132.102.  (a) With the exception of clinics and hospital
outpatient departments that are subject to Section 14105.24,
federally qualified health centers (FQHCs) that are receiving
cost-based reimbursement under the terms of the Los Angeles County
1115 Waiver Demonstration Project on June 30, 2005, shall be required
to transition to a prospective payment system (PPS) rate upon
expiration of that waiver. These FQHCs shall be referred to in this
section as "Los Angeles cost-based FQHCs."
   (b) For visits occurring on or after July 1, 2005, Los Angeles
cost-based FQHCs shall receive a PPS rate equivalent to the
following:
   (1) FQHC sites that were in existence during the FQHC's 2000
fiscal year shall be permitted to elect their 2000 per-visit rates or
the average of the 1999 and 2000 per-visit rates as reported on the
cost reports submitted for those fiscal years adjusted as described
in subdivision (c).
   (2) FQHC sites that were first qualified as an FQHC after the site'
s 2000 fiscal year shall receive a base rate equivalent to the first
full fiscal year rate, as audited on the cost report submitted for
that fiscal year and adjusted as described in subdivision (c).
   (3) Sites that were first qualified as an FQHC after the site's
2000 fiscal year, and that have not yet filed a cost report for their
first full fiscal year shall have a rate set in accordance with
subdivision (i) of Section 14132.100 and adjusted as described in
subdivision (c).
   (c) The base rates described in this section shall be adjusted in
the manner described in subdivision (d), paragraphs (1), (2), (3),
and (7) of subdivision (e), and subdivision (f) of Section 14132.100.

   (d) For Los Angeles cost-based FQHCs, as defined in subdivision
(a), no new cost reports shall be required in order to claim
scope-of-service changes occurring in fiscal years prior to July 1,
2005. Only the following information shall be required by the
department:
   (1) A description of the events triggering any applicable rate
changes in the form of Worksheet 1 of the Change in Scope-of-Service
Request form developed for fiscal years 2004 and thereafter, modified
to identify the applicable fiscal year in which the scope change
occurred.
   (2) The two worksheets to the Change in Scope-of-Service Request
form summarizing the health center's health care practitioners and
services for the applicable fiscal year or years.
   (e) Change in Scope-of-Service Request forms for changes occurring
prior to July 1, 2005, shall be filed with the department no later
than July 1, 2006, and shall be deemed to have been filed only when
both the Medi-Cal cost report for the applicable period and the
referenced Change in Scope-of-Service Request form worksheets have
been filed with the department. The date of filing shall be the date
on which either the Medi-Cal cost report or the referenced Change in
Scope-of-Service Request forms are received by the department,
whichever is later.
   (f) Notwithstanding Section 14132.107, the department shall
calculate a tentative scope-of-service rate adjustment based on 80
percent of the difference in the "as reported" scope-of-service per
visit cost. This adjustment shall occur no later than 150 days after
receipt of the Medi-Cal cost report and the referenced Change in
Scope-of-Service Request forms. Within 12 months after receipt of
request forms, the department shall complete its FQHC fiscal year
audit of the Medi-Cal cost report and associated Change in
Scope-of-Service Request and final rate adjustment pursuant to that
audit. The final rate adjustment will be retroactive to July 1, 2005.
Nothing in this subdivision shall be construed to extend the time
period for review and finalization of cost reports as set forth in
Section 14170.
   (g) The department shall, by no later than March 30, 2006,
promptly seek all necessary federal approvals in order to implement
this section, including any amendments to the state plan. To the
extent that any element or requirement of this section is not
approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that would
be necessary to implement this section.
   (h) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, and only to
the extent that all necessary federal approvals are obtained and
there is an appropriation for the purposes of implementing this
section, the department may implement this section without taking any
regulatory action and by means of a provider bulletin or similar
instructions.



14132.107.  Claims for reimbursement under subdivision (e) of
Section 14132.100 shall be finalized by the department within 150
days of receipt of the claims for reimbursement.  These claims for
reimbursement shall be paid within 30 days of being finalized by the
department.  However, the payment of those amounts that are disputed
shall be subject to the requirements, timeframes, and procedures
specified in Section 14171.  Scope changes going forward shall be
finalized within 90 days of receipt and paid within 30 days of being
finalized by the department.



14132.108.  Notwithstanding any other provision of law, requests for
rate adjustments for scope-of-service rate changes under paragraph
(4) of subdivision (e) of Section 14132.100 for an FQHC's or RHC's
fiscal year ending in 2004 shall be deemed to have been filed in a
timely manner so long as it is filed within 90 days following the end
of the 150-day timeframe applicable to scope-of-service changes
occurring from January 1, 2001, to the end of an FQHC's or RHC's 2003
fiscal year, as specified in paragraph (6) of subdivision (e) of
Section 14132.100.


14132.15.  For purposes of subdivision (p) of Section 14132,
"rehabilitation services" means services intended to assist
physically or cognitively impaired persons to achieve or regain their
maximum functional potential for mobility, self-care, and
independent living.



14132.16.  Mammography for screening or diagnostic purposes upon the
referral of a patient's physician shall be covered under this
chapter on or after January 1, 1988, to the extent required or
permitted by federal law.


14132.17.  Annual cervical cancer tests for screening or diagnostic
purposes, upon the referral of a patient's physician, is a covered
benefit under this chapter, on or after January 1, 1991, to the
extent required or permitted by federal law.




14132.18.  (a) Community supported living arrangement services
approved by the United States Department of Health and Human Services
in accordance with Section 1396v of Title 42 of the United States
Code is a covered benefit under this chapter to the extent that
federal financial participation is available for those services and
shall be subject to the terms, conditions, and duration of any waiver
obtained from the Secretary of the United States Department of
Health and Human Services.
   (b) (1) The department, in consultation with the State Department
of Developmental Services, shall submit an application to the
secretary for approval to provide community supported living
arrangement services and seek any federal waivers necessary to
implement this subdivision.
   (2) State matching funds for the federal medicaid funding shall
come out of purchase of services funds of the regional centers,
established pursuant to Article 1 (commencing with Section 4620) of
Chapter 5 of Division 4.5 and it is the intent of the Legislature
that no new funds from the General Fund shall be appropriated for
this purpose.
   (c) The department, in consultation with the State Department of
Developmental Services, shall establish and maintain program
standards for quality assurance and minimum protection to protect the
health, safety, and welfare of individuals receiving community
supported living arrangement services and as otherwise necessary to
implement this section.
   (d) In order to facilitate the design and development of community
supported living arrangement services; program regulations
implementing, interpreting, or making specific the provisions of
subdivision (a) shall not be subject to Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code.  This subdivision shall become inoperative on January 1, 1997.

   (e) If the provision of community supported living arrangements as
a covered benefit under this chapter receive federal approval, the
department shall collect patient-specific cost data and compare the
costs of providing community supported living arrangements under this
chapter with the costs experienced prior to the provision of
community supported living arrangements as a covered benefit under
this chapter.
   (f) This section shall cease to be operative if the Director of
Health Services determines (1) California's application for federal
funds under the community supported living arrangements medicaid
state plan option is not accepted; (2) California's application for
renewal of funding for community supported living arrangements is not
accepted during the course of the grant; (3) federal funding for
community supported living arrangements ceases to be available; or
(4) California determines that it no longer chooses to participate in
the community supported living arrangements medicaid state plan
option.



14132.21.  The department, in consultation with the State Department
of Alcohol and Drug Programs, shall assess the feasibility of
applying to the federal Health Care Financing Administration for a
Medicaid State Plan amendment to provide targeted case management to
pregnant substance-abusing women and women who have given birth to a
drug-exposed or alcohol-exposed infant.  These women may be
identified through self-referral, family planning or health clinics,
public or private hospitals, drug treatment programs, the Medi-Cal
program, or other public assistance or health treatment programs.
Women eligible for services under the targeted case management
program would be provided the following case management services:
   (a) Intake and service needs assessment of women currently
receiving Medi-Cal benefits.
   (b) Development of a coordinated health and treatment plan for the
eligible woman and her infant, listing needed services.
   (c) Case management services to assist with gaining access to
needed medical, social, educational, and other services.
   (d) Referral to any of the following programs that are listed in
the woman's health and treatment plan:
   (1) Child Health and Disability Prevention Program.
   (2) Supplementary Food Program for Women, Infants, and Children
(WIC).
   (3) Drug abuse treatment and detoxification programs.
   (4) In-home support services to enhance the woman's utilization of
drug treatment programs, and prenatal and perinatal care services.
   (5) Transportation to health and drug treatment services.
   (6) Crisis assistance to address health and drug treatment needs.

   (7) Other case management services authorized by the federal
Health Care Financing Administration.


14132.22.  (a) For purposes of this section, dental restorative
materials are limited to composite resin, glass ionomer cement, resin
ionomer cement, and amalgam, as described on the Dental Board of
California's dental materials factsheet.
   (b) A provider of services that includes the provision of dental
restorative materials to a beneficiary under this chapter may
recommend, after consultation with the beneficiary, a dental
restorative material other than the covered benefit of amalgam.
   (c) A provider may claim and receive the reimbursement rate for an
amalgam restoration when using a different dental restorative
material.



14132.23.   (a) (1) Except as set forth in paragraph (2), and
notwithstanding any other provision of law or regulation, the active
and retentive phases of orthodontic treatment covered under the
Medi-Cal program shall be reimbursed on a quarterly basis, as
determined by dividing the sum of the authorized treatment allowances
by the estimated number of three-month periods that the patient's
treatment will require, subject to the department's utilization
controls.
   (2) The retentive phase of orthodontic treatment shall be
reimbursed pursuant to paragraph (1) only until the department
implements the Code on Dental Procedures and Nomenclature, as
published by the American Dental Association in its Current Dental
Terminology manual, at which time paragraph (1) shall not apply to
retentive phase orthodontic services that are covered under the
Medi-Cal program.
   (b) This section shall become operative on July 1, 2008.



14132.24.  (a) The department shall develop and implement a program
to provide a community-living support benefit to eligible Medi-Cal
beneficiaries. The department shall submit any waiver application,
modification of any existing waiver, or amendment to the Medicaid
state plan, that is necessary to provide this benefit, and shall
implement the benefit only to the extent that federal financial
participation is available.
   (b) The community-living support benefit shall include both of the
following:
   (1) (A) Reimbursement for an array of health-related and
psychosocial services provided or coordinated at community-based
housing sites that enable beneficiaries to remain in the least
restrictive and most homelike environment while receiving the
health-related services, including personal care and psychosocial
services, necessary to protect their health and well-being. These
community-based housing units may include, but are not limited to,
the living area or unit within a facility that is specifically
designed to provide ongoing assisted living services, licensed
residential care facilities for the elderly, publicly funded senior
and disabled housing projects, or supportive housing sites that serve
chronically homeless individuals with chronic or disabling health
conditions.
   (B) For purposes of this section, "assisted living services"
includes, but is not limited to, assistance with personal activities
of daily living, including dressing, feeding, toileting, bathing,
grooming, mobility, and associated tasks, to help provide for and
maintain physical and psychological comfort.
   (2) Access to community-living support services provided or
coordinated at the community-based housing site, including, but not
limited to, the personal care and health services specified in
paragraph (8) of subdivision (a) of Section 1788 of the Health and
Safety Code, and the health related support services specified in
Section 53290 of the Health and Safety Code.
   (c) Services available through the community-living support
benefit shall not duplicate services available through the Medi-Cal
state plan, other Medi-Cal waivers, or other programs financed by the
state.
   (d) An individual shall be eligible for the community-living
support benefit if he or she is eligible for the Medi-Cal program, is
a resident of San Francisco who would otherwise be homeless, living
in shelters, or institutionalized, and meets one or both of the
following criteria:
   (1) The State Department of Mental Health determines that he or
she would benefit from supportive housing, as defined in subdivision
(c) of Section 53260 of the Health and Safety Code.
   (2) The department determines that he or she is eligible for
placement in a skilled nursing facility, as defined in subdivision
(c) of Section 1250 of the Health and Safety Code, or an intermediate
care facility, as defined in subdivision (d) of that section.
   (e) The department may modify the eligibility criteria specified
in subdivision (d), if needed, to qualify the community-living
support benefit for federal financial participation.
   (f) The department shall seek to maximize resources for
community-based housing by coordinating the community-living support
benefit with existing efforts to coordinate care, improve health
outcomes, and reduce long-term care costs for the targeted
population.
   (g) This section shall be implemented only upon adoption of a
resolution by the Board of Supervisors of the City and County of San
Francisco providing county funds for use by the state to match
federal Medicaid funds to receive federal funds for services provided
under the waiver specified in this section, and for any costs
associated with implementing and monitoring the waiver, to limit
additional state costs.



14132.25.  On or before July 1, 1983, the State Department of Health
Services shall establish a subacute care program in health
facilities in order to more effectively use the limited Medi-Cal
dollars available while, at the same time, ensuring needed services
for these patients.  The subacute care program shall be available to
patients in facilities who meet subacute care criteria.  Subacute
care may be provided by any facility designated by the director as
meeting the  subacute care criteria, and which has an approved
provider participation agreement with the State Department of Health
Services.
   The State Department of Health Services shall develop a rate of
reimbursement for this subacute care program.  Reimbursement rates
will be determined in accordance with methodology developed by the
State Department of Health Services, specified in regulation, and may
include the following:
   (1) All inclusive per diem rates.
   (2) Individual patient specific rates according to the needs of
the individual subacute care patient.
   (3) Other rates subject to negotiation with the health facility.
   However, reimbursement at subacute care rates shall only be
implemented when funds are available for this purpose pursuant to the
annual Budget Act.
   The department may negotiate and execute an agreement with any
health facility which meets the standards for providing subacute
care.  An agreement may be negotiated or established between the
health facility and the department for subacute care based on
individual patient assessment.  The department shall establish level
of care criteria and appropriate utilization controls for patients
eligible for the subacute care program.
   For the purposes of this section, subacute patient care shall be
defined by the state department based on the results of its study
pursuant to Chapter 1211 of the Statutes of 1980.



14132.26.  (a) The department shall develop a program that requires
a waiver of federal law to test the efficacy of providing an assisted
living benefit to beneficiaries under the Medi-Cal program.
Assisted living benefits shall include, but are not limited to, the
care and supervision activities specified in Section 1569.2 of the
Health and Safety Code and Section 87101 of Title 22 of the
California Code of Regulations, and other health-related services.
The program developed pursuant to this section shall be known as the
waiver program for purposes of this section.  The department shall
submit any necessary waiver applications or modifications to the
medicaid state plan to the Health Care Financing Administration to
implement the waiver program, and shall implement the waiver program
only to the extent federal financial participation is available.
   (b) The department shall develop the waiver program in conjunction
with other state departments, consumers, consumer advocates, housing
and service providers, and experts in the fields of gerontology,
geriatric health, nursing services, and independent living.
   (c) The assisted living benefit shall be designed to provide
eligible individuals with a range of services that enable them to
remain in the least restrictive and most homelike environment while
receiving the medical and personal care necessary to protect their
health and well-being.  Benefits provided pursuant to this waiver
program shall include only those not otherwise available under the
state plan, and may include, but are not limited to, medicine
management, coordination with a primary health care provider, and
case management.
   (d) (1) Eligible individuals shall be those who are eligible for
the Medi-Cal program and are determined by the department to be
eligible for placement in a nursing facility, as defined under
subdivisions (c) and (d) of Section 1250 of the Health and Safety
Code.  Eligibility shall be based on an assessment of an individual's
ability to perform functional and instrumental activities of daily
living, as well as the individual's medical diagnosis and prognosis,
and other criteria, including other Medi-Cal services that the
beneficiary is receiving, as specified in the waiver.
   (2) An eligible individual shall participate in the waiver program
only if he or she is fully informed of the program and the nature of
the assisted living benefit and indicates in writing his or her
choice to participate.
   (e) (1) The waiver program shall test the effectiveness of
providing a Medi-Cal assisted living benefit through two service
delivery approaches, as specified in paragraphs (2) and (3).
   (2) Under the first model, an assisted living benefit shall be
provided to residents of licensed residential care facilities.
Facility participation in the program shall be determined by the
department in conjunction with the State Department of Social
Services and in accordance with the criteria for participation
specified in the waiver.  Under this model the facility operator
shall be responsible for the provision of services allowed under the
benefit, either directly or through contracts with other provider
agencies, as permitted and specified in the waiver.  During
participation in the waiver program, residential care facilities
shall comply with all terms and conditions of the waiver.  The
department and the State Department of Social Services, may, as
determined necessary and appropriate, waive provisions contained in
Division 2 (commencing with Section 1200) of the Health and Safety
Code, subdivision (h) of Section 14132.95, and Title 22 of the
California Code of Regulations for facilities providing services to
waiver program participants.
   (3) Under the second model, an assisted living benefit shall be
provided to residents in publicly funded senior and disabled housing
projects.  Under this model an independent agency, pursuant to a
contract with the department, shall be responsible for the provision
of case management and other services to eligible individuals, as
specified in the waiver.
   (f) The department shall evaluate the effectiveness of the waiver
program.
   (1) The evaluation shall include, but not be limited to,
participant satisfaction, health, and safety, the quality of life of
the participant receiving the assisted living benefit, and
demonstration of the cost neutrality of the waiver program as
specified in federal guidelines.
   (2) The evaluation shall estimate the projected savings, if any,
in the budgets of state and local governments if the program was
expanded statewide.
   (3) The evaluation shall be submitted to the appropriate policy
and fiscal committees of the Legislature on or before January 1,
2003.
   (g) The department shall limit the number of participants in the
waiver program during the initial three years of its operation to a
number that will be statistically significant for purposes of the
program evaluation and that meets any requirements of the federal
Health Care Financing Administration, including a request to waive
statewide implementation requirements for the waiver program during
the initial years of evaluation.
   (h) In implementing this section, the department may enter into
contracts for the provision of essential administrative and other
services.  Contracts entered into under this section may be on a
noncompetitive bid basis, and shall be exempt from the requirements
of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2
of the Public Contract Code.
   (i) The department shall not implement the waiver program
specified in subdivision (a) if the benefits provided pursuant to the
waiver program will result in additional costs to the Medi-Cal
program.
   (j) The waiver program shall be developed and implemented only to
the extent that funds are appropriated or otherwise available for
that purpose.



14132.27.  (a) (1) The department shall apply for a waiver of
federal law pursuant to Section 1396n of Title 42 of the United
States Code to test the efficacy of providing a disease management
benefit to beneficiaries under the Medi-Cal program.  A disease
management benefit shall include, but not be limited to, the use of
evidence-based practice guidelines, supporting adherence to care
plans, and providing patient education, monitoring, and healthy
lifestyle changes.
   (2) The waiver developed pursuant to this section shall be known
as the Disease Management Waiver.  The department shall submit any
necessary waiver applications or modifications to the Medicaid State
Plan to the federal Centers for Medicare and Medicaid Services to
implement the Disease Management Waiver, and shall implement the
waiver only to the extent federal financial participation is
available.
   (b) The Disease Management Waiver shall be designed to provide
eligible individuals with a range of services that enable them to
remain in the least restrictive and most homelike environment while
receiving the medical care necessary to protect their health and
well-being.  Services provided pursuant to this waiver program shall
include only those not otherwise available under the state plan, and
may include, but are not limited to, medication management,
coordination with a primary care provider, use of evidence-based
practice guidelines, supporting adherence to a plan of care, patient
education, communication and collaboration among providers, and
process and outcome measures.  Coverage for those services shall be
limited by the terms, conditions, and duration of the federal waiver.

   (c) Eligibility for the Disease Management Waiver shall be limited
to those persons who are eligible for the Medi-Cal program as aged,
blind, and disabled persons or those persons over 21 years of age who
are not enrolled in a Medi-Cal managed care plan, or eligible for
the federal Medicare program, and who are determined by the
department to be at risk of, or diagnosed with, select chronic
diseases, including, but not limited to, advanced atherosclerotic
disease syndromes, congestive heart failure, and diabetes.
Eligibility shall be based on the individual's medical diagnosis and
prognosis, and other criteria, as specified in the waiver.
   (d) The Disease Management Waiver shall test the effectiveness of
providing a Medi-Cal disease management benefit.  The department
shall evaluate the effectiveness of the Disease Management Waiver.
   (1) The evaluation shall include, but not be limited to,
participant satisfaction, health and safety, the quality of life of
the participant receiving the disease management benefit, and
demonstration of the cost neutrality of the Disease Management Waiver
as specified in federal guidelines.
   (2) The evaluation shall estimate the projected savings, if any,
in the budgets of state and local governments if the Disease
Management Waiver was expanded statewide.
   (3) The evaluation shall be submitted to the appropriate policy
and fiscal committees of the Legislature on or before January 1,
2008.
   (e) The department shall limit the number of participants in the
Disease Management Waiver during the initial three years of its
operation to a number that will be statistically significant for
purposes of the waiver evaluation and that meets any requirements of
the federal government, including a request to waive statewide
implementation requirements for the waiver during the initial years
of evaluation.
   (f) In undertaking this Disease Management Waiver, the director
may enter into contracts for the purpose of directly providing
Disease Management Waiver services.
   (g) The department shall seek all federal waivers necessary to
allow for federal financial participation under this section.
   (h) The Disease Management Waiver shall be developed and
implemented only to the extent that funds are appropriated or
otherwise available for that purpose.
   (i) The department shall not implement this section if any of the
following apply:
   (1) The department's application for federal funds under the
Disease Management Waiver is not accepted.
   (2) Federal funding for the waiver ceases to be available.



14132.28.  (a) If the department decides to terminate or not renew a
health facility's subacute care services provider contract, the
department shall notify the health facility 30 days before the
termination or nonrenewal becomes effective.
   (b) (1) Once the department has notified the health facility
pursuant to subdivision (a), the department shall provide guidance to
the health facility regarding expectations for the transfer of
patients.  The guidance shall consider the need to minimize trauma of
a patient due to transfer, and shall ensure, prior to any transfer
or discharge, that the facility has complied with the transfer and
discharge requirements of Section 1336.2 of the Health and Safety
Code, subsection (a) of Section 483.12 of Title 42 of the Code of
Federal Regulations, and any other state and federal laws applicable
to the transfer and discharge of patients of a nursing facility, as
defined in subdivision (k) of Section 1250 of the Health and Safety
Code.  The department's Medi-Cal division shall coordinate with the
department's Licensing and Certification Division in developing the
guidance for the protection of patients' transfer rights.
   (2) Prior to any transfer, the health facility shall continue to
provide the subacute level of  services required by a patient and
shall comply with state laws governing subacute staffing levels.  The
health facility shall continue to be paid commensurate with that
subacute level of service.  If the health facility fails to comply
with applicable state laws regarding subacute staffing levels, the
facility shall be paid at the facility's Medi-Cal nursing facility
rate.
   (3) Any health facility that has a subacute services provider
contract that has been terminated or has not been renewed may not be
reimbursed commensurate with the subacute level of service for
patients admitted after the contract is terminated or not renewed,
unless and until the facility obtains a new subacute services
provider contract.  The facility may be reimbursed commensurate with
the subacute level of service where the patient returns to the
facility during the bed-hold period.  Where the patient returns to
the facility following the bed-hold period, the facility shall be
reimbursed at the facility's Medi-Cal nursing facility rate.



14132.29.  (a) A health facility that has a subacute services
provider contract with the department under this chapter shall comply
with the patient transfer and discharge requirements of this
section.
   (b) Before patients are transferred due to any change in the
status of the license or operation of the facility, including the
termination of the subacute services provider contract by the
department, the facility shall comply with the transfer and discharge
requirements of Section 1336.2 of the Health and Safety Code,
subsection (a) of Section 483.12 of Title 42 of the Code of Federal
Regulations, and any other state and federal laws applicable to the
transfer and discharge of patients of a nursing facility, as defined
in subdivision (k) of Section 1250 of the Health and Safety Code.
   (c) All of the rights and procedures that apply to the appeal of
the transfer or discharge of a nursing facility patient pursuant to
the sections cited in subdivision (b) shall apply to an appeal
pursuant to this subdivision.  The facility shall ensure that each
patient and patient's representative is notified of this right to
appeal.  The notification shall be in writing and shall be
communicated in a language and manner that is understood by the
patient or patient's representative.



14132.3.  In addition to any other criteria as provided in
subdivision (p) of Section 14132, no reimbursement shall be made
pursuant to this chapter for any service in a general acute care
hospital for which a special permit or a supplemental service
approval is required pursuant to Section 1256.1 of the Health and
Safety Code unless that general acute care hospital has first
obtained a special permit or a supplemental service approval from the
State Department of Health Services.



14132.34.  (a) Human milk and human milk derivatives supplied by a
mothers' milk bank for human consumption are a covered service under
this chapter.
   (b) For purposes of this section, "mothers' milk bank" means any
person, firm, or corporation which engages in the not-for-profit
procurement, processing, storage, distribution, or use of human milk,
contributed by volunteer donors, in compliance with standards
prescribed by the Human Milk Banking Association of North America.




14132.35.  (a) Outpatient rehabilitation services are covered under
this chapter, subject to utilization controls.
   (b) The department and the Medi-Cal field offices shall not
discriminate against elderly recipients in authorizing services under
this section, and shall recognize the importance of rehabilitation
services in allowing elderly persons to remain independent and at
home.
   (c) Rehabilitation services may be provided in group settings,
including what is referred to as stroke centers which offer programs
and group training for adults in therapeutic exercise, activities of
daily living, speech remediation, or counseling.
   (d) In order to be eligible for reimbursement under this section,
stroke centers shall be certified as participating providers and meet
the rules and regulations of the department.  Stroke centers shall
meet the requirements for licensure of either adult day health care
centers or outpatient rehabilitation clinics.




14132.36.  (a) To the extent that federal financial participation
becomes available, residential care for alcohol and drug exposed
pregnant women and women in the postpartum perinatal period is a
covered service under this chapter, subject to utilization controls.

   (b) For purposes of this section, "residential care" shall consist
of those services specified in the interagency agreement between the
State Department of Alcohol and Drug Programs and the State
Department of Health Services.
   (c) The State Department of Alcohol and Drug Programs shall be the
agency responsible for establishing the residential care programs.
The department shall, for the purposes of this section, provide funds
from the department's budget for the purpose of obtaining federal
matching funds under Title XIX of the Social Security Act (42 U.S.C.
Sec. 1396, and following) for the residential care programs.



14132.38.  (a) Home infusion treatments with tocolytic agents for
pregnant women shall be covered under this chapter. This coverage
shall be subject to both of the following:
   (1) Utilization controls.
   (2) Clinical guidelines or protocols as outlined in peer-reviewed
professional journals.
   (b) By October 1, 2009, the department shall prepare, or contract
for the preparation of, a report evaluating the medical effectiveness
and cost-effectiveness of infusion treatments with tocolytic agents.
The report shall determine, to the extent possible, changes in the
health, birth weight, and length of term for newborns using tocolytic
treatments, and shall provide a comparison to a representative
control population that does not use tocolytic treatments. The report
shall include a summary of peer-reviewed research findings on the
effectiveness of tocolytic agents in the medical literature.
  (c) This section shall remain in effect only until January 1, 2010,
and as of that date is repealed, unless a later enacted statute,
that is enacted before January 1, 2010, deletes or extends that date.



14132.39.  Midwifery services provided by a licensed midwife shall
be covered under this chapter, to the extent that federal financial
participation is available, and, subject to utilization controls.



14132.4.  Nurse-midwifery services provided by a certified
nurse-midwife shall be covered under the provisions of this chapter,
to the extent required by federal law, subject to utilization
controls.



14132.41.  (a) Services provided by a certified nurse practitioner
shall be covered under this chapter to the extent authorized by
federal law, and subject to utilization controls. The department
shall permit a certified nurse practitioner to bill Medi-Cal
independently for his or her services. If a certified nurse
practitioner chooses to bill Medi-Cal independently for his or her
services, the department shall make payment directly to the certified
nurse practitioner.
   (b) For purposes of this section, "certified" means nationally
board certified in a recognized specialty.



14132.42.  Benefits under this chapter shall not be restricted for
inpatient hospital care to a time period less than 48 hours following
a normal vaginal delivery and less than 96 hours following delivery
by caesarean section.  However, coverage for inpatient hospital care
may be for a time period less than 48 or 96 hours following a
delivery if both of the following conditions are met:
   (a) The decision to discharge the mother and newborn before the
48- or 96-hour time period is made by the treating physicians in
consultation with the mother.
   (b) A postdischarge followup visit for the mother and newborn
within 48 hours of discharge, when prescribed by the treating
physician, is also a covered benefit under this chapter.  The visit
shall be by a licensed health care provider whose scope of practice
includes postpartum care and newborn care.  The visit shall include,
at a minimum, parent education, assistance and training in breast or
bottle feeding, and the performance of any necessary maternal or
neonatal physical assessments.  The treating physician shall disclose
to the mother the availability of a postdischarge visit, including
an in-home visit, physician office visit, or plan facility visit.
The treating physician, in consultation with the mother, shall
determine whether the postdischarge visit shall occur at home, the
plan's facility, or the treating physician's office after assessment
of certain factors.  These factors shall include, but not be limited
to, the transportation needs of the family and environmental and
social risks.


14132.44.  (a) Targeted case management (TCM), pursuant to Section
1915(g) of the Social Security Act as amended by Public Law 99-272
(42 U.S.C.  Sec. 1396n(g)), shall be covered as a benefit, effective
January 1, 1995.  Nothing in this section shall be construed to
require any local governmental agency to implement TCM.
   (b) A TCM provider furnishing TCM services shall be a local
governmental agency under contract with the department to provide TCM
services.  Local educational agencies shall not be providers of case
management services under this section.
   (c) A TCM provider may contract with a nongovernmental entity or
the University of California, or both, to provide TCM services on its
behalf under the conditions specified by the department in
regulations.
   (d) Each TCM provider shall have all of the following:
   (1) Established procedures for performance monitoring.
   (2) A countywide system to prevent duplication of services and to
ensure coordination and continuity of care among providers of case
management services provided to beneficiaries who are eligible to
receive case management services from two or more programs.
   (3) A fee mechanism effective January 1, 1995, specific to TCM
services provided, which may vary by program.
   (e) A TCM service provider, a nongovernmental entity or the
University of California, or both, under contract with a TCM provider
may provide TCM services to one or all of the following groups of
Medi-Cal beneficiaries, which shall be defined in regulation:
   (1) High-risk persons.
   (2) Persons who have language or other comprehension barriers.
   (3) Persons on probation.
   (4) Persons who have exhibited an inability to handle personal,
medical, or other affairs.
   (5) Persons abusing alcohol or drugs, or both.
   (6) Adults at risk of institutionalization.
   (7) Adults at risk of abuse or neglect.
   (f) (1) A local governmental agency that elects to provide TCM
services to the groups specified in subdivision (e) shall, for each
fiscal year, for the purpose of obtaining federal medicaid matching
funds, submit an annual cost report as prescribed by the department
that certifies all of the following:
   (A) The availability and expenditure of 100 percent of the
nonfederal share for the provision of TCM services from the local
governmental agency's general fund or from any other funds allowed
under federal law and regulation.
   (B) The amount of funds expended on allowable TCM services.
   (C) Its expenditures represent costs that are eligible for federal
financial participation.
   (D) The costs reflected in the annual cost reports used to
determine TCM rates are developed in compliance with the definitions
contained in the Office of Management and Budget (OMB) Circular A-87.

   (E) Case management services provided in accordance with Section
1396n(g) of Title 42 of the United States Code will not duplicate
case management services provided under any home- and community-based
services waiver.
   (F) Claims for providing case management services pursuant to this
section will not duplicate claims made to public agencies or private
entities under other program authorities for the same purposes.
   (G) The requirements of subdivision (d) have been met.
   (2) The department shall deny any claim if it determines that any
certification required by this subdivision is not adequately
supported for purposes of federal financial participation.
   (g) Only a local governmental agency may submit TCM service claims
to the department for the performance of TCM services.
   (h) During the period from January 1, 1995, through June 30, 1995,
TCM services shall be reimbursed according to the interim mechanism
developed by the state and the Health Care Financing Administration,
which is reflected in the document entitled "Agreement Between the
Health Care Financing Administration and the State of California,
Department of Health Services." For the 1995-96 fiscal year, the
department shall establish an initial rate of reimbursement.
Effective July 1, 1996, and thereafter, TCM services shall be
reimbursed in accordance with regulations that shall be adopted by
the department.
   (i) The department, in consultation with local governmental
agencies, and consistent with federal regulations, and the State
Medicaid Manual of the Department of Health and Human Services,
Health Care Financing Administration, shall adopt regulations that
define TCM services, establish the standards under which TCM services
qualify as a Medi-Cal reimbursable service, prescribe the
methodology for determining the rate of reimbursement, and establish
a claims submission and processing system and method to certify local
matching expenditures.
   (j) (1) Notwithstanding any other provision of this section, the
state shall be held harmless, in accordance with paragraphs (2) and
(3) from any federal audit disallowance and interest resulting from
payments made by the federal medicaid program as reimbursement for
claims for providing TCM services pursuant to this section, less the
amounts already remitted to the state pursuant to subdivision (m) for
the disallowed claim.
   (2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which any local governmental
agency has received reimbursement for TCM services, the department
shall recoup from the local governmental agency that submitted that
disallowed claim, through offsets or by a direct billing, amounts
equal to the amount of the disallowance and interest, in that fiscal
year, less the amounts already remitted to the state pursuant to
subdivision (m) for the disallowed claim.  All subsequent claims
submitted to the department applicable to any previously disallowed
claim, may be held in abeyance, with no payment made, until the
federal disallowance issue is resolved.
   (3) Notwithstanding paragraphs (1) and (2), to the extent that a
federal audit disallowance and interest results from a claim or
claims for which the local governmental agency has received
reimbursement for TCM services performed by a nongovernmental entity
or the University of California, or both, under contract with, and on
behalf of, the participating local governmental agency, the
department shall be held harmless by that particular local
governmental agency for 100 percent of the amount of any such federal
audit disallowance and interest, less the amounts already remitted
to the state pursuant to subdivision (m) for the disallowed claim.
   (k) The use of local matching funds required by this section shall
not create, lead to, or expand the health care funding obligations
or service obligations for current or future years for each local
governmental agency, except as required by this section or as may be
required by federal law.
   (l) TCM services are services which assist beneficiaries to gain
access to needed medical, social, educational, and other services.
Services provided by TCM providers, and their subcontractors, shall
be defined in regulation, and shall include at least one of the
following:
   (1) Assessment.
   (2) Plan development.
   (3) Linkage and consultation.
   (4) Assistance in accessing services.
   (5) Periodic review.
   (6) Crisis assistance planning.
   (m) (1) Each local government agency shall contribute to the
department a portion of the agency's general fund that has been made
available due to the coverage of services described in this section
under the Medi-Cal program.  The contributed funds shall be
reinvested in health services through the Medi-Cal program.  The
total contribution amount shall be equal to 331/3 percent of the
amounts that have been made available under this section, but in no
case shall this contribution exceed twenty million dollars
(,000,000) in a fiscal year less the amount contributed pursuant
to subdivision (m) of Section 14132.47.  Beginning with the 1994-95
fiscal year, each local governmental agency's share of the total
contribution shall be determined by claims submitted and approved for
payment through January 1 of the following calendar year.  Claims
received and approved for payment after January 1 for dates of
service in the previous fiscal year shall be included in the
following year's calculation.  Each local governmental agency's share
of the contribution for the previous fiscal year shall be determined
no later than February 15 and shall be remitted to the state no
later than April 1 of each year.  The contribution amount shall be
paid from nonfederal, general fund revenues, and shall be deposited
in the Targeted Case Management Claiming Fund, which is hereby
created, for transfer to the Health Care Deposit Fund.
   (2) Moneys received by the department pursuant to this subdivision
are hereby continuously appropriated, notwithstanding Section 13340
of the Government Code, to the department for the support of the
Medi-Cal program, and the funds shall be administered in accordance
with procedures prescribed by the Department of Finance.  If not paid
as provided in this section, the department may offset payments due
to each local governmental agency from the state, not related to
payments required to be made pursuant to this section, in order to
recoup these funds for the Targeted Case Management Claiming Fund.
   (3) This subdivision shall only apply to claims approved for the
1994-95 to 1997-98 fiscal years, inclusive.
   (n) As a condition of participation and in consideration of the
joint effort of the local governmental agencies and the department in
implementing this section and the ongoing need of local governmental
agencies to receive technical support from the department, as well
as assistance in claims processing and program monitoring, the local
governmental agencies shall cover the costs of the administrative
activities performed by the department.  Each local governmental
agency shall annually pay a portion of the total costs of
administrative activities performed by the department through a
mechanism agreed to by the department and the local governmental
agencies, or if no agreement is reached by August 1 of each year,
directly to the state.  The department shall determine and report the
staffing requirements upon which projected costs will be based.
Projected costs shall include the anticipated salaries, benefits, and
operating expenses necessary to administer targeted case management.

   (o) For the purposes of this section a "local governmental agency"
means a county or chartered city.



14132.45.  Regulations implementing, interpreting, or making
specific the provisions of subdivision (z) of Section 14132 shall not
be subject to Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code.




14132.46.  Pursuant to Sections 14024 and 14124.90, the Director of
Health Services may recover for the cost of targeted case management
services rendered under Section 14132.44 to eligible Medi-Cal
beneficiaries, from any person, corporation, or partnership who, at
the time services are rendered, has a contractual or legal obligation
to pay for the services.



14132.47.  (a) It is the intent of the Legislature to provide local
governmental agencies the choice of participating in either or both
of the Targeted Case Management (TCM) and Administrative Claiming
process programs at their option, subject to the requirements of this
section and Section 14132.44.
   (b) The department may contract with each participating local
governmental agency or each local educational consortium to assist
with the performance of administrative activities necessary for the
proper and efficient administration of the Medi-Cal program, pursuant
to Section 1396b(a) of Title 42 of the United States Code, Section
1903a of the federal Social Security Act, and this activity shall be
known as the Administrative Claiming process.
   (c) (1) As a condition for participation in the Administrative
Claiming process, each participating local governmental agency or
each local educational consortium shall, for the purpose of claiming
federal medicaid matching funds, enter into a contract with the
department and shall certify to the department the amount of local
governmental agency or each local educational consortium general
funds or any other funds allowed under federal law and regulation
expended on the allowable administrative activities.
   (2) The department shall deny the claim if it determines that the
certification is not adequately supported for purposes of federal
financial participation.
   (d) Each participating local governmental agency or local
educational consortium may subcontract with nongovernmental entities
to assist with the performance of administrative activities necessary
for the proper and efficient administration of the Medi-Cal program
under the conditions specified by the department in regulations.
   (e) Each Administrative Claiming process contract shall include a
requirement that each participating local governmental agency or each
local educational consortium submit a claiming plan in a manner that
shall be prescribed by the department in regulations, developed in
consultation with local governmental agencies.
   (f) The department shall require that each participating local
governmental agency or each local educational consortium certify to
the department both of the following:
   (1) The availability and expenditure of 100 percent of the
nonfederal share of the cost of performing Administrative Claiming
process activities.  The funds expended for this purpose shall be
from the local governmental agency's general fund or the general
funds of local educational agencies or from any other funds allowed
under federal law and regulation.
   (2) In each fiscal year that its expenditures represent costs that
are eligible for federal financial participation for that fiscal
year.  The department shall deny the claim if it determines that the
certification is not adequately supported for purposes of federal
financial participation.
   (g) (1) Notwithstanding any other provision of this section, the
state shall be held harmless, in accordance with paragraphs (2) and
(3), from any federal audit disallowance and interest resulting from
payments made to a participating local governmental agency or local
educational consortium pursuant to this section, less the amounts
already remitted to the state pursuant to subdivision (m) for the
disallowed claim.
   (2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which any participating local
governmental agency or local educational consortium has received
reimbursement for Administrative Claiming process activities, the
department shall recoup from the local governmental agency or local
educational consortium that submitted the disallowed claim, through
offsets or by a direct billing, amounts equal to the amount of the
disallowance and interest, in that fiscal year, less the amounts
already remitted to the state pursuant to subdivision (m) for the
disallowed claim.  All subsequent claims submitted to the department
applicable to any previously disallowed administrative activity or
claim, may be held in abeyance, with no payment made, until the
federal disallowance issue is resolved.
   (3) Notwithstanding paragraph (2), to the extent that a federal
audit disallowance and interest results from a claim or claims for
which the participating local governmental agency or local
educational consortium has received reimbursement for Administrative
Claiming process activities performed by a nongovernmental entity
under contract with, and on behalf of, the participating local
governmental agency or local educational consortium, the department
shall be held harmless by that particular participating local
governmental agency or local educational consortium for 100 percent
of the amount of the federal audit disallowance and interest, less
the amounts already remitted to the state pursuant to subdivision (m)
for the disallowed claim.
   (h) The use of local matching funds required by this section shall
not create, lead to, or expand the health care funding obligations
or service obligations for current or future years for any
participating local governmental agency or local educational
consortium, except as required by this section or as may be required
by federal law.
   (i) The department shall deny any claim from a participating local
governmental agency or local educational consortium if the
department determines that the claim is not adequately supported in
accordance with criteria established pursuant to this subdivision and
implementing regulations before it forwards the claim for
reimbursement to the federal medicaid program.  In consultation with
local government agencies and local educational consortia, the
department shall adopt regulations that prescribe the requirements
for the submission and payment of claims for administrative
activities performed by each participating local governmental agency
and local educational consortium.
   (j) Administrative activities shall be those determined by the
department to be necessary for the proper and efficient
administration of the state's medicaid plan and shall be defined in
regulation.
   (k) If the department denies any claim submitted under this
section, the affected participating local governmental agency or
local educational consortium may, within 30 days after receipt of
written notice of the denial, request that the department reconsider
its action.  The participating local governmental agency or local
educational consortium may request a meeting with the director or his
or her designee within 30 days to present its concerns to the
department after the request is filed.  If the director or his or her
designee cannot meet, the department shall respond in writing
indicating the specific reasons for which the claim is out of
compliance to the participating local governmental agency or local
educational consortium in response to its appeal.  Thereafter, the
decision of the director shall be final.
   (l) Participating local governmental agencies or local educational
consortium may claim the actual costs of nonemergency, nonmedical
transportation of Medi-Cal eligibles to Medi-Cal covered services,
under guidelines established by the department, to the extent that
these costs are actually borne by the participating local
governmental agency or local educational consortium.  A local
educational consortium may only claim for nonemergency, nonmedical
transportation of Medi-Cal eligibles for Medi-Cal covered services,
through the Medi-Cal administrative activities program.  Medi-Cal
medical transportation services shall be claimed under the local
educational agency Medi-Cal billing option, pursuant to Section
14132.06.
   (m) (1) Each participating local governmental agency shall
contribute to the department a portion of the agency's general fund
that has been made available due to the coverage of administrative
activities described in this section under the Medi-Cal program.  The
contributed funds shall be reinvested in health services through the
Medi-Cal program.  The total contribution amount shall be equal to
331/3 percent of amounts made available under this section, but in no
case shall the contribution exceed twenty million dollars
(,000,000) a fiscal year less the amount contributed pursuant to
subdivision (m) of Section 14132.44.  Beginning with the 1994-95
fiscal year, each local governmental agency's share of the total
contribution shall be determined by claims submitted and approved for
payment through January 1 of the following calendar year.  Claims
received and approved for payment after January 1 for dates of
service in the previous fiscal year shall be included in the
following year's calculation.  Each local governmental agency's share
of the contribution for the previous fiscal year shall be determined
no later than February 15 and shall be remitted to the state no
later than April 1 of each year.  The contribution amount shall be
paid from nonfederal, general fund revenues and shall be deposited in
the Administrative Claiming Fund for transfer to the Health Care
Deposit Fund.
   (2) Moneys received by the department pursuant to this subdivision
are hereby continuously appropriated to the department for support
of the Medi-Cal program, and the funds shall be administered in
accordance with procedures prescribed by the Department of Finance.
If not paid as provided in this section, the department may offset
payments due to each participating local governmental agency from the
state, not related to payments required to be made pursuant to this
section in order to recoup these funds for the Administrative
Claiming Fund.
   (3) This subdivision shall only apply to claims approved for the
1994-95 to 1997-98 fiscal years, inclusive.
   (n) As a condition of participation in the Administrative Claiming
process and in recognition of revenue generated to each
participating local governmental agency and each local educational
consortium in the Administrative Claiming process, each participating
local governmental agency and each local educational consortium
shall pay an annual participation fee through a mechanism agreed to
by the state and local governmental agencies and local educational
consortia, or, if no agreement is reached by August 1 of each year,
directly to the state.  The participation fee shall be used to cover
the cost of administering the Administrative Claiming process,
including, but not limited to, claims processing, technical
assistance, and monitoring.  The department shall determine and
report staffing requirements upon which projected costs will be
based.  The amount of the participation fee shall be based upon the
anticipated salaries, benefits, and operating expenses, to administer
the Administrative Claiming process and other costs related to that
process.
   (o) For the purposes of this section "participating local
governmental agency" means a county, chartered city, Native American
Indian tribe, tribal organization, or subgroup of a Native American
Indian tribe or tribal organization, under contract with the
department pursuant to subdivision (b).
   (p) For purposes of this section, "local educational agency" means
a local educational agency, as defined in subdivision (h) of Section
14132.06, that participates under the Administrative Claiming
process as a subcontractor to the local educational consortium in its
service region.
   (q) (1) For purposes of this section, "local educational
consortium" means a local agency that is one of the service regions
of the California County Superintendent Educational Services
Association.
   (2) Each local educational consortium shall contract with the
department pursuant to paragraph (1) of subdivision (c).
   (r) (1) Each participating local educational consortium shall be
responsible for the local educational agencies in its service region
that participate in the Administrative Claiming process.  This
responsibility includes, but is not limited to, the preparation and
submission of all administrative claiming plans, training of local
educational agency staff, overseeing the local educational agency
time survey process, and the submission of detailed quarterly
invoices on behalf of any participating local educational agency.
   (2) Each participating local educational consortium shall ensure
local educational agency compliance with all requirements of the
Administrative Claiming process established for local governmental
agencies.
   (3) Ninety days prior to the initial participation in the
Administrative Claiming process, each local educational consortium
shall notify the department of its intent to participate in the
process, and shall identify each local educational agency that will
be participating as its subcontractor.
   (s) (1) Each local educational agency that elects to participate
in the Administrative Claiming process shall submit claims through
its local educational consortium or through the local governmental
agency, but not both.
   (2) Each local educational agency participating as a subcontractor
to a local educational consortium shall comply with all requirements
of the Administrative Claiming process established for local
governmental agencies.
   (t) For the purposes of this section, a "nongovernmental entity"
does not include an entity or person administered by, affiliated
with, or employed by a participating local governmental agency or a
local educational consortium.
   (u) The requirements of subdivision (m) shall not apply to claims
for administrative activities, pursuant to the Administrative
Claiming process, performed by public health programs administered by
the state.
   (v) A participating local governmental agency or a local
educational consortium may charge an administrative fee to any entity
claiming Administrative Claiming through that agency.
   (w) The department shall continue to administer the Administrative
Claiming process in conformity with federal requirements.
   (x) The department shall provide technical assistance to all
participating local governmental agencies and local educational
consortia in order to maximize federal financial participation in the
Administrative Claiming process.
   (y) This section shall be applicable to Administrative Claiming
process activities performed, and to moneys paid to participating
local governmental agencies for those activities in the 1994-95
fiscal year and thereafter, and to local educational consortia in the
1998-99 fiscal year and thereafter.



14132.48.  Targeted case management services to which Sections
14132.44 and 14132.47 does not apply, and as specified in Section
1915(g) of the federal Social Security Act, as amended by Public Law
99-272 (42 U.S.C.  Section 1396n(g)), shall be covered as a benefit
under this chapter, subject to utilization controls, for the
following populations:
   (a) Persons served by regional centers administered by the State
Department of Developmental Services.
   (b) Persons served in other programs administered by the State
Department of Developmental Services.
   (c) Persons receiving services pursuant to Section 14021.3.
   (d) Persons in programs determined appropriate by the director.



14132.49.  (a) Upon federal approval of the state plan amendments
made pursuant to Section 14021.7 for federal financial assistance,
targeted case management, pursuant to subdivision (g) of Section
1396n of Title 42 of the United States Code, is covered as a benefit,
subject to the availability of funding through the budget process,
and subject to utilization controls, for pregnant and parenting
adolescents and their children.
   (b) In administering subdivision (a), the department shall limit
the targeted case management benefit to the amount of General Fund or
other public moneys, and federal matching funds made available in
the Budget Act or other legislation.
   (c) The department may redirect General Fund moneys for local
assistance for existing adolescent family life programs to the extent
necessary to provide state matching funds for implementation of
subdivision (a).  The amount which may be redirected shall not exceed
the amount appropriated for local assistance for the Adolescent
Family Life Program.
   (d) It is the intent of the Legislature that the additional
federal matching funds made available by implementation of
subdivision (a) be used to expand the Adolescent Family Life Program
and not supplant General Fund or other public moneys or federal funds
provided for pursuant to Titles V and XIX of the federal Social
Security Act (Sec. 701 and following, and Sec. 1396 and following,
respectively, of Title 42 of the United States Code).
   (e) Determinations to continue, expand, or terminate the program
shall be based on all of the following:
   (1) The department's assessment of the effect of Medi-Cal funding
for services on the effectiveness of the Adolescent Family Life
Program.
   (2) A determination of the amount of federal funds received for
this service.
   (3) An assessment of the cost-effectiveness of the services to the
General Fund.
   (4) An estimate of the amount of federal funds that could be
received by expanding the project to all adolescent family programs
statewide.
   (f) The department shall submit, not later than June 30, 1993,
amendments to the state plan required to implement the amendments
made to this section during the 1992 portion of the 1991-92 Regular
Session for approval by the Secretary of Health and Human Services.



14132.55.  For the purposes of reimbursement under the Medi-Cal
program, a speech pathologist or audiologist shall be licensed by the
Speech-Language Pathology and Audiology Examining Committee of the
Medical Board of California or similarly licensed by a comparable
agency in the state in which he or she practices.  Licensed
speech-language pathologists or licensed audiologists are authorized
to utilize and shall be reimbursed for the services of those
personnel in the process of completing requirements under the
provisions of subdivision (d) of Section 2532.2 of the Business and
Professions Code.



14132.6.  External prostheses constructed of silicon or other
comparable materials, prosthetic implants, and reconstructive surgery
incident to mastectomy shall be deemed medically necessary and shall
be covered under this chapter.  As used in this section, "mastectomy"
means the removal of all or part of the breast for medically
necessary reasons, as determined by a licensed physician and surgeon.

   Coverage under this section shall include the provision of initial
and subsequent prosthetic devices pursuant to an order of the
patient's physician.


14132.62.  (a) Reconstructive surgery shall be covered under this
chapter, as defined in subdivision (c), when necessary to achieve the
purposes specified in paragraphs (1) or (2) of subdivision (c).
Nothing in this section shall be construed to require coverage for
cosmetic surgery, as defined in subdivision (d).
   (b) No individual, other than a licensed physician competent to
evaluate the specific clinical issues involved in the care requested,
may deny initial requests for authorization of coverage for
treatment pursuant to this section.  For a treatment authorization
request submitted by a podiatrist or an oral and maxillofacial
surgeon, the request may be reviewed by a similarly licensed
individual competent to evaluate the specific clinical issues
involved in the care requested.
   (c) "Reconstructive surgery" means surgery performed on abnormal
structures of the body caused by congenital defects, developmental
abnormalities, trauma, infection, tumors, or disease to do either of
the following:
   (1) To improve function.
   (2) To create a normal appearance, to the extent possible.
   (d) "Cosmetic surgery" means surgery that is performed to alter or
reshape normal structures of the body in order to improve
appearance.
   (e) In connection with the interpretation of the definition of
reconstructive surgery, a proposed surgical procedure may be subject
to prior authorization and utilization review that may include, but
need not be limited to, denial under any of the following
circumstances:
   (1) There is another more appropriate surgical procedure that will
be approved for the enrollee.
   (2) The procedure or procedures offer only a minimal improvement
in the appearance of the enrollee, as defined in regulations adopted
by the department.
   (3) Denial of payment for procedures performed without prior
authorization.
   (f) This section shall become operative July 1, 1999.




14132.63.  (a) An orthotist or prosthetist providing services under
this chapter shall be required to be certified in orthotics or
prosthetics by either the Board for Orthotist Certification or the
American Board of Certification in Orthotics and Prosthetics.
   (b) This section shall remain in effect only until the date that
the director executes a declaration, that shall be retained by the
director, stating that the department has adopted regulations
requiring an orthotist or prosthetist to be certified in orthotics or
prosthetics by either the Board for Orthotist Certification or the
American Board of Certification in Orthotics and Prosthetics, as a
condition of providing orthotist or prosthetic services under this
chapter, and as of that date is repealed.



14132.69.  (a) Notwithstanding any other provision of law, donor and
recipient organ transplant surgeries are covered under the Medi-Cal
program when an organ transplant is provided to a beneficiary who is
eligible for full-scope benefits under this chapter in a medical
facility that meets the requirements of, and is approved by, the
department.
   (b) Any donor or recipient organ transplant surgeries authorized
by the department pursuant to this chapter are subject to utilization
controls.
   (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all-county letters, provider bulletins, or other
instructions, without taking any further regulatory action.
   (d) This section shall not apply to Section 14133.8.



14132.71.  (a) For purposes of donor and recipient organ transplant
surgeries, the department shall establish standards as to both the
circumstances and the criteria that the department will use for
approving facilities eligible for receiving reimbursement under the
Medi-Cal program.
   (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all-county letters, provider bulletins, or other
instructions, without taking any further regulatory action.



14132.72.  (a) It is the intent of the Legislature to recognize the
practice of telemedicine as a legitimate means by which an individual
may receive medical services from a health care provider without
person-to-person contact with the provider.
   (b) For the purposes of this section, "telemedicine" and
"interactive" are defined as those terms are defined in subdivision
(a) of Section 2290.5 of the Business and Professions Code.
   (c) (1) Commencing July 1, 1997, face-to-face contact between a
health care provider and a patient shall not be required under the
Medi-Cal program for services appropriately provided through
telemedicine, subject to reimbursement policies developed by the
Medi-Cal program to compensate licensed health care providers who
provide health care services, that are otherwise covered by the
Medi-Cal program, through telemedicine.  The audio and visual
telemedicine system used shall, at a minimum, have the capability of
meeting the procedural definition of the Current Procedural
Terminology Fourth Edition (CPT-4) codes which represent the service
provided through telemedicine.  The telecommunications equipment
shall be of a level of quality to adequately complete all necessary
components to document the level of service for the CPT-4 code
billed.  If a peripheral diagnostic scope is required to assess the
patient, it shall provide adequate resolution or audio quality for
decisionmaking.
   (2) The department shall report to the appropriate committees of
the Legislature, by January 1, 2000, on the application of
telemedicine to provide home health care; emergency care; critical
and intensive care, including neonatal care; psychiatric evaluation;
psychotherapy; and medical management as potential Medi-Cal benefits.

   (d) The Medi-Cal program shall not be required to pay for
consultation provided by the health care provider by telephone or
facsimile machines.
   (e) The Medi-Cal program shall pursue private or federal funding
to conduct an evaluation of the cost-effectiveness and quality of
health care provided through telemedicine by those providers who are
reimbursed for telemedicine services by the program.



14132.725.  (a) Commencing July 1, 2006, to the extent that federal
financial participation is available, face-to-face contact between a
health care provider and a patient shall not be required under the
Medi-Cal program for teleophthalmology and teledermatology by store
and forward. Services appropriately provided through this store and
forward process are subject to billing and reimbursement policies
developed by the department.
   (b) For purposes of this section, "teleophthalmology and
teledermatology by store and forward" means an asynchronous
transmission of medical information to be reviewed at a later time by
a physician at a distant site who is trained in ophthalmology or
dermatology, where the physician at the distant site reviews the
medical information without the patient being present in real time. A
patient receiving teleophthalmology or teledermatology by store and
forward shall be notified of the right to receive interactive
communication with the distant specialist physician, and shall
receive an interactive communication with the distant specialist
physician, upon request. If requested, communication with the distant
specialist physician may occur either at the time of the
consultation, or within 30 days of the patient's notification of the
results of the consultation.
   (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, and make specific this section
by means of all county letters, provider bulletins, and similar
instructions.
   (d) On or before January 1, 2008, the department shall report to
the Legislature the number and type of services provided, and the
payments made related to the application of store and forward
telemedicine as provided, under this section as a Medi-Cal benefit.
   (e) The health care provider shall comply with the informed
consent provisions of subdivisions (c) to (g), inclusive, of, and
subdivisions (i) and (j) of, Section 2290.5 of the Business and
Professions Code when a patient receives teleophthalmology or
teledermatology by store and forward.
  (f) This section shall remain in effect only until January 1, 2009,
and as of that date is repealed, unless a later enacted statute,
that is enacted before January 1, 2009, deletes or extends that date.



14132.73.  The State Department of Health Services shall allow
psychiatrists to receive fee-for-service Medi-Cal reimbursement for
services provided through telemedicine until June 30, 2004, or until
the State Department of Mental Health and mental health plans, in
collaboration with stakeholders, develop a method for reimbursing
psychiatric services provided through telemedicine that is
administratively feasible for the mental health plans, primary care
providers, and psychiatrists providing the services, whichever occurs
later.


14132.74.  (a) The department, in consultation with interested
stakeholders, shall develop, as a pilot project, a pediatric
palliative care benefit to evaluate whether, and to what extent, such
a benefit should be offered under the Medi-Cal program. The pilot
project shall be implemented only to the extent that federal
financial participation is available.
   (b) Beneficiaries eligible to receive the pediatric palliative
care benefit shall be under 21 years of age. The department may
further limit the population served by the pilot project to a size
deemed sufficient to make the evaluation required pursuant to
subdivision (a).
   (c) Services covered under the pediatric palliative care benefit
shall be designed to meet the unique needs of children, and shall
include those types of services that are available through the
Medi-Cal hospice benefit. The benefit shall also include the
following services, regardless of whether those services are covered
under the Medi-Cal hospice benefit:
   (1) Hospice services that are provided at the same time that
curative treatment is available, to the extent that the services are
not duplicative.
   (2) Hospice services provided to individuals whose conditions may
result in death, regardless of the estimated length of the individual'
s remaining period of life.
   (3) Any other services that the department determines to be
appropriate.
   (d) The department, in consultation with interested stakeholders,
shall determine the medical conditions and prognoses that render a
beneficiary eligible for the benefit.
   (e) Providers authorized to provide services under the pilot
program shall include licensed hospice agencies and home health
agencies licensed to provide hospice care, subject to criteria
developed by the department for provider participation.
   (f) (1) The department shall submit any necessary application to
the federal Centers for Medicare and Medicaid Services for a waiver
to implement the pilot project described in this section. The
department shall determine the form of waiver most appropriate to
achieve the purposes of this section. The waiver request shall be
included in any waiver application submitted within 12 months after
the effective date of this section, or shall be submitted as an
independent application within that time period. After federal
approval is secured, the department shall implement the waiver within
12 months of the date of approval.
   (2) The waiver shall be designed to cover a period of time
necessary to evaluate the medical necessity for, and
cost-effectiveness of, a pediatric palliative care benefit. The
results of the pilot project shall be made available to the
Legislature and appropriate policy and fiscal committees to determine
the effectiveness of the benefit.
   (g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement the provisions of this section by means of
provider bulletins or similar instructions, without the adoption of
regulations. The department shall notify the fiscal and appropriate
policy committees of the Legislature of its intent to issue a
provider bulletin or other similar instruction at least five days
prior to issuance.
   (h) (1) Nothing in this section shall result in the elimination or
reduction of any covered benefits or services under the Medi-Cal
program or the California Children's Services Program.
   (2) This section shall not affect an individual's eligibility to
receive, concurrently with the benefit provided for in this section,
any services, including home health services, for which the
individual would have been eligible in the absence of this section.



14132.765.  (a) No treatment authorization request shall be required
for the provision of prosthetic devices or for the replacement or
repair of prosthetic devices, if the cost does not exceed five
hundred dollars (0).
   (b) No treatment authorization request shall be required for the
provision of orthotic devices or for the replacement or repair of
orthotic devices, if the cost does not exceed two hundred fifty
dollars (0).
   (c) The department shall implement subdivisions (a) and (b)
commencing March 1, 1994.
   (d) Notwithstanding subdivision (c), the department shall
implement subdivisions (a) and (b) only if one of the following
occurs:
   (1) The report required by Section 14132.76 contains a conclusion
that the pilot demonstration program required by that section was
cost-effective.
   (2) The report required by Section 14132.76 is not submitted to
the appropriate committees of the Legislature by December 31, 1993.
   (d) Notwithstanding subdivisions (a) and (b), the director may
reinstate the requirement for prior authorization if the director
determines that the elimination of the requirement results in
unnecessary utilization, after notice to the Joint Legislative Budget
Committee 30 days prior to the reinstatement of the requirement for
prior authorization.



14132.77.  (a) (1) Any rural hospital may request to participate in
a two-year pilot project to perform delegated acute inpatient
hospital treatment authorization review under the Medi-Cal program.
   (2) Any hospital that elects to participate in the pilot project
under this section shall enter into an agreement with the department
to ensure the appropriateness of the treatments and services that it
provides to a Medi-Cal beneficiary.
   (3) Any rural hospital that elects to participate in a pilot
project pursuant to this section shall remain in the project for not
less than one year, unless it is removed by the department pursuant
to subdivision (c).
   (b) The department shall review, on a random basis, every six
months, up to 25 percent of the Medi-Cal beneficiaries treated by
each participating hospital.  As long as a hospital participates in a
pilot project authorized by this section, reviews required by this
section shall not interfere with, or delay, the processing of the
hospital's claims for payment.  Consistent with subdivision (c), if
the department finds that a hospital participating in a pilot project
under this section is accumulating a significant overpayment, the
department shall notify the provider.
   (c) (1) (A) If the department determines, as a result of a review
required by subdivision (b), that the hospital has provided treatment
that cannot be approved by the department, the department shall take
an immediate disallowance that shall require offsets against pending
Medi-Cal payments and any direct payment that may be required by the
department.  The disallowance shall be based on full extrapolation
of the sample to the universe of Medi-Cal days covered by the sample
period.
   (B) In addition to the requirements of subparagraph (A), if the
department determines that the hospital has provided treatment that
cannot be approved by the department for 3 percent or more of the
Medi-Cal beneficiary days, the department shall take corrective
action relative to the hospital's participation in the pilot project.
  The corrective action shall include at least one of the following
actions:
   (i) The revocation of the hospital's participation pursuant to
subdivision (a).
   (ii) An increased random review process.
   (iii) Mandatory educational programs.
   (2) After the random review required by subdivision (b), the
hospital shall, through the reduction of the regularly scheduled
periodic interim payment over a one-year period, pay the state an
amount equal to the reimbursement received by the hospital for
services for which approval has been denied and extrapolated pursuant
to paragraph (1).  This paragraph does not preclude any hospital
from appealing a determination of the department under Article 5.3
(commencing with Section 14170).  However, any issue under appeal
shall not delay any disallowance or corrective action taken by the
department under paragraph (1) until the appeal is resolved.
   (d) The department may reinstate any hospital's participation
revoked pursuant to subdivision (c) if, after a period of three
months, the hospital's requests for a treatment authorization are not
denied in 3 percent or more of the Medi-Cal days.
   (e) Six months after the conclusion of the first year of the pilot
project, the department shall prepare a report with an evaluation of
the project and shall submit it to the appropriate committees of the
Legislature.  The department shall include its determination as to
whether the project should be extended, modified, or terminated in
the report and the basis for any determinations made by the
department.
   (f) (1) As part of the pilot project implemented under this
section, the department may, subject to federal approval, authorize
the reimbursement of a participating rural hospital at a
predetermined amount every two weeks or on some other basis
determined to be appropriate by the department.  Following every
six-month period, the department shall immediately begin adjustment
of any overpayment or underpayment, based on the amount paid to the
provider as compared to the actual amount of claims approved by the
department.  Any hospital that is selected to participate in the
pilot project under this section that elects to be paid for acute
inpatient services under this subdivision shall be subject to the
payment provisions of this section for the duration of the hospital's
participation in the pilot project.
   (2) The amount of reimbursement under paragraph (1) shall be based
on the actual claims payment experience for each hospital for the
immediately preceding period of six months and rate adjustments made
in accordance with existing Medi-Cal reimbursement requirements.
   (g) For purposes of this section, "rural hospital" means a small
and rural hospital as defined in Section 124840 of the Health and
Safety Code.
   (h) The scope of the pilot project shall be subject to federal
approval and the necessary resources made available from sources
other than the General Fund or savings from program efficiencies that
may be identified for this purpose.
   (i) The department shall implement this section only upon receipt
of all appropriate federal waivers.



14132.8.  Services covered under this chapter shall include
rehabilitative services for the physically or cognitively impaired
stroke patient, or a patient who has brain injury for whom the
medical prognosis and signs indicate potential for faster or more
complete recovery, or maintenance or prevention of degeneration, in a
variety of situations, including acute inpatient intensive
rehabilitation immediately after the occurrence of stroke or injury,
inpatient maintenance for the chronically impaired in a hospital or
long-term care facility, outpatient services in a rehabilitation
clinic or an adult day health care center, and in-home care or home
health agency services for the patient at home.
   Rehabilitative services for the physically or cognitively impaired
patient only for those whom the medical prognosis and signs indicate
potential for faster or more complete recovery, or maintenance or
prevention of degeneration, shall be considered to fall within the
definition of medical necessity, as that term is used in Section
14133.3.
   For purposes of this section, "brain injury" means clinically
evident brain damage resulting directly or indirectly from tumor,
trauma, infection, anoxia, or vascular lesions not primarily due to
degenerative or aging processes which result in temporary or
permanent physical or cognitive deficits.
   This section shall not negate the department's utilization review
authority under subdivision (a) of Section 14133.



14132.81.  (a) The purchase of identification bracelets for eligible
recipients under the Medi-Cal program who have Alzheimer's Disease
or some other cognitive defect, or medication allergies that could be
life threatening, shall be a covered benefit under this chapter.
   (b) The bracelets shall be purchased from an organization which
maintains a 24-hour toll-free telephone number for emergency or
medical personnel to make inquiries.
   (c) The director shall develop regulations to implement this
section.
   (d) For purposes of this section "eligible recipients" means those
persons who, in addition to qualifying for benefits under this
chapter, have been determined by a licensed physician and surgeon to
need the benefit authorized by this section.
   (e) Benefits shall be provided under this section only to the
extent that full federal financial participation is made available.
   (f) Benefits shall be provided under this section only when the
director determines that two or more organizationally independent
providers are available to supply the benefit authorized by this
section.


14132.88.  (a) Notwithstanding subdivision (h) of Section 14132 and
to the extent funds are made available in the annual Budget Act for
this purpose, the following are covered benefits for beneficiaries 21
years of age or older under this chapter:
   (1) One dental prophylaxis cleaning per year.
   (2) One initial dental examination by a dentist.
   (b) The following are covered benefits for beneficiaries under 21
years of age under this chapter:
   (1) Two dental prophylaxis cleanings per year.
   (2) Two periodic dental examinations per year.
   (c) For persons 21 years of age or older, laboratory-processed
crowns on posterior teeth are not a covered benefit except when a
posterior tooth is necessary as an abutment for any fixed or
removable prosthesis.
   (d) Any prefabricated crown made from ADA-approved materials may
be used on posterior teeth and may be reimbursed as a stainless steel
crown.
   (e) The department shall reduce the rate of subgingival curettage
and root planing by 41 percent for all beneficiaries except those
residing in a skilled nursing facility or an intermediate care
facility for the developmentally disabled. Notwithstanding Section
14105 and Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code, the department may
implement this subdivision by means of a provider bulletin or similar
instruction, without taking regulatory action.
   (f) (1) Except as provided in paragraph (2), the department shall
require pretreatment radiograph documentation on posttreatment claims
to establish the medical necessity for dental restorations. The
pretreatment documentation required under this subdivision is
intended to reduce fraudulent claims for unnecessary dental fillings.
  In order to avoid any undue barriers to accessing dental care, the
department shall stipulate that the pretreatment radiograph
documentation for posttreatment claims will be required only when
there are four or more dental fillings being completed in any
12-month period.
   (2) For any beneficiary who is under four years of age, or who,
regardless of age, has a developmental disability, as defined in
subdivision (a) of Section 4512, radiographs or photographs that
indicate decay on any tooth surface shall be considered sufficient
documentation to establish the medical necessity for treatment
provided.
   (3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this subdivision by means of a provider
bulletin or similar instruction, without taking regulatory action.




14132.9.  Notwithstanding subdivision (h) of Section 14132, any
utilization controls imposed under such subdivision shall not include
mandatory examination by any person not licensed as a dentist under
the Dental Practice Act.


14132.90.  (a) As of September 15, 1995, day care habilitative
services, pursuant to subdivision (c) of Section 14021 shall be
provided only to alcohol and drug exposed pregnant women and women in
the postpartum period, or as required by federal law.
   (b) (1) Notwithstanding any other provision of law, except to the
extent required by federal law, if, as of May 15, 2000, the projected
costs for the 1999-2000 fiscal year for outpatient drug abuse
services, as described in Section 14021, exceed forty-five million
dollars (,000,000) in state General Fund moneys, then the
outpatient drug free services, as defined in Section 51341.1 of Title
22 of the California Code of Regulations, shall not be a benefit
under this chapter as of July 1, 2000.
   (2) Notwithstanding paragraph (1), narcotic replacement therapy
and Naltrexone shall remain benefits under this chapter.
   (3) Notwithstanding paragraph (1), residential care, outpatient
drug free services, and day care habilitative services, for alcohol
and drug exposed pregnant women and women in the postpartum period
shall remain benefits under this chapter.
   (c) Expenditures for services purchased at the direction of county
welfare departments on behalf of CalWORKs recipients shall not be
included in the computation of costs for subdivision (b).
   (d) For the 1999-2000 fiscal year and each fiscal year thereafter,
there shall be separate annual fiscal year General Fund
appropriations for drug Medi-Cal perinatal services (Item
4200-104-0001 of the Budget Act), drug Medi-Cal nonperinatal services
(Item 4200-103-0001 of the Budget Act), nondrug Medi-Cal perinatal
services (Item 4200-102-0001 of the Budget Act), and nondrug Medi-Cal
nonperinatal services (Item 4200-101-0001 of the Budget Act).
   (e) Notwithstanding any other provision of law, the State
Department of Alcohol and Drug Programs shall maintain a contingency
reserve of the reappropriated General Fund moneys for the purpose of
drug Medi-Cal program expenditures.
   (f) Unexpended General Fund moneys appropriated for the drug
Medi-Cal program may be transferred for use as nondrug Medi-Cal
county expenditures in the current or budget years.  Unexpended
General Fund moneys shall not be transferred from nondrug Medi-Cal to
the drug Medi-Cal program for purposes of providing matching funds
for federal financial participation.



14132.91.  (a) Subject to the availability of funding, the
department shall conduct a dental outreach and education program for
Medi-Cal beneficiaries.  The program shall inform Medi-Cal
beneficiaries of the availability of dental care and provide
information regarding recommended frequencies for regular and
preventive dental care, how to obtain Medi-Cal dental care, how to
avoid inappropriate care or fraudulent providers, and how to obtain
assistance in getting care or resolving problems with dental care.
   (b) The program shall particularly target underserved populations
and parents of young and adolescent children, and it shall include
the following components:
   (1) Incorporation of dental themes and information in ongoing
outreach and advertising efforts, including those for Medi-Cal and
the Healthy Families program.
   (2) Education and outreach materials for inclusion in mailings to
beneficiaries.
   (3) Education and consumer protection materials for display and
distribution at sites providing Medi-Cal dental care, clinics, and
other health care facilities and sites.
   (c) The department shall consult with dental professional groups
and experts, community organizations, advertising and media experts,
and other parties, as the department deems appropriate, in order to
develop and structure the program in an effective and efficient
manner.



14132.92.  (a) Notwithstanding subdivision (a) of Section 4512, or
any other provision of this chapter or Chapter 8 (commencing with
Section 14200), services provided on or after July 1, 2000, by
facilities defined in subdivisions (e) and (h) of Section 1250 of the
Health and Safety Code that are otherwise covered services under
this chapter shall be reimbursed by the Medi-Cal program when
provided to a Medi-Cal beneficiary that has a developmental
disability as defined in Section 6001(8) of Title 42 of the United
States Code or is a person with a related condition as defined in
Section 435.1009 of Title 42 of the Code of Federal Regulations,
provided that the Medi-Cal beneficiary was residing in a licensed
intermediate care facility/developmentally disabled-habilitative or a
licensed intermediate care facility/developmentally disabled-nursing
on July 1, 2000, but only for as long as the beneficiary continues,
from that date, to reside in a licensed intermediate care
facility/developmentally disabled-habilitative or a licensed
intermediate care facility/developmentally disabled-nursing.
   (b) Nothing in subdivision (a) shall eliminate, for purposes of
reimbursement under this section, the requirements and time limits
set forth in Section 14115, or any regulations adopted thereunder.
   (c) The department shall seek further financial participation, and
shall seek federal approval of a state plan amendment if necessary
under Section 440.150 of Title 42 of the Code of Federal Regulations,
for services provided pursuant to subdivision (a).  If federal
financial participation is not made available for the services, the
services nonetheless shall be reimbursed from the General Fund.



14132.93.  It is the intent of the Legislature that if services
meeting the conditions of subdivision (a) of Section 14132.92 have
been provided to a Medi-Cal beneficiary during the time period of
June 15, 1998, to July 2, 2000, and notwithstanding Section 14115, a
bill for these services is submitted on behalf of each beneficiary
receiving these services postmarked to the department on or before
April 30, 2001, the services shall be reimbursed by the General Fund.
  However, the department shall seek federal financial participation
and shall seek federal approval of a state plan amendment if
necessary under Section 440.150 of Title 42 of the Code of Federal
Regulations, for these services provided during that period.  If
federal financial participation is not made available for that
period, the services nonetheless shall be reimbursed from the General
Fund.


14132.94.  (a) Subject to approval by the Centers for Medicare and
Medicaid Services of a medicaid state plan amendment electing the
Programs of All-Inclusive Care for the Elderly (PACE) as a state
medicaid option, as provided for by Subtitle I (commencing with
Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public
Law 105-33) and Part 460 (commencing with Section 460.2) of
Subchapter E of Title 42 of the Code of Federal Regulations, PACE
program services shall become a covered benefit of the Medi-Cal
program, subject to utilization controls and eligibility criteria
that require that the beneficiary be certifiable for nursing facility
services based on Medi-Cal criteria.
   (b) Covered services under the PACE benefit of the Medi-Cal
program include those set forth in 42 C.F.R. 460.92.




14132.95.  (a) Personal care services, when provided to a
categorically needy person as defined in Section 14050.1 is a covered
benefit to the extent federal financial participation is available
if these services are:
   (1) Provided in the beneficiary's home and other locations as may
be authorized by the director subject to federal approval.
   (2) Authorized by county social services staff in accordance with
a plan of treatment.
   (3) Provided by a qualified person.
   (4) Provided to a beneficiary who has a chronic, disabling
condition that causes functional impairment that is expected to last
at least 12 consecutive months or that is expected to result in death
within 12 months and who is unable to remain safely at home without
the services described in this section.
   (b) The department shall seek federal approval of a state plan
amendment necessary to include personal care as a Medicaid service
pursuant to subdivision (f) of Section 440.170 of Title 42 of the
Code of Federal Regulations.  For any persons who meet the criteria
specified in subdivision (a) or (p), but for whom federal financial
participation is not available for a service or services under this
section, eligibility for the service or services shall be determined
according to the waiver authorized pursuant to Section 14132.951.  If
federal financial participation for the service or services is not
available under this section or Section 14132.951, eligibility for
the service or services shall be determined pursuant to Article 7
(commencing with Section 12300) of Chapter 3.
   (c) Subdivision (a) shall not be implemented unless the department
has obtained federal approval of the state plan amendment described
in subdivision (b), and the Department of Finance has determined, and
has informed the department in writing, that the implementation of
this section will not result in additional costs to the state
relative to state appropriation for in-home supportive services under
Article 7 (commencing with Section 12300) of Chapter 3, in the
1992-93 fiscal year.
   (d) (1) For purposes of this section, personal care services shall
mean all of the following:
   (A) Assistance with ambulation.
   (B) Bathing, oral hygiene and grooming.
   (C) Dressing.
   (D) Care and assistance with prosthetic devices.
   (E) Bowel, bladder, and menstrual care.
   (F) Skin care.
   (G) Repositioning, range of motion exercises, and transfers.
   (H) Feeding and assurance of adequate fluid intake.
   (I) Respiration.
   (J) Paramedical services.
   (K) Assistance with self-administration of medications.
   (2) Ancillary services including meal preparation and cleanup,
routine laundry, shopping for food and other necessities, and
domestic services may also be provided as long as these ancillary
services are subordinate to personal care services.  Ancillary
services may not be provided separately from the basic personal care
services.
   (e) (1) (A) After consulting with the State Department of Social
Services, the department shall adopt emergency regulations to
establish the amount, scope, and duration of personal care services
available to persons described in subdivision (a) in the fiscal year
whenever the department determines that General Fund expenditures for
personal care services provided under this section and expenditures
of both General Fund moneys and federal funds received under Title XX
of the federal Social Security Act for services pursuant to Article
7 (commencing with Section 12300) of Chapter 3, are expected to
exceed the General Fund appropriation and the federal appropriation
under Title XX of the federal Social Security Act provided for the
1992-93 fiscal year pursuant to Article 7 (commencing with Section
12300) of Chapter 3, as it read on June 30, 1992, as adjusted for
caseload growth or as increased in the Budget Act or appropriated by
statute.  At least 30 days prior to filing these regulations with the
Secretary of State, the department shall give notice of the expected
content of these regulations to the fiscal committees of both houses
of the Legislature.
   (B) In establishing the amount, scope, and duration of personal
care services, the department shall ensure that General Fund
expenditures for personal care services provided for under this
section and expenditures of both General Fund moneys and federal
funds received under Title XX of the federal Social Security Act for
services pursuant to Article 7 (commencing with Section 12300) of
Chapter 3, do not exceed the General Fund appropriation and the
federal appropriation under Title XX of the federal Social Security
Act provided for the 1992-93 fiscal year pursuant to Article 7
(commencing with Section 12300) of Chapter 3, as it read on June 30,
1992, as adjusted for caseload growth or as increased in the Budget
Act or appropriated by statute.
   (C) For purposes of this subdivision, "caseload growth" means an
adjustment factor determined by the department based on (1) growth in
the number of persons eligible for benefits under Chapter 3
(commencing with Section 12000) on the basis of their disability, (2)
the average increase in the number of hours in the program
established pursuant to Article 7 (commencing with Section 12300) of
Chapter 3 in the 1988-89 to 1992-93 fiscal years, inclusive, due to
the level of impairment, and (3) any increase in program costs that
is required by an increase in the mandatory minimum wage.
   (2) In establishing the amount, scope, and duration of personal
care services pursuant to this subdivision, the department may define
and take into account, among other things:
   (A) The extent to which the particular personal care services are
essential or nonessential.
   (B) Standards establishing the medical necessity of the services
to be provided.
   (C) Utilization controls.
   (D) A minimum number of hours of personal care services that must
first be assessed as needed as a condition of receiving personal care
services pursuant to this section.
   The level of personal care services shall be established so as to
avoid, to the extent feasible within budgetary constraints, medical
out-of-home placements.
   (3) To the extent that General Fund expenditures for services
provided under this section and expenditures of both General Fund
moneys and federal funds received under Title XX of the federal
Social Security Act for services pursuant to Article 7 (commencing
with Section 12300) of Chapter 3 in the 1992-93 fiscal year, adjusted
for caseload growth, exceed General Fund expenditures for services
provided under this section and expenditures of both General Fund
moneys and federal funds received under Title XX of the federal
Social Security Act for services pursuant to Article 7 (commencing
with Section 12300) of Chapter 3 in any fiscal year, the excess of
these funds shall be expended for any purpose as directed in the
Budget Act or as otherwise statutorily disbursed by the Legislature.

   (f) Services pursuant to this section shall be rendered, under the
administrative direction of the State Department of Social Services,
in the manner authorized in Article 7 (commencing with Section
12300) of Chapter 3, for the In-Home Supportive Services program.  A
provider of personal care services shall be qualified to provide the
service and shall be a person other than a member of the family.  For
purposes of this section, a family member means a parent of a minor
child or a spouse.
   (g) The maximum number of hours available under the In-Home
Supportive Services program pursuant to Article 7 (commencing with
Section 12300) of Chapter 3, Section 14132.951, and this section,
combined, shall be 283 hours per month.
   (h) Personal care services shall not be provided to residents of
facilities licensed by the department, and shall not be provided to
residents of a community care facility or a residential care facility
for the elderly licensed by the Community Care Licensing Division of
the State Department of Social Services.
   (i) Subject to any limitations that may be imposed pursuant to
subdivision (e), determination of need and authorization for services
shall be performed in accordance with Article 7 (commencing with
Section 12300) of Chapter 3.
   (j) (1) To the extent permitted by federal law, reimbursement
rates for personal care services shall be equal to the rates in each
county for the same mode of services in the In-Home Supportive
Services program pursuant to Article 7 (commencing with Section
12300) of Chapter 3, plus any increase provided in the annual Budget
Act for personal care services rates or included in a county budget
pursuant to paragraph (2).
   (2) (A) The department shall establish a provider reimbursement
rate methodology to determine payment rates for the individual
provider mode of service that does all of the following:
   (i) Is consistent with the functions and duties of entities
created pursuant to Section 12301.6.
   (ii) Makes any additional expenditure of state general funds
subject to appropriation in the annual Budget Act.
   (iii) Permits county-only funds to draw down federal financial
participation consistent with federal law.
   (B) This ratesetting method shall be in effect in time for any
rate increases to be included in the annual Budget Act.
   (C) The department may, in establishing the ratesetting method
required by subparagraph (A), do both of the following:
   (i) Deem the market rate for like work in each county, as
determined by the Employment Development Department, to be the cap
for increases in payment rates for individual practitioner services.

   (ii) Provide for consideration of county input concerning the rate
necessary to ensure access to services in that county.
   (D) If an increase in individual practitioner rates is included in
the annual Budget Act, the state-county sharing ratio shall be as
established in Section 12306.  If the annual Budget Act does not
include an increase in individual practitioner rates, a county may
use county-only funds to meet federal financial participation
requirements consistent with federal law.
   (3) (A) By November 1, 1993, the department shall submit a state
plan amendment to the federal Health Care Financing Administration to
implement this subdivision.  To the extent that any element or
requirement of this subdivision is not approved, the department shall
submit a request to the federal Health Care Financing Administration
for any waivers as would be necessary to implement this subdivision.

   (B) The provider reimbursement ratesetting methodology authorized
by the amendments to this subdivision in the 1993-94 Regular Session
of the Legislature shall not be operative until all necessary federal
approvals have been obtained.
   (k) (1) The State Department of Social Services shall, by
September 1, 1993, notify the following persons that they are
eligible to participate in the personal care services program:
   (A) Persons eligible for services pursuant to the Pickle
Amendment, as adopted October 28, 1976.
   (B) Persons eligible for services pursuant to subsection (c) of
Section 1383c of Title 42 of the United States Code.
   (2) The State Department of Social Services shall, by September 1,
1993, notify persons to whom paragraph (1) applies and who receive
advance payment for in-home supportive services that they will
qualify for services under this section without a share of cost if
they elect to accept payment for services on an arrears rather than
an advance payment basis.
   (l) An individual who is eligible for services subject to the
maximum amount specified in subdivision (b) of Section 12303.4 shall
be given the option of hiring his or her own provider.
   (m) The county welfare department shall inform in writing any
individual who is potentially eligible for services under this
section of his or her right to the services.
   (n) It is the intent of the Legislature that this entire section
be an inseparable whole and that no part of it be severable.  If any
portion of this section is found to be invalid, as determined by a
final judgment of a court of competent jurisdiction, this section
shall become inoperative.
   (o) Paragraphs (2) and (3) of subdivision (a) shall be implemented
so as to conform to federal law authorizing their implementation.
   (p) (1) Personal care services shall be provided as a covered
benefit to a medically needy aged, blind, or disabled person, as
defined in subdivision (a) of Section 14051, to the same extent and
under the same requirements as they are provided under subdivision
(a) of this section to a categorically needy, aged, blind, or
disabled person, as defined in subdivision (a) of Section 14050.1,
and to the extent that federal financial participation is available.

   (2) The department shall seek federal approval of a state plan
amendment necessary to include personal care services described in
paragraph (1) as a Medicaid service pursuant to subdivision (f) of
Section 440.170 of Title 42 of the Code of Federal Regulations.
   (3) In the event that the Department of Finance determines that
expenditures of both General Fund moneys for personal care services
provided under this subdivision to medically needy aged, blind, or
disabled persons together with expenditures of both General Fund
moneys and federal funds received under Title XX of the federal
Social Security Act for all aged, blind, and disabled persons
receiving in-home supportive services pursuant to Article 7
(commencing with Section 12300) of Chapter 3, in the 2000-01 fiscal
year or in any subsequent fiscal year, are expected to exceed the
General Fund appropriation and the federal appropriation received
under Title XX of the federal Social Security Act for expenditures
for all aged, blind, and disabled persons receiving in-home
supportive services provided in the 1999-2000 fiscal year pursuant to
Article 7 (commencing with Section 12300) of Chapter 3, as it read
on June 30, 1998, as adjusted for caseload growth or as changed in
the Budget Act or by statute or regulation, then this subdivision
shall cease to be operative on the first day of the month that begins
after the expiration of a period of 30 days subsequent to a
notification in writing by the Director of the Department of Finance
to the chairperson of the committee in each house that considers
appropriations, the chairpersons of the committees and the
appropriate subcommittees in each house that consider the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
   (4) Solely for purposes of paragraph (3), caseload growth means an
adjustment factor determined by the department based on:
   (A) Growth in the number of persons eligible for benefits under
Chapter 3 (commencing with Section 12000) on the basis of their
disability.
   (B) The average increase in the number of hours in the program
established pursuant to Article 7 (commencing with Section 12300) of
Chapter 3 in the 1994-95 to 1998-99 fiscal years, inclusive, due to
the level of impairment.
   (C) Any increase in program cost that is required by an increase
in hourly costs pursuant to the Budget Act or statute.
   (5) In the event of a final judicial determination by any court of
appellate jurisdiction or a final determination by the Administrator
of the federal Centers for Medicare and Medicaid Services that
personal care services must be provided to any medically needy person
who is not aged, blind, or disabled, then this subdivision shall
cease to be operative on the first day of the first month that begins
after the expiration of a period of 30 days subsequent to a
notification in writing by the Director of Finance to the chairperson
of the committee in each house that considers appropriations, the
chairpersons of the committees and the appropriate subcommittees in
each house that consider the State Budget, and the Chairperson of the
Joint Legislative Budget Committee.
   (6) If this subdivision ceases to be operative, all aged, blind,
and disabled persons who would have been eligible to receive services
under this section shall be immediately eligible for services under
the IHSS Plus waiver authorized pursuant to Section 14132.951, if
otherwise eligible, upon this section becoming inoperative.  If this
section becomes inoperative and a person is ineligible for the IHSS
Plus waiver, then eligibility shall be determined under the In-Home
Supportive Services program pursuant to Article 7 (commencing with
Section 12300) of Chapter 3.



14132.951.  (a) It is the intent of the Legislature that the State
Department of Health Services seek approval of a Medicaid waiver
under the federal Social Security Act in order that the services
available under Article 7 (commencing with Section 12300) of Chapter
3, known as the In-Home Supportive Services program, may be provided
as a Medi-Cal benefit under this chapter, to the extent federal
financial participation is available.  The waiver shall be known as
the "IHSS Plus waiver."
   (b) To the extent feasible, the IHSS Plus waiver described in
subdivision (a) shall incorporate the eligibility requirements,
benefits, and operational requirements of the In-Home Supportive
Services program as it exists on the effective date of this section.
The director shall have discretion to modify eligibility
requirements, benefits, and operational requirements as needed to
secure approval of the Medicaid waiver.
   (c) Upon implementation of the IHSS Plus waiver, and to the extent
federal financial participation is available, the services available
through the In-Home Supportive Services program shall be furnished
as benefits of the Medi-Cal program through the IHSS Plus waiver to
persons who meet the eligibility requirements of the IHSS Plus
waiver.  The benefits shall be limited by the terms and conditions of
the IHSS Plus waiver and by the availability of federal financial
participation.
   (d) Upon implementation of the IHSS Plus waiver:
   (1) A person who is eligible for the IHSS Plus waiver shall no
longer be eligible to receive services under the In-Home Supportive
Services program to the extent those services are available through
the IHSS Plus waiver.
   (2) A person shall not be eligible to receive services pursuant to
the IHSS Plus waiver to the extent those services are available
pursuant to Section 14132.95.
   (e) Services provided pursuant to this section shall be rendered,
under the administrative direction of the State Department of Social
Services, in the manner authorized in Article 7 (commencing with
Section 12300) of Chapter 3, for the In-Home Supportive Services
program.
   (f) Services shall not be provided to residents of facilities
licensed by the department, and shall not be provided to residents of
a community care facility or a residential care facility for the
elderly licensed by the State Department of Social Services.
   (g) To the extent permitted by federal law, reimbursement rates
for services shall be equal to the rates in each county for the same
mode of services in the In-Home Supportive Services program pursuant
to Article 7 (commencing with Section 12300) of Chapter 3.
   (h) (1) Notwithstanding the Administrative Procedure Act, Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code, the department may implement the provisions
of this section through all-county welfare director letters or
similar publications.  Actions taken to implement, interpret, or make
specific this section shall not be subject to the Administrative
Procedure Act or to the review and approval of the Office of
Administrative Law.  Upon request of the department, the Office of
Administrative Law shall publish the regulations in the California
Code of Regulations.  All county welfare director letters or similar
publications authorized pursuant to this section shall remain in
effect for no more than 18 months.
   (2) The department may also adopt emergency regulations
implementing the provisions of this section.  The adoption of
regulations implementing this section shall be deemed an emergency
and necessary for the immediate preservation of the public peace,
health, safety, or general welfare.  The emergency regulations
authorized by this section shall be exempt from review by the Office
of Administrative Law.  Any emergency regulations authorized by this
section shall be submitted to the Office of Administrative Law for
filing with the Secretary of State and shall remain in effect for no
more than 18 months by which time final regulations shall be adopted.
  The department shall seek input from the entities listed in Section
12305.72 when developing the regulations, all county welfare
director letters, or similar publications.
   (i) In the event of a conflict between the terms of the IHSS Plus
waiver and any provision of this part or any regulation, all-county
welfare directors letters or similar publications adopted for the
purpose of implementing this part, the terms of the waiver shall
control to the extent that the services are covered by the waiver.
If the department determines that a conflict exists, the department
shall issue updated instructions to counties for the purposes of
implementing necessary program changes.  The department shall post a
copy of, or a link to, the instructions on its Web site.
   (j) (1) Notwithstanding subdivision (b) or any other provision of
this section, the department shall not waive or modify the provisions
of Section 12301.2, 12301.6, 12302.25, 12306.1, or 12309.
   (2) Upon receipt of the IHSS Plus waiver, the director shall
report to the Legislature on any modifications in benefits or
eligibility and operational requirements of the In-Home Supportive
Services program required for receipt of the waiver.



14132.955.  Personal care services that are provided pursuant to
Section 14132.95 shall include services in the recipient's place of
employment if both of the following conditions are met:
   (a) The personal care services are limited to those that are
currently authorized for the recipient in the recipient's home and
those services are to be utilized by the recipient at the recipient's
place of employment to enable the recipient to obtain, retain, or
return to, work.  Authorized services utilized by the recipient at
the recipient's place of employment shall be services that are
relevant and necessary in supporting and maintaining employment.
However, work place services shall not be used to supplant any
reasonable accommodations required of an employer by the Americans
with Disabilities Act (42 U.S.C. Sec. 12101 et seq.) or other legal
entitlements or third-party obligations.
   (b) The provision of personal care services at the recipient's
place of employment shall be authorized only to the extent that the
total hours utilized at the work place are within the total personal
care services hours authorized for the recipient in the home.
Additional personal care services hours may not be authorized in
connection with a recipient's employment.



14132.96.  Medi-Cal personal care services provider rates
established as provided in the state plan under Subchapter 19
(commencing with Section 1396) of Chapter 7 of Title 42 of the United
States Code, by an in-home supportive services public authority
established pursuant to paragraph (2) of subdivision (a) and
paragraph (4) of subdivision (b) of Section 12301.6 shall be reviewed
by the county in which the in-home supportive services public
authority operates, to determine that the rates are consistent with
the county budget and that the county will be able to fund any
increase in its share of costs, prior to the submission of the rates
to the department.  Certification of the county's ability to fund any
increase in rates shall accompany the submission of rates to the
department.


14132.966.  (a) Services provided by a physician assistant are a
covered benefit under this chapter to the extent authorized by
federal law and subject to utilization controls.
   (b) Subject to subdivision (a), all services performed by a
physician assistant within his or her scope of practice that would be
a covered benefit if performed by a physician and surgeon shall be a
covered benefit under this chapter.
   (c) The department shall not impose chart review,
countersignature, or other conditions of coverage or payment on a
physician and surgeon supervising physician assistants that are more
stringent than requirements imposed by Chapter 7.7 (commencing with
Section 3500) of Division 2 of the Business and Professions Code or
regulations of the Medical Board of California promulgated under that
chapter.



14132.97.  (a) For purposes of this section, "waiver personal care
services" means personal care services authorized by the department
for persons who are eligible for either nursing or model nursing
facility waiver services.  Waiver personal care services shall be
defined in these respective waivers, shall differ in scope from
personal care services that may be authorized in Section 14132.95,
and shall not replace any hours of services authorized or that may be
authorized under Section 14132.95.
   (b) An individual may receive waiver personal care services if all
of the following conditions are met:
   (1) The individual has been approved by the department to receive
services in accordance with a waiver approved under Section 1915(c)
of the federal Social Security Act (42 U.S.C. Sec. 1396n(c)) for
persons who would otherwise require care in a nursing facility.
   (2) The individual has doctor's orders that specify that he or she
requires waiver personal care services in order to remain in his or
her own home.
   (3) The individual chooses, either personally or through a
substitute decisionmaker who is recognized under state law for
purposes of giving consent for medical treatment, to receive waiver
personal care services, as well as medically necessary skilled
nursing services, in order to remain in his or her own home.
   (4) The waiver personal care services and all other waiver
services for the individual do not result in costs that exceed the
fiscal limit established under the waiver.
   (c) The department shall notify the administrator of the in-home
supportive services program in the county of residence of any
individual who meets all requirements of subdivision (b) and has been
authorized by the department to receive waiver personal care
services.  The county of residence shall then do the following:
   (1) Inform the department of the personal care services that the
individual is authorized to receive under Section 14132.95 at the
time he or she becomes eligible for waiver personal care services.
   (2) Determine the individual's eligibility for personal care
services under Section 14132.95 if he or she is not currently
authorized to receive those services and if he or she has not been
previously determined eligible for those services.
   (3) Implement the department's authorization for waiver personal
care services for the individual at the quantity and scope authorized
by the department.
   (d) (1) Waiver personal care services approved by the department
for individuals who meet the requirements of subdivision (b) may be
provided in either of the following ways, or a combination of both:
   (A) By a licensed and certified home health agency participating
in the Medi-Cal program.
   (B) By one or more providers of personal care services under
Article 7 (commencing with Section 12300) of Chapter 3 and
subdivision (d) of Section 14132.95, when the individual elects, in
writing, to utilize these service providers.
   (2) The department shall approve waiver personal care services for
individuals who meet the requirements of subdivision (b) only when
the department finds that the individual's receipt of waiver personal
care services is necessary in order to enable the individual to be
maintained safely in his or her own home and community.
   (3) When waiver personal care services are provided by a licensed
and certified home health agency, the home health agency shall
receive payment in the manner by which it would receive payment for
any other service approved by the department.
   (4) When waiver personal care services are provided by one or more
providers of personal care services under Article 7 (commencing with
Section 12300) of Chapter 3 and subdivision (d) of Section 14132.95,
the providers shall receive payment on a schedule and in a manner by
which providers of personal care services receive payment.  The
State Department of Social Services shall commence making payments
for waiver personal care services when its payment system has been
modified to accommodate those payments.  No county shall be obligated
to administer waiver personal care services until the State
Department of Social Services payment system has been modified to
accommodate those payments.  However, any county or public authority
or nonprofit consortium that administers the in-home supportive
services program and personal care services program may pay providers
for the delivery of waiver personal care services if it chooses to
do so.  In such a case, the county, public authority, or nonprofit
consortium shall be reimbursed by the department for the waiver
personal care services authorized by the department and provided to
an individual upon submittal of documentation as required by the
waiver, and in accordance with the requirements of the department.
   (e) Waiver personal care services shall not count as alternative
resources in a county's determination of the amount of services an
individual may receive under Section 14132.95.
   (f) Any administrative costs to the State Department of Social
Services, a county, or a public authority or nonprofit consortium
associated with implementing this section shall be considered
administrative costs under the waiver and shall be reimbursed by the
department.
   (g) Two hundred fifty thousand dollars (0,000) is appropriated
from the General Fund to the State Department of Social Services for
the 1998-99 fiscal year for the purpose of making changes to the case
management, information, and payrolling system that are necessary
for the implementation of this section.
   (h) This section shall not be implemented until the department has
obtained federal approval of any necessary amendments to the
existing nursing facility and model nursing facility waivers and the
state plan under Title 19 of the federal Social Security Act (42
U.S.C. Sec. 1396 et seq.).  Any amendments to the existing nursing
facility and model nursing facility waivers and the state plan which
are deemed to be necessary by the director shall be submitted to the
federal Health Care Financing Administration by April 1, 1999.
   (i) The department shall implement this section only to the extent
that its implementation results in fiscal neutrality, as required
under the terms of the waivers.



14132.98.  (a) For a beneficiary diagnosed with cancer and accepted
into a phase I, phase II, phase III, or phase IV clinical trial for
cancer, the Medi-Cal program shall provide coverage for all routine
patient care costs related to the clinical trial if the beneficiary's
treating physician, who is providing covered health care services to
the beneficiary under the Medi-Cal program, recommends participation
in the clinical trial after determining that participation in the
clinical trial has a meaningful potential to benefit the beneficiary.
  For purposes of this section, a clinical trial's endpoints shall
not be defined exclusively to test toxicity, but shall have a
therapeutic intent.
   (b) (1) "Routine patient care costs" means the costs associated
with the provision of health care services, including drugs, items,
devices, and services that would otherwise be covered under the
Medi-Cal program if those drugs, items, devices, and services were
not provided in connection with an approved clinical trial program,
including:
   (A) Health care services typically provided absent a clinical
trial.
   (B) Health care services required solely for the provision of the
investigational drug, item, device, or service.
   (C) Health care services required for the clinically appropriate
monitoring of the investigational item or service.
   (D) Health care services provided for the prevention of
complications arising from the provision of the investigational drug,
item, device, or service.
   (E) Health care services needed for the reasonable and necessary
care arising from the provision of the investigational drug, item,
device, or service, including the diagnosis or treatment of the
complications.
   (2) For purposes of this section, "routine patient care costs"
does not include the costs associated with the provision of any of
the following:
   (A) Drugs or devices that have not been approved by the federal
Food and Drug Administration and that are associated with the
clinical trial.
   (B) Services other than health care services, such as travel,
housing, companion expenses, and other nonclinical expenses, that a
beneficiary may require as a result of the treatment being provided
for purposes of the clinical trial, except as required under the
Medicaid Program (42 U.S.C. Sec.  1396a et seq.).
   (C) Any item or service that is provided solely to satisfy data
collection and analysis needs and that is not used in the clinical
management of the patient.
   (D) Health care services that, except for the fact that they are
being provided in a clinical trial, are otherwise specifically
excluded from coverage by the Medi-Cal program.
   (E) Health care services customarily provided by the research
sponsors free of charge for any beneficiary in the trial.
   (c) The treatment shall be provided in a clinical trial that
either:
   (1) Involves a drug that is exempt under federal regulations from
a new drug application.
   (2) Is approved by one of the following:
   (A) One of the National Institutes of Health.
   (B) The federal Food and Drug Administration, in the form of an
investigational new drug application.
   (C) The United States Department of Defense.
   (D) The United States Veterans' Administration.
   (d) Nothing in this section shall be construed to prohibit the
Medi-Cal program from restricting coverage for clinical trials to
participating hospitals and physicians in California unless the
protocol for the clinical trial is not provided for at a California
hospital or by a California physician.
   (e) The provision of services when required by this section shall
not, in itself, give rise to liability on the part of the Medi-Cal
program.


14132.99.  For services provided pursuant to Chapter 7 (commencing
with Section 14000) of Part 3 of Division 9, Section 14499.5, or
Chapter 1 (commencing with Section 101525) to Chapter 4 (commencing
with Section 101825), inclusive, of Part 4 of Division 101 of the
Health and Safety Code, the cost for services defined in Section
1370.6 of the Health and Safety Code, and Sections 14087.11 and
14132.98 shall be provided by state only funds if federal financial
participation is not available.



14132.99.  (a) For the purposes of this section, "facility residents"
means individuals who are currently residing in a nursing facility
and whose care is paid for by Medi-Cal either with or without a share
of cost. The term "facility residents" also includes individuals who
are hospitalized and who are or will be waiting for transfer to a
nursing facility.
   (b) An additional 500 slots beyond those currently authorized for
the home- and community-based Level A/B nursing facility waiver shall
be added and 250 of these slots shall be reserved for residents
residing in facilities and transitioning out of facilities.
   (c) For those patients who are in acute care hospitals and who are
pending placement in a nursing facility, the department shall
expedite the processing of waiver applications in order to divert
hospital discharges from nursing facilities into the community.
   (d) The nursing facility Level A/B waivers shall be amended to add
the following services:
   (1) One-time community transition services as defined and allowed
by the federal Centers for Medicare and Medicaid Services, including,
but not limited to, security deposits that are required to obtain a
lease on an apartment or home, essential furnishings, and moving
expenses required to occupy and use a community domicile, set-up
fees, or deposits for utility or service access, including, but not
limited to, telephone, electricity, and heating, and health and
safety assurances, including, but not limited to, pest eradication,
allergen control, or one-time cleaning prior to occupancy. These
costs shall not exceed five thousand dollars (,000).
   (2) Habilitation services, as defined in Section 1915(c)(5) of the
federal Social Security Act (42 U.S.C. Sec.  1396n(c)(5)), and in
attachment 3-d to the July 25, 2003, State Medicaid Directors Letter
re Olmstead Update No. 3, to mean services designed to assist
individuals in acquiring, retaining, and improving the self-help,
socialization, and adaptive skills necessary to reside successfully
in home- and community-based settings.
   (e) When requesting the renewal of the waiver, the department
shall consider expanding the number of waiver slots. Prior to
submission of the waiver renewal request, the department shall notify
the appropriate fiscal and policy committees of the Legislature of
the number of waiver slots included in the waiver renewal request
along with supportive data for those slots.
   (f) The department shall implement this section only to the extent
it can demonstrate fiscal neutrality within the overall department
budget, and federal fiscal neutrality as required under the terms of
the federal waiver, and only if the department has obtained the
necessary approvals and receives federal financial participation from
the federal Centers for Medicare and Medicaid Services. Contingent
upon federal approval of the waiver expansion, implementation shall
commence within six months of the department receiving authorization
for the necessary resources to provide the services to additional
waiver participants.


14132.992.  (a)  (1) By March 15, 2009, the department shall submit
to the federal Centers for Medicare and Medicaid Services a home-and
community-based services waiver application pursuant to Section 1396n
(c) of Title 42 of the United States Code, or an amendment of the
state plan for home- and community-based services pursuant to Section
1396n(i) of Title 42 of the United States Code, to serve at least
100 adults with acquired traumatic brain injuries who otherwise would
require care in a Medi-Cal funded nursing facility or an
intermediate care facility for persons with developmental
disabilities or, for the amendment of the state plan, who would meet
the eligibility criteria in Section 1396n(i).
   (2) As authorized by Section 1396n(c)(3) and 1396n(i)(3) of Title
42 of the United States Code, the waiver or amendment of the state
plan shall waive the statewide application of this section as well as
comparability of services so that waiver services may be provided by
one or more of the sites designated to provide services to persons
with acquired traumatic brain injury pursuant to Section 4356.
   (3) The waiver services to be provided to eligible Medi-Cal
recipients shall include case management services, community
reintegration and supported living services, vocational supportive
services including prevocational services, neuropsychological
assessments, and rehabilitative services provided by project sites
currently serving persons with acquired traumatic brain injuries
pursuant to Chapter 5 (commencing with Section 4353).
   (4) The waiver services to be provided shall include as a
habilitation service pursuant to Section 1396n(c)(5) of Title 42 of
the United States Code "extended supported employment services" to
support and maintain an individual with an acquired traumatic brain
injury in supported employment following that individual's transition
from support provided as a vocational rehabilitation service,
including job coaching, by the State Department of Rehabilitation
pursuant to paragraphs (1) and (5) of subdivision (a) of Section
19150.
   (5) The waiver services to be provided shall include
rehabilitative therapies, including, but not limited to, occupational
therapy, physical therapy, speech therapy, and cognitive therapy,
that are different in kind and scope from state plan services.
   (6) The waiver shall require an aggregate cost-effectiveness
formula be used.
   (b) The development process of the home- and community-based
services waiver application or state plan amendment shall include the
solicitation of the opinions and help of the affected communities,
including the working group members pursuant to Section 4357.1 and
representatives of project sites currently serving persons with
acquired traumatic brain injuries pursuant to Chapter 5 (commencing
with Section 4353) of Part 3 of Division 4.
   (c) The waiver or state plan amendment shall be implemented only
if the following conditions are met:
   (1) Federal financial participation is available for the services
under the waiver or state plan amendment.
   (2) Cost neutrality is achieved in accordance with the terms and
conditions of the waiver or state plan amendment and the requirements
of the federal Centers for Medicare and Medicaid Services.
   (3) State funds are appropriated, otherwise made available, or
both, for this waiver or state plan amendment, including funds for
staff to develop, implement, administer, monitor, and oversee the
waiver or state plan amendment.
   (d) It is the intent of the Legislature that the home- and
community-based services waiver or state plan amendment augment funds
available to meet the needs of persons with acquired traumatic brain
injuries served by the participating project sites in accordance
with subdivision (b) of Section 4358.5.


14132aa.  (a) Services provided by facilities licensed as congregate
living health facilities to individuals diagnosed as having acquired
immune deficiency syndrome (AIDS), are a covered benefit under this
chapter, subject to utilization controls.
   (b) Congregate living health facilities shall be reimbursed for
services covered by this section at a rate set by the department and
the provision of those services shall be subject to audit.
   (c) This section shall be operative only to the extent that
federal medicaid financial participation is made available pursuant
to Subchapter XIX (commencing with Section 1396) of Title 42 of the
United States Code.



14133.  Utilization controls that may be applied to the services set
forth in Section 14132 which are subject to utilization controls
shall be limited to:
   (a) Prior authorization, which is approval by a department
consultant, of a specified service in advance of the rendering of
that service based upon a determination of medical necessity.  Prior
authorization includes authorization for multiple services which are
requested and granted on the basis of an extended treatment plan
where there is a need for continuity in the treatment of a chronic or
extended condition.
   (b) Postservice prepayment audit, which is review for medical
necessity and program coverage after service was rendered but before
payment is made.  Payment may be withheld or reduced if the service
rendered was not a covered benefit, deemed medically unnecessary or
inappropriate.  Nothing in this subdivision shall supersede the
claims processing deadlines provided by Section 14104.3.
   (c) Postservice postpayment audit, which is review for medical
necessity and program coverage after service was rendered and the
claim paid.  The department may take appropriate steps to recover
payments made if subsequent investigation uncovers evidence that the
claim should not have been paid.
   (d) Limitation on number of services, which means certain services
may be restricted as to number within a specified time frame.
   (e) Review of services pursuant to Professional Standards Review
Organization agreements entered into in accordance with Section
14104.



14133.01.  (a) Notwithstanding any other provision of law, the
director or his or her designee may apply prior authorization by
designing a sampling methodology that will result in a generally
acceptable audit standard for approval of a treatment authorization
request (TAR), or a class of TARs.  The director or his or her
designee shall determine the applicable sampling methodology based
upon health care industry standards and discussions with applicable
Medi-Cal providers or their representatives.  This sampling
methodology shall be implemented by no later than July 1, 2005, and
an outline of it shall be provided to the fiscal and policy
committees of both houses of the Legislature.  It is the intent of
the Legislature for the department to review the sampling methodology
on an ongoing basis and update it as applicable on a periodic basis
in order to keep abreast of health care industry trends and the need
to manage an efficient and effective Medi-Cal program.
   (b) The department shall pursue additional means to improve and
streamline the treatment authorization request process including,
where applicable, those identified by independent analyses such as
the July 2003 report by the California Healthcare Foundation entitled
Medi-Cal Treatment Authorizations and Claims Processing:  Improving
Efficiency and Access to Care, and those identified by Medi-Cal
providers.  It is the Legislature's intent that any identified
improvements be cost-beneficial to the state and to the Medi-Cal
program as a whole.
   (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific, this section
by means of all-county letters, provider bulletins, or similar
instructions.  Thereafter, the department may adopt regulations 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.


14133.05.  (a) Notwithstanding any other provision of law, a request
for a treatment authorization received by the department shall be
reviewed for medical necessity only.
   (b) Any claim for a service that is authorized pursuant to a
treatment authorization request that qualifies for approval under the
requirements established by the department in regulations shall be
reduced in accordance with Section 14115.
   (c) If a provider does not agree with the decision on a treatment
authorization request, the provider may appeal the decision pursuant
to procedures set forth in regulations adopted by the department.
   (d) Providers shall comply with the administrative remedies
available to them prior to seeking a judicial remedy with respect to
a decision of the department on a treatment authorization request.




14133.07.  (a) Prior authorization for podiatric services provided
on an outpatient or inpatient basis shall not be required when all of
the following conditions are met:
   (1) The services are provided by a doctor of podiatric medicine
acting within the scope of his or her practice.
   (2) The services are related to trauma, infection management, pain
control, wound management, diabetic foot care, or limb salvage.
   (3) The services are medically necessary.
   (4) An urgent or emergency need for services exists at the time
the service is provided.
   (5) The patient was referred to the doctor of podiatric medicine
by a physician.
   (6) Prior authorization is not required for a physician providing
the same service.
   (b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all county letters, provider bulletins, or similar
instructions.
   (c) This section shall become operative October 1, 2006.



14133.1.  (a) The director shall determine which of the utilization
controls in Section 14133 shall be applied to any specific service or
group of services which are subject to utilization controls.  Each
utilization control shall be reasonably related to the purpose for
which it is imposed.
   (b) Except as provided in Sections 14103.6 and 14133.15, neither
prior authorization nor the limitation specified in subdivision (d)
of Section 14133 shall be required for the first two services per
month which are included among the services listed in subdivision (a)
of Section 14132, or for the first two drug prescriptions purchased
during any one month, provided that the prescription drugs are
included in the Medi-Cal Drug Formulary and the prescription
otherwise conforms to applicable formulary requirements.
   (c) The director shall, after a determination of cost benefit,
modify or eliminate the requirement of prior authorization as a
control for treatment, supplies, or equipment which costs less than
one hundred dollars (0), except for prescribed drugs, provided
that the requirement of prior authorization for treatment, supplies,
or equipment may be reinstituted upon a finding by the department
that the elimination of the requirement has resulted in unnecessary
utilization, and upon notice to the Joint Legislative Budget
Committee 30 days prior to the reinstitution of the requirement of
prior authorization. Modification of the utilization controls may
include establishing prior authorization review thresholds at levels
other than one hundred dollars (0) if indicated by the
cost-benefit analysis.



14133.10.  (a) Where it is expected to be cost-effective, the
director may, in conducting Medi-Cal acute care inpatient hospital
utilization control, establish a program of aggressive case
management of elective, nonemergency acute care hospital admissions
for the purpose of reducing both the numbers and duration of acute
care hospital stays by Medi-Cal beneficiaries.
   (b) In conducting the case management program, the department may,
conduct daily reviews to determine the need for additional days of
inpatient care.
   (c) In undertaking this case management program, the director may
enter into contracts, on a bid or nonbid basis, for the purposes of
obtaining the necessary expertise to train and educate utilization
control staff in case management concepts, principles and techniques,
identify and recommend cost-effective therapies, services and
technology as alternatives to elective acute care hospitalization or
to directly provide the case management and diversion services.
   (d) In order to achieve maximum cost savings the Legislature
hereby determines that an expedited contract process for contracts
under this section is necessary.  Therefore, contracts under this
article may be on a nonbid basis, and shall be exempt from the
provisions of Chapter 2 (commencing with Section 10290) of Part 2 of
Division 2 of the Public Contract Code.  Contracts shall have no
force and effect unless approved by the Department of Finance.
   (e) The department shall seek all federal waivers necessary to
allow for federal financial participation under this section.



14133.12.  (a) The director shall apply utilization controls to
continuous skilled nursing care services provided pursuant to the
pilot program established under Section 14495.10, including, but not
limited to, prior authorization and monitoring by the department.
Prior authorization shall ensure that continuous skilled nursing care
services are medically necessary, and that the provision of
continuous skilled nursing care will avoid a transfer to, or
placement at, a higher level of service.  Monitoring shall be
conducted by the department including, but not limited to, evaluation
of quality of life, health, safety, and well-being of the
beneficiary, and quality, efficiency, and cost effectiveness of the
continuous skilled nursing care services.  The department shall
consult with the State Department of Developmental Services and
regional centers to design monitoring efforts.
   (b) Payment of the reimbursement rates established pursuant to
Section 14110.55 shall be subject to all billing criteria of the
Medi-Cal program and the utilization controls set forth in this
section.
   (c) This section shall become operative only if the federal waiver
identified under Section 14495.10 is approved by the federal Health
Care Financing Administration.  The director shall maintain a record
of the satisfaction of this condition.



14133.14.  The criteria that the department shall use to identify
providers to be placed on prior authorization for noninvasive testing
procedures shall include, but not be limited to, Medi-Cal trend
analysis, provider profiling data, provider and beneficiary history
data, or appropriateness of the services as related to diagnosis,
volume of services, utilization patterns, and specialty of provider.
The existing prior authorization appeals process shall be available
to these providers for denial of services.



14133.15.  (a) The provision of services to beneficiaries eligible
for medical assistance benefits may be subject to utilization
controls, as provided for in Section 50793 of Title 22 of the
California Administrative Code as the section existed on January 1,
1984, when the director finds that the utilization controls are
necessary to carry out the provisions of this chapter.
   (b) Where the director determines that a recipient has been
abusing drugs or services, the recipient may, in order to prevent his
or her abuse, be placed on utilization controls for a  maximum
period of two years, which may be extended for an additional period
upon a determination by the director that the potential for abuse
still exists after notice and hearing, as set forth in subdivisions
(f) and (g).
   (c) If the director determines that a recipient has violated
utilization controls placed upon that recipient pursuant to
subdivision (b), the director may provide that the recipient shall
receive medical assistance benefits referred, ordered, or prescribed
through only one primary care provider of services for a  maximum
period of two years, which may  be extended for an additional period
upon a determination by the director that the potential for abuse
still exists after notice and hearing, as set forth in subdivisions
(f) and (g). The director shall afford the beneficiary an opportunity
to nominate a primary care provider for department consideration.
Circumvention of beneficiary utilization controls includes, but is
not limited to, the following acts:
   (1) Altering restricted Medi-Cal identification cards.
   (2) Obtaining temporary nonrestricted cards.
   (3) Establishing an additional nonrestricted eligibility status.
   (d) If a recipient is convicted of any misdemeanor or felony
involving fraud or abuse either of medical assistance benefits or
services, or in connection with any public assistance program, the
director may restrict the recipient's eligibility for medical
assistance benefits for a  maximum period of two years, which may be
extended for an additional period upon a determination by the
director that the potential for fraud or abuse still exists and upon
giving notice to the recipient setting forth the facts upon which the
determination is made.   The record of conviction or a certified
copy thereof, certified by the clerk of the court in which the
conviction is had, shall be conclusive evidence of the fact that the
conviction occurred.  A plea or verdict of guilty, or a conviction
following a plea of nolo contendere, is deemed to be a conviction
within the meaning of this section.  The restriction shall not take
effect earlier than the date of the director's order.  Restriction
following a conviction is not subject to the proceedings required in
subdivision (g).
   (e) Where the director determines that a recipient deliberately
abuses or misuses program benefits, the director may provide that the
recipient shall receive medical assistance benefits referred,
ordered, or prescribed through only one primary care provider of
services for a  maximum period of two years, which may be extended
for an additional period upon a determination by the director that a
potential for abuse still exists after notice and hearing as set
forth in subdivisions (f) and (g). Deliberate abuse or misuse of
program benefits includes, but is not limited to, the following:
   (1) Forging prescriptions.
   (2) Sale or lending of Medi-Cal identification cards.
   (3) Collusion with providers for services or supplies.
   (f) A recipient who commits a violation of subdivision (b), (c),
or (e) shall be notified of the impending restriction, the reasons
for the restriction and be provided an opportunity for a fair
hearing.
   (g) A recipient who commits a violation of subdivision (b), (c),
or (e) is subject to restriction of fee for service Medi-Cal
assistance benefits.  The proceedings  for restriction shall be
conducted in accordance with Chapter 7 (commencing with Section
10950) of Part 2, or any rule or regulation promulgated by the
director pursuant to this section.
   (h) The imposition of restrictions, pursuant to this section, with
respect to  the eligibility of any individual shall not affect the
eligibility of any other person for medical assistance benefits under
this program, regardless of the relationship between that individual
and the other person.
   (i) This section shall not apply in any instance where a bona fide
emergency exists which requires immediate treatment.




14133.16.  (a) Notwithstanding subdivision (l) of Section 14132,
hearing aids are covered when supplied by a hearing aid dispenser on
prescription of an otolaryngologist, or the attending physician where
there is no otolaryngologist available in the community, plus an
audiological evaluation, which shall be performed by or under the
supervision of the attending physician or by a licensed audiologist.

   (b) Prior to prescribing a hearing aid, a physician or
otolaryngologist shall perform a complete ear, nose, and throat
examination.
   (c) Prior to coverage, a hearing aid assessment shall be performed
by the dispensing practitioner, either a physician, a licensed
audiologist, or a licensed hearing aid dispenser acting within the
scope of practice as described in Section 3306 of the Business and
Professions Code.
   (d) Coverage shall be based on the results of the examination,
evaluation, and assessment required by this section.
   (e) One hearing aid assessment within a 12-month period is a
covered benefit.  In the event the beneficiary receives more than one
hearing aid assessment within a 12-month period, Medi-Cal shall
reimburse the first valid claim received by the program for only one
hearing aid assessment unless additional assessments are deemed to be
medically necessary.



14133.2.  (a) The director shall include in the Medi-Cal list of
contract drugs any drug approved for the treatment of cancer by the
federal Food and Drug Administration, so long as the manufacturer has
executed a contract with the Health Care Financing Administration
which provides for rebates in accordance with Section 1396r-8 of
Title 42 of the United States Code.  These drugs shall be exempt from
the contract requirements of Section 14105.33.
   (b) In addition to any drug added to the list of contract drugs
pursuant to subdivision (a), any drug that meets either of the
following criteria and for which the manufacturer has executed a
contract with the Health Care Financing Administration that provides
for rebates in accordance with Section 1396r-8 of Title 42 of the
United States Code, shall be a Medi-Cal benefit, subject to
utilization controls, unless the contract requirements of Section
14105.33 have been complied with:
   (1) Any drug approved by the federal Food and Drug Administration
for treatment of opportunistic infections associated with cancer.
   (2) Any drug or biologic used in an anticancer chemotherapeutic
regimen for a medically accepted indication, which has either been
approved by the federal Food and Drug Administration, or recognized
for that use in one of the following:
   (A) The American Medical Association Drug Evaluations.
   (B) The United States Pharmacopoeia Dispensing Information.
   (C) Two articles from peer reviewed medical journals that present
data supporting the proposed use or uses as generally safe and
effective.


14133.22.  (a) Prescribed drugs shall be limited to no more than six
per month, unless prior authorization is obtained.
   (b) The limit in subdivision (a) shall not apply to patients
receiving care in a nursing facility.
   (c) The limit in subdivision (a) shall not apply to drugs for
family planning.
   (d) The department may issue Medi-Cal cards that contain labels
for prescribed drugs to implement this section.
   (e) In carrying out this section, the department may contract
either directly, or through the fiscal intermediary, for pharmacy
consultant staff necessary to accomplish the treatment authorization
request reviews.



14133.225.  Notwithstanding any other law, the department shall not
provide or pay for any prescription drug or other therapy to treat
erectile dysfunction for any person who is required to register
pursuant to Section 290 of the Penal Code, except to the extent
required under federal law. The department may require from the
Department of Justice the information necessary to implement this
section.



14133.23.  (a) To the extent that federal financial participation is
not available, the provision of drug benefits under this chapter to
full-benefit dual eligible beneficiaries who are eligible for drug
benefits under Part D of Title XVIII of the Social Security Act (42
U.S.C. Sec. 1395w-101 et seq.) or under a Medicare
Advantage-Prescription Drug plan (MA-PD plan) under Part C of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.),
is eliminated, except as otherwise provided under this section.
   (b) (1) Notwithstanding any other provision of law, only drug
benefits for which federal financial participation is available shall
be provided under this chapter to a full-benefit dual eligible
beneficiary, except as otherwise provided under subdivision (c).
   (2) As a benefit under this chapter, the department, subject to
the approval of the Department of Finance and only to the extent that
federal financial participation is available, may elect to provide a
drug or drugs in a class of drugs not covered under Part D of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.)
or under a MA-PD plan under Part C of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-21 et seq.) to full-benefit dual
eligible beneficiaries.
   (3) As a benefit under this chapter, and only to the extent that
federal financial participation is available, the department shall
provide a drug or drugs to full-benefit dual eligible beneficiaries
who are otherwise eligible to receive the drug or drugs due to their
entitlement under Title 42 United States Code, Chapter 7, Title
XVIII, Part A or their enrollment under Title 42 United States Code,
Chapter 7, Title XVIII, Part B.
   (4) Except as provided under paragraph (3) and subdivision (c),
nothing in this section shall be interpreted to require the
department to provide any drug or drugs not covered under Part D of
Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et
seq.) or under a MA-PD plan under Part C of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-21 et seq.) if federal financial
participation is not available.
   (c) (1) The department shall review the drug formularies of
prescription drug plans under Part D of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or MA-PD plans under
Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec.
1395w-21 et seq.) available to full-benefit dual eligible
beneficiaries.
   (2) The department shall develop a process that would allow the
department to provide to a full-benefit dual eligible beneficiary, on
an emergency basis only, coverage for a drug or drugs not included
on the full-benefit dual eligible beneficiary's prescription drug
plan's formulary or by prior authorization under Part D of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.)
or MA-PD plans under Part C of Title XVIII of the Social Security Act
(42 U.S.C. Sec. 1395w-21 et seq.) for which federal financial
participation is not available.
   (3) Only to the extent that the Legislature made a specific
appropriation to fund the provision of emergency drug benefits for
which federal financial participation is not available to
full-benefit dual eligible beneficiaries, the department shall
provide, through the process described in paragraph (2), these
emergency drug benefits to a full-benefit dual eligible beneficiary
only when all of the following conditions are met:
   (A) The drug is not available to the full-benefit dual eligible
beneficiary under his or her plan's drug formulary or by prior
authorization.
   (B) The pharmacist provides or dispenses the drug as an emergency
service.
   (C) The quantity of the drug provided or dispensed in no greater
than a 60-day supply.
   (D) The pharmacist has not previously provided or dispensed nor
has knowledge that another pharmacist has provided or dispensed the
same drug for that full-benefit dual eligible beneficiary on or after
January 1, 2006.
   (E) The date of service is from January 1, 2006, through December
31, 2006, inclusive.
   (4) The department may impose a pre- or post-service prepayment or
postpayment review or audit, to review the medical necessity of
emergency services provided to full-benefit dual eligible
beneficiaries.
   (d) The department shall seek approval of any amendments to the
state plan necessary to implement this section as required by Title
XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.).
   (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret or make specific this section by
means of all county letters, provider bulletins, or similar
instructions. Thereafter, the department may adopt regulations 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.
   (f) (1) Notwithstanding any other provision of this section, and
only to the extent that funds are appropriated for this purpose, the
department shall provide on a time-limited basis, as described in
paragraphs (7) and (8), drug benefits to a full-benefit dual eligible
beneficiary who is not able to obtain drug benefits from his or her
Medicare Drug Plan only when one or more of the following conditions
are met:
   (A) The pharmacy has submitted a claim for the provision of drug
benefits to the full-benefit dual eligible beneficiary's Medicare
Drug Plan and the claim has been denied payment for reasons other
than processing errors or omissions made by the pharmacy, lack of
medical necessity, or health or safety reasons.
   (B) The pharmacy is unable to submit a claim for the provision of
drug benefits solely due to the unavailability of complete or
accurate Medicare Drug Plan enrollment information from the
full-benefit dual eligible beneficiary's Medicare Drug Plan, the
federal Centers for Medicare and Medicaid Services, or entities under
contract with the Centers for Medicare and Medicaid Services to
provide enrollment information.
   (C) The Medicare Drug Plan provides information that the
full-benefit dual eligible beneficiary's deductible or copayment
amount is higher than the copayment amounts that are established by
Medicare for full-benefit dual eligible beneficiaries.
   (2) The director may impose a pre- or post-service prepayment or
postpayment review or audit to determine whether a pharmacy has
accurately and in good faith established the existence of any
condition certified by the pharmacy pursuant to subparagraph (A),
(B), or (C) of paragraph (1) in support of a submitted claim to the
department.
   (3) If the claim submitted by the pharmacy to the Medicare Drug
Plan meets the circumstances described in subparagraph (C) of
paragraph (1), the department shall pay the Medi-Cal rate less the
Medicare Drug Plan reimbursement amount and the Medicare copayment
amount.
   (4) To obtain reimbursement from the department, a pharmacy must
be an enrolled provider in the Medi-Cal program and certify on its
claims under penalty of perjury that one of the conditions specified
in paragraph (1) exists.
   (5) The department shall seek reimbursement from the federal
government of all funds spent to comply with the provisions of this
subdivision.
   (6) To the extent that the department reimburses a pharmacy for
claims authorized under this subdivision, the director shall have the
right to recover or recoup the full cost expended by the state for
that reimbursement from the full-benefit dual eligible beneficiary's
Medicare Drug Plan.
   (7) Reimbursement for claims authorized under this subdivision
shall be limited to those drug benefits provided to a full-benefit
dual eligible beneficiary from January 12, 2006, to February 15,
2006, inclusive.
   (8) After February 15, 2006, the Governor may, upon notice to the
Joint Legislative Budget Committee, extend coverage for drug benefits
to a full-benefit dual eligible beneficiary for coverage periods of
up to 30 days each. In no event shall the reimbursement authorized by
this paragraph extend beyond May 16, 2006.
   (9) Any drug benefits made available to full-benefit dual eligible
beneficiaries under the authority of this subdivision shall be
limited to the funds appropriated by the Legislature to the
department for this purpose. These drug benefits shall not be deemed
to be an entitlement.
   (g) (1) Notwithstanding any other provision of this section, and
only to the extent that funds are appropriated for this purpose,
beginning May 17, 2006, and ending January 31, 2007, the department
shall provide emergency drug benefits to a full-benefit dual eligible
beneficiary who is unable to obtain drug benefits from his or her
Medicare Drug Plan only when one or more of the following conditions
are met:
   (A) The pharmacy has submitted a claim for the provision of drug
benefits to the full-benefit dual eligible beneficiary's Medicare
Drug Plan and the claim has been denied payment due to error by the
Medicare Program and the pharmacy has made a good faith effort to
resolve the error with the Medicare Drug Plan and the Medicare
Program.
   (B) The pharmacy is unable to submit a claim for the provision of
drug benefits solely due to incomplete or inaccurate Medicare Drug
Plan enrollment information from the full-benefit dual eligible
beneficiary's Medicare Drug Plan, the federal Centers for Medicare
and Medicaid Services, or entities under contract with the Centers
for Medicare and Medicaid Services to provide enrollment information,
and the pharmacy has attempted to resolve these problems with the
Medicare facilitated enrollment contractor and the Medicare Drug
Plan, where appropriate.
   (C) The Medicare Drug Plan provides information that the
full-benefit dual eligible beneficiary's deductible or copayment
amount is higher than the copayment amounts that are established by
Medicare for full-benefit dual eligible beneficiaries.
   (D) Request for prior authorization or exception to the
full-benefit dual eligible beneficiary's Medicare Drug Plan is
required and was sought by the pharmacist, but the pharmacy does not
receive a response within 24 hours for an emergency drug or within 72
hours for a nonemergency drug. When submitting a request for prior
authorization to the department, a pharmacy shall show proof of the
submission of the request that was made to either the Medicare Drug
Plan or the beneficiary's prescribing physician.
   (2) In providing these benefits, the department shall implement
prepayment utilization controls, including prior authorization, and
may implement postpayment reviews or audits to determine whether a
pharmacy has accurately and in good faith established the existence
of any condition certified by the pharmacy pursuant to subparagraph
(A), (B), (C), or (D) of paragraph (1) in support of a submitted
claim to the department.
   (3) If the claim submitted by the pharmacy to the Medicare Drug
Plan meets the circumstances described in subparagraph (C) of
paragraph (1), the department shall pay only the difference between
the copayment amount established by Medicare for full-benefit dual
eligible beneficiaries and the actual copayment amount charged.
   (4) To obtain reimbursement from the department, a pharmacy must
be an enrolled provider in the Medi-Cal program and certify on its
claims under penalty of perjury that one of the conditions specified
in paragraph (1) exists.
   (5) To the extent that the department reimburses a pharmacy for
claims authorized under this subdivision, the director shall have the
right to recover or recoup the full cost expended by the state for
that reimbursement from the full-benefit dual eligible beneficiary's
Medicare Drug Plan.
   (6) Any drug benefits made available to full-benefit dual eligible
beneficiaries under the authority of this subdivision shall not be
deemed to be an entitlement. Beginning September 1, 2006, the
department shall not cover drug benefits when prior authorization or
exception to the full-benefit dual eligible beneficiary's Medicare
Drug Plan is required, unless that authorization was sought by the
physician and the Medicare Drug Plan does not provide a response
within 24 hours for an emergency drug or within 72 hours for a
nonemergency drug.
   (h) (1) For the purposes of this section, a "full-benefit dual
eligible beneficiary" means an individual who meets both of the
following criteria:
   (A) The beneficiary is eligible or would be eligible for coverage
for the month for covered Part D drugs under a prescription drug plan
under Part D of Title XVIII of the Social Security Act (42 U.S.C.
Sec. 1395w-101 et seq.) or under a MA-PD plan under Part C of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.).
   (B) Notwithstanding any other provision of this section, the
beneficiary is determined eligible for full-scope services, including
drug benefits, for which federal financial participation is
available.
   (2) For the purposes of this section, "Medicare Drug Plan" means a
prescription drug plan under Part D of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan
under Part C of Title XVIII of the Social Security Act (42 U.S.C.
Sec. 1395w-21 et seq.).
   (i) Subdivisions (a) and (b) and paragraph (3) of subdivision (c)
shall become operative on January 1, 2006.



14133.25.  (a) The director shall identify those surgical and
medical procedures capable of outpatient performance and establish
conditions for assuring performance in an outpatient rather than
inpatient setting when medically appropriate.
   (b) The director shall identify and apply appropriate utilization
controls to review outpatient and office medical and surgical
procedures for medical necessity and program coverage.  The director
may under this section identify and require prior authorization for
any specified outpatient or office medical or surgical procedure
performed during a month without regard to the provisions of Section
14133.1, provided that, with respect to outpatient or office medical
procedures, those medical procedures which remain not subject to
prior authorization are sufficient in number and scope as to achieve
the general purpose of Section 14133.  1.
   (c) The director may establish a schedule of differential
reimbursement rates to the operating surgeon for surgery procedures.
Those surgery procedures which can safely be performed on an
outpatient basis may be reimbursed at a higher level when performed
in an outpatient setting than the same procedures performed on an
inpatient basis.
   (d) Provisions of this section shall not be applied to mental
health services as defined under Division 5 (commencing with Section
5000) or Section 14021, or any other mental health services funded by
the Medi-Cal program.



14133.3.  (a) The director shall require fully documented medical
justification from providers that the requested services are
medically necessary to prevent significant illness, to alleviate
severe pain, to protect life, or to prevent significant disability,
on all requests for prior authorization.
   (b) For services not subject to prior authorization controls,
offered by noncontract hospitals in closed health facility planning
areas to beneficiaries who were experiencing life-threatening or
emergency situations, but could not be stabilized sufficiently in
order to facilitate being transported to contracting hospitals, the
director shall additionally determine utilization controls that shall
be applied to ensure that the health care services provided and the
conditions treated, are medically necessary to prevent significant
illness, alleviate severe pain, to protect life, or prevent
significant disability.  These utilization controls shall take into
account those diseases, illnesses, or injuries that require
preventive health services or treatment to prevent serious
deterioration of health.
   (c) Nothing in this section shall preclude payment for family
planning services or early and periodic screening, diagnosis, and
treatment services mandated by federal law.
   (d) For the purposes of this section, a "noncontract hospital"
means a hospital that has not contracted with the department for the
provision of inpatient services pursuant to Article 2.6 (commencing
with Section 14081).
   (e) This section shall not be applied to mental health services as
defined under Division 5 (commencing with Section 5000) or Section
14021, or any other mental health services funded by the Medi-Cal
program.


14133.37.  For drugs covered under this chapter requiring prior
authorization, the department shall ensure the timely and efficient
processing of authorization requests by doing all of the following:
   (a) Providing a response by telephone or other means of
telecommunication within 24 hours of the receipt of an authorization
request.
   (b) To the extent permitted by federal law, providing for the
dispensing of at least a 72-hour supply of a covered drug in an
emergency situation, as defined by federal regulation.



14133.4.  Notwithstanding any other provision of law, utilization
controls adopted by the State Department of Health Services shall not
include prior authorization for portable X-ray services provided in
nursing facilities and all categories of intermediate care facilities
for the developmentally disabled, as defined in Section 1250 of the
Health and Safety Code.



14133.45.  (a) Utilization controls adopted by the department shall
not include prior authorization for renal dialysis treatment provided
to eligible recipients for the treatment of end stage renal disease.

   (b) For purposes of this section, "end stage renal disease" is the
same as defined in subdivision (d) of Section 1794.02 of the Health
and Safety Code.
   (c) Notwithstanding the provisions of Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of the Government Code, the
department may implement this section by provider manual or similar
notice without further regulatory action.



14133.5.  There shall be established a two-year pilot program,
whereby in Alameda County, utilization controls shall not be required
when, pursuant to Title XVIII of the federal Social Security Act, a
county hospital based utilization review committee has been
established to determine the level of authorization for payment and a
utilization plan has been filed with the department and approved by
it.  The department shall adopt rules and regulations to implement
this section, within 60 days of the effective date of this act,
including requirements that a hospital's utilization review committee
shall demonstrate that it is more cost-effective than the Medi-Cal
utilization control function.
   No later than 18 months following the commencement of the pilot
program, the department shall submit a report to the Legislature on
the program.


14133.51.  Notwithstanding Section 14133.5, the Alameda County pilot
program, as established in Section 14133.5, shall be a permanent
program.


14133.6.  In acting upon prior authorization requests for
nonemergency medical transportation services, the department shall
consider all relevant information in its possession regarding the
beneficiary for whom services are requested.  The department shall
act upon such requests in a timely and expeditious manner.  The
department shall not form separate units within its field offices to
receive and act upon prior authorization requests for nonemergency
medical transportation.  The provisions of this section shall be
applicable only in counties having a population in excess of
6,000,000.



14133.65.  Prior authorization for the use of nonemergency medical
transportation services by patients to and from dialysis treatment
shall be approved for a period of up to one year when the patient has
received the transportation services for the immediately preceding
12 months, the request for renewed prior authorization is supported
by a physician's certification that the patient's condition is
unlikely to improve during the period covered by the request, and the
department has determined that there is medical necessity for the
service.  Whenever there is a change or improvement in the patient's
condition, the physician shall submit a new certification to the
department.


14133.7.  The department shall not require emergency certification
statements for hospital inpatient claims which have been reviewed and
approved by the department for appropriateness of emergency
admission or length of stay.


14133.8.  (a) A bone marrow transplant for the treatment of cancer
for beneficiaries who are eligible for full-scope benefits under this
chapter, shall be reimbursable under this chapter, when all of the
following conditions are met:
   (1) The bone marrow transplant is recommended by the recipient's
physician.
   (2) The bone marrow transplant is performed in a hospital that is
approved for participation in the Medi-Cal program.
   (3) The bone marrow transplant is a reasonable course of treatment
and is approved by the hospital medical policy committee when there
is an existing committee or a committee can be established.
   (4) The bone marrow transplant has been deemed appropriate for the
recipient by the program's medical consultant. The medical
consultant shall not disapprove the bone marrow transplant solely on
the basis that it is classified as experimental or investigational.
   (b) The program shall provide reimbursement for both donor and
recipient surgery.
   (c) The department may establish inpatient rates of reimbursement
not in accordance with the state plan for those hospitals not under
contract with the state pursuant to Article 2.6 (commencing with
Section 14081), provided that the state plan is subsequently amended
to reflect the method of reimbursement.
   (d) This section shall not be construed as prohibiting
reimbursement for any bone marrow transplants otherwise provided for
under this chapter.
   (e) Any bone marrow transplant authorized by the department
pursuant to this section shall be subject to utilization controls.
   (f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section by
means of all-county letters, provider bulletins, or other
instructions, without taking any further regulatory action.



14133.85.  (a) (1) Except as otherwise provided in this subdivision,
prior authorization shall not be required for hospice services.
   (2) Paragraph (1) shall not apply to any admission which violates
federal law.
   (b) Prior authorization shall be required for inpatient hospice
services.


14133.9.  The implementation of prior authorization permitted by
subdivision (a) of Section 14133 shall be subject to all of the
following provisions:
   (a) The department shall secure a toll free phone number for the
use of providers of Medi-Cal services listed in Section 14132.  For
providers, the department shall provide access to an individual
knowledgeable in the program to provide Medi-Cal providers with
information regarding available services. Access shall include a
toll-free phone number that provides reasonable access to that
person.  The number shall be operated 24 hours a day, seven days a
week.
   (b) For major categories of treatment subject to prior
authorization, the department shall publicize and continue to develop
its list of objective medical criteria that indicate when
authorization should be granted.  Any request meeting these criteria,
as determined by the department, shall be approved, or deferred as
authorized in subdivision (e) by specific medical information.
   (c) The objective medical criteria required by subdivision (d)
shall be adopted and published in accordance with the Administrative
Procedure Act, and shall be made available at appropriate cost.
   (d) When a proposed treatment meets objective medical criteria,
and is not contraindicated, authorization for the treatment shall be
provided within an average of five working days.  When a treatment
authorization request is not subject to objective medical criteria, a
decision on medical necessity shall be made by a professional
medical employee or contractor of the department within an average of
five working days.
   (e) Notwithstanding the provisions of subdivisions (c) and (d),
the department shall adopt, by emergency regulations as provided by
this subdivision, a list of elective services that the director
determines may be nonurgent.  In determining these services, the
department shall be guided by commonly accepted medical practice
parameters.  Authorization for these services may be deferred for a
period of up to 90 days.  In making determinations regarding these
referrals, the department may use criteria separate from, or in
addition to, those specified in subdivision (c).  These deferrals
shall be determined through the treatment authorization request
process.  When a proposed service is on the list of elective services
that the director determines may be considered nonurgent,
authorization for the service shall be granted or deferred within an
average of 10 working days.  The State Department of Health Services
may adopt emergency regulations to implement this subdivision in
accordance with the Administrative Procedure Act (Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code).  The initial adoption of emergency regulations
and one readoption of the initial regulations shall be deemed to be
an emergency and necessary for the immediate preservation of the
public peace, health and safety or general welfare.  Initial
emergency regulations and the first readoption of those regulations
shall be exempt from review by the Office of Administrative Law.  The
emergency regulations authorized by this subdivision shall be
submitted to the Office of Administrative Law for filing with the
Secretary of State and publication in the California Code of
Regulations and shall remain in effect for no more than 120 days.
   (f) The department shall submit to the Legislature, every three
months, its treatment authorization request status report.
   (g) Final decisions of the department on denial of requests for
prior authorization for inpatient acute hospital care shall be
reviewable upon request of a provider by a Professional Standards
Review Organization established pursuant to Public Law 92-603, or a
successor organization if either of the following applies:
   (1) The original decision on the request was not performed by a
Professional Standards Review Organization, or its successor
organization.
   (2) The original decision on the request was performed by a
Professional Standards Review Organization, or its successor
organization, and the original decision was reversed by the
department.  The department shall contract with one or more of these
organizations to, among other things, perform the review function
required by this subdivision.  The review performed by the
contracting organization shall result in a finding that the
department's decision is either appropriate or unjustified, in
accordance with existing law, regulation, and medical criteria.  The
cost of each review shall be borne by the party that does not
prevail.
   The decision of this body shall be reviewable by civil action.
   (h) This section, and any amendments made to Section 14103.6 by
Assembly Bill 2254 of the 1985-86 Regular Legislative Session, shall
not apply to treatment or services provided under contracts awarded
by the department under which the contractor agrees to assume the
risk of utilization or costs of services.


14134.  Except for any prescription, refill, visit, service, device,
or item for which the program's payment is ten dollars () or
less, in which case no copayment shall be required, a recipient of
services under this chapter shall be required to make copayments not
to exceed the maximum permitted under federal regulations or federal
waivers as follows:
   (a) Copayment of five dollars () shall be made for nonemergency
services received in an emergency room.  For the purposes of this
section, "nonemergency services" means any services not required for
the alleviation of severe pain or the immediate diagnosis and
treatment of severe medical conditions which, if not immediately
diagnosed and treated, would lead to disability or death.
   (b) Copayment of one dollar () shall be made for each drug
prescription or refill.
   (c) Copayment of one dollar () shall be made for each visit for
services under subdivisions (a) and (h) of Section 14132.
   (d) The copayment amounts set forth in subdivisions (a), (b), and
(c) may be collected and retained or waived by the provider.
   (e) The department shall not reduce the reimbursement otherwise
due to providers as a result of the copayment.  The copayment amounts
shall be in addition to any reimbursement otherwise due the provider
for services rendered under this program.
   (f) This section does not apply to emergency services, family
planning services, or to any services received  by:
   (1) Any child in AFDC-Foster Care, as defined in Section 11400.
   (2) Any person who is an inpatient in a health facility, as
defined in Section 1250 of the Health and Safety Code.
   (3) Any person 18 years of age or under.
   (4) Any woman receiving perinatal care.
   (g) Subdivision (b) does not apply to any person 65 years of age
or over.
   (h) A provider of service shall not deny care or services to an
individual solely because of that person's inability to copay under
this section.  An individual shall, however, remain liable to the
provider for any copayment amount owed.
   (i) The department shall seek any federal waivers necessary to
implement this section.  The provisions for which appropriate federal
waivers cannot be obtained shall not be implemented, but provisions
for which waivers are either obtained or found to be unnecessary
shall be unaffected by the inability to obtain federal waivers for
the other provisions.
   (j) The director shall adopt any regulations necessary to
implement this section as emergency regulations in accordance with
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code. The adoption of the regulations
shall be deemed to be an emergency and necessary for the immediate
preservation of the public peace, health and safety, or general
welfare.  The director shall transmit these emergency regulations
directly to the Secretary of State for filing and the regulations
shall become effective immediately upon filing.  Upon completion of
the formal regulation adoption process and prior to the expiration of
the 120 day duration period of emergency regulations, the director
shall transmit directly to the Secretary of State for filing the
adopted regulations, the rulemaking file, and the certification of
compliance as required by subdivision (e) of Section 11346.1 of the
Government Code.



14134.1.  Except as provided in subdivision (b) of  Section 14134,
no provider under this chapter may deny care or services to an
individual eligible for such care or services under this chapter on
account of the individual's inability to pay a copayment, as defined
in Section 14134.  The requirements of this section shall not
extinguish the liability of the individual to whom the care or
services were furnished for payment of the copayment.



14134.2.  The reimbursement rate for any three or more laboratory
services for the same patient on the same day, which are commonly
performed in an automated manner, as defined by the department, shall
be reimbursed at the rate established for automated services.  The
director shall exempt from this provision laboratory services
performed for urgent medical reasons or in rural areas, as defined by
the department, if performed as individual tests.



14134.5.  All of the following provisions apply to the provision of
services pursuant to subdivision (u) of Section 14132:
   (a) "Comprehensive perinatal provider" means any general practice
physician, family practice physician, obstetrician-gynecologist,
pediatrician, certified nurse midwife, a group, any of whose members
is one of the above-named physicians, or any preferred provider
organization or clinic enrolled in the Medi-Cal program and certified
pursuant to the standards of this section.
   (b) "Perinatal" means the period from the establishment of
pregnancy to one month following delivery.
   (c) "Comprehensive perinatal services" shall include, but not be
limited to, the provision of the combination of services developed
through the Department of Health Services Obstetrical Access Pilot
Program.
   (d) The comprehensive perinatal provider shall schedule visits
with appropriate providers and shall track the patient to verify
whether services have been received. As part of the reimbursement for
coordinating these services, the comprehensive perinatal provider
shall ensure the provision of the following services either through
the provider's own service or through subcontracts or referrals to
other providers:
   (1) A psychosocial assessment and when appropriate referrals to
counseling.
   (2) Nutrition assessments and when appropriate referral to
counseling on food supplement programs, vitamins and breast-feeding.

   (3) Health, childbirth, and parenting education.
   (e) Except where existing law prohibits the employment of
physicians, a health care provider may employ or contract with all of
the following medical and other practitioners for the purpose of
providing the comprehensive services delineated in this section:
   (1) Physicians, including a general practitioner, a family
practice physician, a pediatrician, or an obstetrician-gynecologist.

   (2) Certified nurse midwives.
   (3) Nurses.
   (4) Nurse practitioners.
   (5) Physician assistants.
   (6) Social workers.
   (7) Health and childbirth educators.
   (8) Registered dietitians.
   The department shall adopt regulations which define the
qualifications of any of these practitioners who are not currently
included under the regulations adopted pursuant to this chapter.
Providers shall, as feasible, utilize staffing patterns which reflect
the linguistic and cultural features of the populations they serve.

   (f) The California Medical Assistance Program and the Maternal and
Child Health Branch of the State Department of Health Services in
consultation with the California Conference of Local Health Officers
shall establish standards for health care providers and for services
rendered pursuant to this subdivision.
   (g) The department shall assist local health departments to
establish a community perinatal program whose responsibilities may
include certifying and monitoring providers of comprehensive
perinatal services.  The department shall provide the local health
departments with technical assistance for the purpose of implementing
the community perinatal program. The department shall, to the extent
feasible, and to the extent funding for administrative costs is
available, utilize local health departments in the administration of
the perinatal program. If these funds are not available, the
department shall use alternative means to implement the community
perinatal program.
   (h) It is the intent of the Legislature that the department shall
establish a method for reimbursement of comprehensive perinatal
providers which shall include a fee for coordinating services and
which shall be sufficient to cover reasonable costs for the provision
of comprehensive perinatal services. The department may utilize fees
for service, capitated fees, or global fees to reimburse providers.
However, if capitated or global fees are established, the department
shall set minimum standards for the provision of services including,
but not limited to, the number of prenatal visits and the amount and
type of psychosocial, nutritional, and educational services patients
shall receive.
   Notwithstanding the type of reimbursement system, the
comprehensive perinatal provider shall not be financially at risk for
the provision of inpatient services. The provision of inpatient
services which are not related to perinatal care shall not be subject
to the provisions of this section. Inpatient services related to
services pursuant to this subdivision shall be reimbursed, in
accordance with Section 14081, 14086, 14087, or 14087.2, whichever is
applicable.
   (i) The department shall develop systems for monitoring and
oversight of the comprehensive perinatal services provided in this
section. The monitoring shall include, but shall not be limited to,
collection of information using the perinatal data form.
   (j) Participation for services provided pursuant to this section
shall be voluntary. The department shall adopt patient rights
safeguards for recipients of the comprehensive perinatal services.



14134.55.  The department shall streamline and simplify existing
Medi-Cal program procedures in order to improve access to lactation
supports and breast pumps among Medi-Cal recipients.



14134.6.  Long-term health care facilities may charge a resident
only the actual price paid by the facility for goods and services
actually supplied to the resident and may not charge for hospital
gowns.  Facilities in the original contract shall inform residents of
charges for personal laundry and drycleaning, haircuts, beautician
services, manicures, pedicures, phone calls, television rental, and
any other services payable by the resident.  The facility shall also
inform residents of any changes in those charges, and shall indicate
on a resident's bill every good, product, service, and medication for
which the resident is being charged, including, if the patient is a
senior citizen, whether or not a senior discount was obtained on the
medication.



14135.  To assure maximum federal financial participation under this
chapter, the director shall establish an enrollment fee, premium or
similar charge to the extent required by federal law.



14136.  (a) No city or county shall establish equipment and
personnel standards for the furnishing of nonemergency medical
transportation services for eligible Medi-Cal beneficiaries which are
in conflict with equipment and personnel standards for reimbursement
established by the department pursuant to this chapter.  No standard
adopted by cities or counties shall require the use of ambulances to
supply nonemergency medical transportation, where that standard
would conflict with Section 14136.1.
   (b) No city or county shall establish any permit, license, or
inspection fees in excess of the actual cost of providing services
directly associated with the provision of a permit, license, or
inspection of nonemergency medical transportation vehicles.
   (c) Prior to collection of any permit, license, or inspection
fees, the city or county shall provide the nonemergency medical
transportation provider from whom the fees will be collected with an
itemized cost analysis specifying how the fees will be used.
   (d) Nothing in this section shall be construed to otherwise limit
the authority of a city or county to license, inspect, or regulate
nonemergency medical transportation services so long as the
regulation is not in conflict with standards established by the
department.
   (e) Nothing in this section shall be construed to prevent a city
or county from allowing both emergency and nonemergency medical
transportation services to operate within its jurisdiction under a
sole franchise when such a franchise has been  determined necessary
to assure the economic viability of those services.
   (f) Nothing in this section shall be construed to restrict the
authority of local government to issue or deny licenses or permits to
operate medical transportation services within its jurisdiction on
the basis of need and necessity findings.



14136.1.  It is the intent of the Legislature that, in order for
payment to be made to a medical transportation service provider, a
patient who requires continuous intravenous medication, medical
monitoring, or observation during transport and patients being
transferred from an acute care facility to another acute care
facility shall be transported by ambulance.
   In other situations where nonemergency medical transportation is
given, ambulances need not be used.


14136.3.  No prior authorization shall be necessary for the
provision of nonemergency medical transportation services to Medi-Cal
beneficiaries when the beneficiary is being transported from an
acute care hospital following a stay as an inpatient to a nursing
facility or any category of intermediate care facility for the
developmentally disabled licensed pursuant to Section 1250 of the
Health and Safety Code.



14136.4.  A written treatment authorization request for nonemergency
medical transportation services for which a department employed
medical consultant had provided conditional prior authorization to
the provider of services via telephone, shall not be denied by the
Medi-Cal field office when the written treatment authorization
request subsequently submitted by the provider substantiates the
medical information given with the earlier verbal request, so long as
the beneficiary was eligible to receive such services.



14136.5.  No entity which has received funds under paragraph (2) of
subsection (b) of Section 1601 of the federal Urban Mass
Transportation Act shall receive reimbursement for medical
transportation services rendered to beneficiaries of the Medi-Cal
program in any amount greater or higher than the fee charged by the
provider to persons for whom services are not reimbursed by Medi-Cal.



14136.8.  No reimbursement shall be made for medical transportation
services provided pursuant to subdivision (i) of Section 14132 when
the services are prescribed or ordered by a person who has a
significant beneficial interest in the medical transportation
services rendered unless the nature and extent of that interest have
been disclosed in accordance with, and subject to, Section 51466 of
Title 22 of the California Administrative Code.



14137.  The State Department of Health Services, following review
and approval from the State Health and Welfare Agency, shall seek all
necessary waivers from the United States Department of Health and
Human Services in order to provide in-home and community-based care,
as provided for under Section 2176 of  the federal Omnibus Budget
Reconciliation Act of 1981.  The waiver proposal shall specifically
include plans for the provision of services to any person who would
be eligible for community-based and in-home services, as defined by
the Department of Health Services, and who would be eligible for the
Medi-Cal program, provided for pursuant to this chapter, except for
the person's income and who can, therefore, become eligible by
meeting spend-down requirements.



14137.6.  (a) Notwithstanding any other provision of law, and
subject to federal financial participation, covered services under
this chapter shall include, subject to utilization controls,
medically necessary inpatient and outpatient services associated with
the administration of any drug that has been classified by the
department or the Food and Drug Administration as having treatment
Investigational New Drug (IND) status, when the drug is being
administered for the treatment of acquired immune deficiency syndrome
(AIDS), AIDS-related complex (ARC), or human immunodeficiency virus
(HIV), to otherwise eligible persons.
   (b) The department shall adopt emergency regulations pursuant to
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code to implement this section.  The
adoption of the regulations shall be deemed to be an emergency and
necessary for the immediate preservation of the public peace, health,
or safety.  Notwithstanding the provisions of Chapter 3.5
(commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code, emergency regulations adopted by the department
in order to implement this section shall not be subject to the
review and approval of the Office of Administrative Law.  These
regulations shall become effective immediately upon filing with the
Secretary of State.
   (c) No part of this section shall be construed to require the
department to pay for the cost of treatment IND drugs provided for
research purposes by pharmaceutical companies or any other sponsors
at no cost.
   (d) Payment for care to any Medi-Cal eligible HIV infected person
in need of treatment shall not be denied solely on the basis of the
use of a drug having treatment IND status.
   (e) When medically feasible, every effort shall be made to
administer drugs having treatment IND status on an outpatient basis.



14137.8.  Approval of a request for acute inpatient care shall be
solely dependent upon the medical necessity for this care, as
documented in the proposed treatment plan.  Treatment with
Investigational New Drugs, clinical trials, or other ancillary or
investigational services, if medical necessity is otherwise
documented, shall not in itself be construed to be part of a research
study protocol, and shall not constitute grounds for denial on that
basis.


14138.  (a) To the extent permitted by federal law, the department
shall purchase vaccines and biological products in bulk from the
Centers for Disease Control or any other sources at the lowest cost
possible, for use by providers of services under this chapter and the
Child Health and Disability Prevention program under Article 6
(commencing with Section 124025) of Chapter 3 of Part 2 of Division
106 of the Health and Safety Code, in the immunization of eligible
children.
   (b) It is the intent of the Legislature that, to the maximum
extent possible, any savings of General Fund moneys realized from the
program established pursuant to this section shall be reinvested in
programs that are most likely to increase access to, and the quality
of, immunization services for children.
   (c) In order to achieve maximum cost savings, the Legislature
hereby determines that an expedited contract process for contracts
under this section is necessary.  Therefore, contracts under this
section may be on a nonbid basis and shall be exempt from the
provisions of the Public Contract Code.
   (d) No part of this section shall be construed to require the
department to undertake distribution of vaccines and biological
products.