2009 California Health and Safety Code - Section 11758.40-11758.47 :: Chapter 3.4. Medi-cal Drug Treatment Program

11758.40.  Notwithstanding subdivision (c) of Section 11758.23, the
department may enter into a Medi-Cal Drug Treatment Program contract
with each county for the provision of services within the county
service area.

11758.42.  (a) For purposes of this chapter, "LAAM" means
levoalphacetylmethadol.
   (b) (1) The department shall establish a narcotic replacement
therapy dosing fee for methadone and LAAM.
   (2) In addition to the narcotic replacement therapy dosing fee
provided for pursuant to paragraph (1), narcotic treatment programs
shall be reimbursed for the ingredient costs of methadone or LAAM
dispensed to Medi-Cal beneficiaries. These costs may be determined on
an average daily dose of methadone or LAAM, as set forth by the
department, in consultation with the State Department of Health Care
Services.
   (c) Reimbursement for narcotic replacement therapy dosing and
ancillary services provided by narcotic treatment programs shall be
based on a per capita uniform statewide daily reimbursement rate for
each individual patient, as established by the department, in
consultation with the State Department of Health Care Services. The
uniform statewide daily reimbursement rate for narcotic replacement
therapy dosing and ancillary services shall be based upon, where
available and appropriate, all of the following:
   (1) The outpatient rates for the same or similar services under
the fee-for-service Medi-Cal program.
   (2) Cost report data.
   (3) Other data deemed reliable and relevant by the department.
   (4) The rate studies completed pursuant to Section 54 of Assembly
Bill 3483 of the 1995-96 Regular Session of the Legislature.
   (d) The uniform statewide daily reimbursement rate for ancillary
services shall not exceed, for individual services or in the
aggregate, the outpatient rates for the same or similar services
under the fee-for-service Medi-Cal program.
   (e) The uniform statewide daily reimbursement rate shall be
established after consultation with narcotic treatment program
providers and county alcohol and drug program administrators.
   (f) Reimbursement for narcotic treatment program services shall be
limited to those services specified in state law and state and
federal regulations governing the licensing and administration of
narcotic treatment programs. These services shall include, but are
not limited to, all of the following:
   (1) Admission, physical evaluation, and diagnosis.
   (2) Drug screening.
   (3) Pregnancy tests.
   (4) Narcotic replacement therapy dosing.
   (5) Intake assessment, treatment planning, and counseling
services. Frequency of counseling or medical psychotherapy, outcomes,
and rates shall be addressed through regulations adopted by the
department. For purposes of this paragraph, these services include,
but are not limited to, substance abuse services to pregnant and
postpartum Medi-Cal beneficiaries.
   (g) Reimbursement under this section shall be limited to claims
for narcotic treatment program services at the uniform statewide
daily reimbursement rate for these services. These rates shall be
exempt from the requirements of Section 14021.6 of the Welfare and
Institutions Code.
   (h) (1) Reimbursement to narcotic treatment program providers
shall be limited to the lower of either the uniform statewide daily
reimbursement rate, pursuant to subdivision (c), or the provider's
usual and customary charge to the general public for the same or
similar service.
   (2) (A) Reimbursement paid by a county to a narcotic treatment
program provider for services provided to any person subject to
Section 1210.1 or 3063.1 of the Penal Code, and for which the
individual client is not liable to pay, does not constitute a usual
and customary charge to the general public for the purposes of this
section.
   (B) Subparagraph (A) does not constitute a change in, but is
declaratory of, existing law.
   (i) No program shall be reimbursed for services not rendered to or
received by a patient of a narcotic treatment program.
   (j) Reimbursement for narcotic treatment program services provided
to substance abusers shall be administered by the department and
counties electing to participate in the program. Utilization and
payment for these services shall be subject to federal Medicaid and
state utilization and audit requirements.

11758.421.  (a) (1) The Legislature finds and declares all of the
following:
   (A) Medical treatment for indigent patients who are not eligible
for Medi-Cal is essential to protecting the public health.
   (B) The Legislature supports the adoption of standardized and
simplified forms and procedures in order to promote the drug
treatment of indigent patients who are not eligible for Medi-Cal.
   (C) Providers should not be required by the state to subsidize the
medical treatment provided to indigent patients who are not eligible
for Medi-Cal.
   (D) The Legislature supports the therapeutic value of indigent
patients who are not eligible for Medi-Cal contributing some level of
fees for drug treatment services in order to support the goals of
those drug treatment services.
   (2) It is the intent of the Legislature in enacting this section
to encourage narcotic treatment program providers to serve indigent
patients who are not eligible for Medi-Cal. It is also the intent of
the Legislature that the State Department of Alcohol and Drug
Programs allow narcotic treatment program providers to charge
therapeutic fees for providing drug treatment to indigent patients
who are not eligible for Medi-Cal if the providers establish a fee
scale that complies with the documentation requirements established
pursuant to this section and federal law.
   (b) (1) The Legislature recognizes that narcotic treatment program
providers are reimbursed for controlled substances provided under
the Medi-Cal Drug Treatment Program, also known as Drug Medi-Cal
(Chapter 3.4 (commencing with Section 11758.40)), and pursuant to
federal law at a rate that is the lower of the per capita uniform
statewide daily reimbursement or Drug Medi-Cal rate, or the provider'
s usual and customary charge to the general public for the same or
similar services.
   (2) It furthers the intent of the Legislature to ensure that
narcotic treatment programs in the state are able to serve indigent
clients and that there is an exception to the reimbursement
requirements described in paragraph (1), as the federal law has been
interpreted by representatives with the Centers for Medicare and
Medicaid Services. Pursuant to this exception, if a narcotic
treatment program provider who is serving low-income non-Drug
Medi-Cal clients complies with a federal requirement for the
application of a sliding indigency scale, the reduced charges under
the sliding indigency scale shall not lower the provider's usual and
customary charge determination for purposes of Medi-Cal
reimbursement.
   (c) A licensed narcotic treatment program provider that serves
low-income non-Drug Medi-Cal clients shall be deemed in compliance
with federal and state law, for purposes of the application of the
exception described in paragraph (2) of subdivision (b), and avoid
audit disallowances, if the provider implements a sliding indigency
scale that meets all of the following requirements:
   (1) The maximum fee contained in the scale shall be the provider's
full nondiscounted, published charge and shall be at least the rate
that Drug Medi-Cal would pay for the same or similar services
provided to Drug Medi-Cal clients.
   (2) The sliding indigency scale shall provide for an array of
different charges, based upon a client's ability to pay, as measured
by identifiable variables. These variables may include, but need not
be limited to, financial information and the number of dependents of
the client.
   (3) Income ranges shall be in increments that result in a
reasonable distribution of clients paying differing amounts for
services based on differing abilities to pay.
   (4) A provider shall obtain written documentation that supports an
indigency allowance under the sliding indigency scale established
pursuant to this section, including a financial determination. In
cases where this written documentation cannot be obtained, the
provider shall document at least three attempts to obtain this
written documentation from a client.
   (5) The provider shall maintain all written documentation that
supports an indigency allowance under this section, including, if
used, the financial evaluation form set forth in Section 11758.425.
   (6) Written policies shall be established and maintained that set
forth the basis for determining whether an indigency allowance may be
granted under this section and establish what documentation shall be
requested from a client.
   (d) In developing the sliding indigency scale, a narcotic
treatment program provider shall consider, but need not include, any
or all of the following components:
   (1) Vertically, the rows would reflect increments of family or
household income. There would be a sufficient number of increments to
allow for differing charges, such as a six hundred dollar ($600)
increase per interval.
   (2) Horizontally, the columns would provide for some other
variable, such as family size, in which case, the columns would
reflect the number of people dependent on the income, including the
client.
   (3) Each row, except the first and last rows, would contain at
least two different fee amounts and each of the columns, four or more
in number, would contain at least six different fee amounts.
   (4) The cells would contain an array of fees so that no fee would
be represented in more than 25 percent of the cells.
   (e) A narcotic treatment program provider that uses the financial
evaluation form instructions and financial form set forth in Section
11758.425 in obtaining written documentation that supports an
indigency allowance as required under paragraph (4) of subdivision
(c) shall be deemed in compliance with that paragraph.

11758.425.  A narcotic treatment program provider may use the
following instructions and financial evaluation form to comply with
the requirements of paragraph (4) of subdivision (c) of Section
11758.421:
                      FINANCIAL EVALUATION FORM INSTRUCTIONS
   MONTHLY INCOME DATA--This data should specify the source and the
amount and be supported by sufficient documentation. Income data may
include, but are not limited to, income received as a paid employee,
unemployment benefits, disability benefits, pension payments, family
income, savings income, or other sources.
   MONTHLY EXPENSES DATA--This data is not required unless there is
no evidence or documentation of income data. Expense data may
include, but are not limited to, any known expenses related to the
following:
   (1) Court-ordered payments, such as child support, fines, debts,
restitution, or other payments.
   (2) Housing-related expenses, such as rent, mortgage, insurance,
utilities, or other obligations.
   (3) Transportation costs, such as any related expenses, including
automobile payments or automobile insurance payments.
   (4) Insurance coverage should also be noted if it produces either
an expense or benefit to the client.
   CLIENT MONTHLY TREATMENT FEE--The following applies to this data:
   (1) The amount box indicates the client's fee according to his or
her location on the sliding scale.
   (2) The adjusted client monthly fee box is to be filled only if
the fee to be charged differs from the fee indicated by the client's
location on the sliding scale.
   (3) If the fee is adjusted from what the sliding scale would
indicate, a reason for the adjustment must be provided. (Valid
reasons might include extraordinary medical expenses for a client
suffering from HIV/AIDS, etc.)
   PLEASE NOTE--The documentation for this form requires that the
provider make at least three documented attempts to collect
documentation from a client. Any questions on this form may be
directed to the department at (___).

11758.43.  To the extent any county refuses to execute the Medi-Cal
Drug Treatment Program contract in accordance with the requirements
of federal medicaid and state Medi-Cal laws, and in accordance with
the federal court order and any future action in the case of Sobky v.
Smoley, 855 F. Supp. 1123 (E. D. Cal.), the department shall
contract directly with the certified providers in that county, and
retain that portion of that county's state General Fund allocation
necessary to meet the cost of providing services to eligible
beneficiaries and the costs to the state of administering the
Medi-Cal Drug Treatment Program contracts.

11758.44.  (a) In addition to narcotic treatment program services, a
narcotic treatment program provider who is also enrolled as a
Medi-Cal provider, may provide medically necessary medical treatment
of concurrent diseases, within the scope of the provider's practice,
to Medi-Cal beneficiaries who are not enrolled in managed care plans.
Medi-Cal beneficiaries enrolled in managed care plans shall be
referred to those plans for receipt of medically necessary medical
treatment of concurrent diseases.
   (b) Diagnosis and treatment of concurrent diseases of Medi-Cal
beneficiaries not enrolled in managed care plans by a narcotic
treatment program provider may be provided within the Medi-Cal
coverage limits. When the services are not part of the substance
abuse treatment reimbursed pursuant to Section 11758.42, services
shall be reimbursed at Medi-Cal program outpatient rates. Services
reimbursable under this section shall include, but are not limited
to, all of the following:
   (1) Medical treatment visits.
   (2) Diagnostic blood, urine, and X-rays.
   (3) Psychological and psychiatric tests and services.
   (4) Quantitative blood and urine toxicology assays.
   (5) Medical supplies.
   (c) A narcotics treatment program provider, who is enrolled as a
Medi-Cal fee-for-service provider, shall not seek reimbursement from
a beneficiary for substance abuse treatment services, if services for
treatment of concurrent diseases are billed to the Medi-Cal
fee-for-service program.

11758.45.  The department may enter into procurement contracts in
accordance with Chapter 2 (commencing with Section 10290) of Part 2
of Division 2 of the Public Contract Code, for the procurement of
services to assist the department in administering the Medi-Cal Drug
Treatment Program.

11758.46.  (a) For purposes of this section, "drug Medi-Cal services"
means all of the following services, administered by the department,
and to the extent consistent with state and federal law:
   (1) Narcotic treatment program services, as set forth in Section
11758.42.
   (2) Day care rehabilitative services.
   (3) Perinatal residential services for pregnant women and women in
the postpartum period.
   (4) Naltrexone services.
   (5) Outpatient drug-free services.
   (b) Upon federal approval of a federal Medicaid state plan
amendment authorizing federal financial participation in the
following services, and subject to appropriation of funds, "drug
Medi-Cal services" shall also include the following services,
administered by the department, and to the extent consistent with
state and federal law:
   (1) Notwithstanding subdivision (a) of Section 14132.90 of the
Welfare and Institutions Code, day care habilitative services, which,
for purposes of this paragraph, are outpatient counseling and
rehabilitation services provided to persons with alcohol or other
drug abuse diagnoses.
   (2) Case management services, including supportive services to
assist persons with alcohol or other drug abuse diagnoses in gaining
access to medical, social, educational, and other needed services.
   (3) Aftercare services.
   (c) (1) Annually, the department shall publish procedures for
contracting for drug Medi-Cal services with certified providers and
for claiming payments, including procedures and specifications for
electronic data submission for services rendered.
   (2) The department, county alcohol and drug program
administrators, and alcohol and drug service providers shall automate
the claiming process and the process for the submission of specific
data required in connection with reimbursement for drug Medi-Cal
services, except that this requirement applies only if funding is
available from sources other than those made available for treatment
or other services.
   (d) A county or a contractor for the provision of drug Medi-Cal
services shall notify the department, within 30 days of the receipt
of the county allocation, of its intent to contract, as a component
of the single state-county contract, and provide certified services
pursuant to Section 11758.42, for the proposed budget year. The
notification shall include an accurate and complete budget proposal,
the structure of which shall be mutually agreed to by county alcohol
and drug program administrators and the department, in the format
provided by the department, for specific services, for a specific
time period, and including estimated units of service, estimated rate
per unit consistent with law and regulations, and total estimated
cost for appropriate services.
   (e) (1) Within 30 days of receipt of the proposal described in
subdivision (d), the department shall provide, to counties and
contractors proposing to provide drug Medi-Cal services in the
proposed budget year, a proposed multiple-year contract, as a
component of the single state-county contract, for these services, a
current utilization control plan, and appropriate administrative
procedures.
   (2) A county contracting for alcohol and drug services shall
receive a single state-county contract for the net negotiated amount
and drug Medi-Cal services.
   (3) Contractors contracting for drug Medi-Cal services shall
receive a drug Medi-Cal contract.
   (f) (1) Upon receipt of a contract proposal pursuant to
subdivision (d), a county and a contractor seeking to provide
reimbursable drug Medi-Cal services and the department may begin
negotiations and the process for contract approval.
   (2) If a county does not approve a contract by July 1 of the
appropriate fiscal year, in accordance with subdivisions (c) to (e),
inclusive, the county shall have 30 additional days in which to
approve a contract. If the county has not approved the contract by
the end of that 30-day period, the department shall contract directly
for services within 30 days.
   (3) Counties shall negotiate contracts only with providers
certified to provide reimbursable drug Medi-Cal services and that
elect to participate in this program. Upon contract approval by the
department, a county shall establish approved contracts with
certified providers within 30 days following enactment of the annual
Budget Act. A county may establish contract provisions to ensure
interim funding pending the execution of final contracts,
multiple-year contracts pending final annual approval by the
department, and, to the extent allowable under the annual Budget Act,
other procedures to ensure timely payment for services.
   (g) (1) For counties and contractors providing drug Medi-Cal
services, pursuant to approved contracts, and that have accurate and
complete claims, reimbursement for services from state General Fund
moneys shall commence no later than 45 days following the enactment
of the annual Budget Act for the appropriate state fiscal year.
   (2) For counties and contractors providing drug Medi-Cal services,
pursuant to approved contracts, and that have accurate and complete
claims, reimbursement for services from federal Medicaid funds shall
commence no later than 45 days following the enactment of the annual
Budget Act for the appropriate state fiscal year.
   (3) The State Department of Health Care Services and the
department shall develop methods to ensure timely payment of drug
Medi-Cal claims.
   (4) The State Department of Health Care Services, in cooperation
with the department, shall take steps necessary to streamline the
billing system for reimbursable drug Medi-Cal services, to assist the
department in meeting the billing provisions set forth in this
subdivision.
   (h) The department shall submit a proposed interagency agreement
to the State Department of Health Care Services by May 1 for the
following fiscal year. Review and interim approval of all contractual
and programmatic requirements, except final fiscal estimates, shall
be completed by the State Department of Health Care Services by July
1. The interagency agreement shall not take effect until the annual
Budget Act is enacted and fiscal estimates are approved by the State
Department of Health Care Services. Final approval shall be completed
within 45 days of enactment of the Budget Act.
   (i) (1) A county or a provider certified to provide reimbursable
drug Medi-Cal services, that is contracting with the department,
shall estimate the cost of those services by April 1 of the fiscal
year covered by the contract, and shall amend current contracts, as
necessary, by the following July 1.
   (2) A county or a provider, except for a provider to whom
subdivision (j) applies, shall submit accurate and complete cost
reports for the previous fiscal year by November 1, following the end
of the fiscal year. The department may settle cost for drug Medi-Cal
services, based on the cost report as the final amendment to the
approved single state-county contract.
   (j) Certified narcotic treatment program providers that are
exclusively billing the state or the county for services rendered to
persons subject to Section 1210.1 or 3063.1 of the Penal Code or
Section 11758.42 of this code shall submit accurate and complete
performance reports for the previous state fiscal year by November 1
following the end of that fiscal year. A provider to which this
subdivision applies shall estimate its budgets using the uniform
state daily reimbursement rate. The format and content of the
performance reports shall be mutually agreed to by the department,
the County Alcohol and Drug Program Administrators Association of
California, and representatives of the treatment providers.

11758.47.  Service providers may assist Medi-Cal beneficiaries, upon
request, to file a fair hearing request in accordance with Chapter 7
(commencing with Section 10950) of Part 2 of Division 9 of the
Welfare and Institutions Code, or may inform Medi-Cal beneficiaries
about the Department of Managed Health Care's toll-free telephone
number for health care service plan members or the State Department
of Health Services' ombudsman for Medi-Cal beneficiaries enrolled in
Medi-Cal managed care plans.