2009 California Welfare and Institutions Code - Section 14093-14093.10 :: Article 2.97. Managed Care Plan Contracts

14093.  The purpose of this article is to ensure quality of care and
to provide increased access to health care services in the most
cost-effective and efficient manner possible, to persons who are
eligible to receive medical benefits under publicly supported
programs other than Medi-Cal.

14093.05.  (a) The director shall enter into contracts with managed
care plans under this chapter and Chapter 8 (commencing with Section
14200), including, but not limited to, health maintenance
organizations, prepaid health plans, and primary care case management
plans; counties, primary care providers, independent practice
associations, private foundations, children's hospitals, community
health centers, rural health centers, community clinics, and
university medical center systems, or other entities for the
provision of medical benefits to all persons who are eligible to
receive medical benefits under publicly supported programs. The
director may also amend existing Medi-Cal managed care contracts to
include the provision of medical benefits to persons who are eligible
to receive medical benefits under publicly supported programs.
Contracts may be on an exclusive or nonexclusive basis.
   (b) Contractors pursuant to this article and participating
providers acting pursuant to subcontracts with those contractors,
shall agree to hold harmless the beneficiaries of the publicly
supported programs if the contract between the sponsoring government
agency and the contractor does not ensure sufficient funding to cover
program benefits.
   (c) Any managed care contractor serving children with conditions
eligible under the California Children's Services (CCS) program shall
maintain and follow standards of care established by the program,
including use of paneled providers and CCS-approved special care
centers and shall follow treatment plans approved by the program,
including specified services and providers of services. If there are
insufficient paneled providers willing to enter into contracts with
the managed care contractor, the program shall seek to establish new
paneled providers willing to contract. If a paneled provider cannot
be found, the managed care contractor shall seek program approval to
use a specific nonpaneled provider with appropriate qualifications.
   (d) (1) Any managed care contractor serving children with
conditions eligible under the CCS program shall report expenditures
and savings separately for CCS covered services and CCS eligible
children.
   (2) If the managed care contractor is paid according to a
capitated or risk-based payment methodology, there shall be separate
actuarially sound rates for CCS eligible children.
   (3) Notwithstanding paragraph (2), a managed care pilot project
may, if approval is obtained from the State CCS program director,
utilize an alternative rate structure for CCS eligible children.
   (e) This article is not intended to and shall not be interpreted
to permit any reduction in benefits or eligibility levels under the
CCS program. Any medically necessary service not available under the
managed care contracts authorized under this article shall remain the
responsibility of the state and county.
   (f) To assure CCS benefits are provided to enrollees with a CCS
eligible condition according to CCS program standards, there shall be
oversight by the state and local CCS program agencies for both
services covered and not covered by the managed care contract.
   (g) Any managed care contract which will affect the delivery of
care to CCS eligible children shall be approved by the state CCS
program director prior to execution. The state CCS program shall
continue to be responsible for selection of CCS paneled providers and
monitoring of contractors to see that CCS state standards are
maintained.

14093.06.  (a) When a managed care contractor authorized to provide
California Children's Services (CCS) covered services pursuant to
subdivision (a) of Section 14094.3 expands to other counties, the
contractor shall comply with CCS program standards including, but not
limited to, referral of newborns to the appropriate neonatal
intensive care level, referral of children requiring pediatric
intensive care to CCS-approved pediatric intensive care units, and
referral of children with CCS eligible conditions to CCS-approved
inpatient facilities and special care centers in accordance with
subdivision (c) of Section 14093.05.
   (b) The managed care contractor shall comply with CCS program
medical eligibility regulations. Questions regarding interpretation
of state CCS medical eligibility regulations, or disagreements
between the county CCS program, and the managed care contractor
regarding interpretation of those regulations, shall be resolved by
the local CCS program, in consultation with the state CCS program.
The resolution determined by the CCS program shall be communicated in
writing to the managed care contractor.
   (c) In following the treatment plan approved by the CCS program,
the managed care contractor shall ensure the timely referral of
children with special health care needs to CCS-paneled providers who
are board-certified in both pediatrics and in the appropriate
pediatric subspecialty.
   (d) The managed care contractor shall report expenditures and
savings separately for CCS covered services and CCS eligible
children, in accordance with paragraph (1) of subdivision (d) of
Section 14093.05.
   (e) All children who are enrolled with a managed care contractor
who are seeking CCS program benefits shall retain all rights to CCS
program appeals and fair hearings of denials of medical eligibility
or of service authorizations. Information regarding the number,
nature, and disposition of appeals and fair hearings shall be part of
an annual report to the Legislature on managed care contractor
compliance with CCS standards, regulations, and procedures. This
report shall be made available to the public.
   (f) The state, in consultation with stakeholder groups, shall
develop unique pediatric plan performance standards and measurements,
including, but not limited to, the health outcomes of children with
special health care needs.

14093.07.  For purposes of this article the following definitions
apply:
   (a) "Foster child" means any child who has been taken into custody
or placed by a juvenile court pursuant to Article 6 (commencing with
Section 300) of Chapter 2 of Part 1 of Division 2 or Section 601 or
602.
   (b) "Medi-Cal managed care plan" means any person or entity that
has entered into a contract with the director pursuant to Article 2.7
(commencing with Section 14087.3), Article 2.9 (commencing with
Section 14088), or Article 2.91 (commencing with Section 14089) of
this chapter or pursuant to Article 1 (commencing with Section 14200)
of Chapter 8.
   (c) "Out-of-county placement" means any foster care placement in
which the child has been placed outside of the county with the
responsibility for the care and placement of the child.

14093.09.  (a) No child in foster care shall be required to enroll
in a Medi-Cal managed care plan. A foster child may be voluntarily
enrolled in a Medi-Cal managed care plan only when the county child
welfare agency with responsibility for the care and placement of the
child, in consultation with the child's foster caregiver, determines
that it is in the best interest of the child to do so and the
department determines that enrollment is available to the child.
   (b) Whenever a foster child is placed in an out-of-county
placement, the county child welfare agency with responsibility for
the care and placement of the child shall determine, in consultation
with the child's foster caregiver, if the child should remain in, or
has enrolled in, a Medi-Cal managed care plan in the county where the
child will be placed or in the county with responsibility for the
care and placement of the child, as long as the department determines
that enrollment is available for the child.
   (c) The State Department of Health Services shall establish for
Medi-Cal managed care plans urgent disenrollment procedures that
provide for disenrollment of foster children in out-of-county
placements within two working days of receipt by the department's
enrollment contractor, or the department, if the department has no
enrollment contractor, of a request for disenrollment made by the
child welfare services agency, the foster caregiver, or other person
authorized to make medical decisions on behalf of the foster child.
   (d) Medi-Cal managed care plans shall process and pay
appropriately documented claims submitted by out-of-plan providers
for services provided to foster children in out-of-county placements
while they are Medi-Cal members of the plan. This section shall not
be construed to prevent a plan from requiring prior authorization for
nonemergency services consistent with the plan's established
policies and procedures.

14093.10.  (a) Whenever a foster child enrolled in a county
organized health system, established pursuant to Article 2.8
(commencing with Section 14087.5), is placed in an out-of-county
placement, the county child welfare agency or probation department
with responsibility for the care and placement of the child shall
determine, in consultation with the child's foster caregiver, whether
the child should remain enrolled in that county organized health
system. The determination shall be made no later than one working day
after the out-of-county placement begins.
   (b) If it is determined, pursuant to subdivision (a) or at any
later date, that a foster child should be disenrolled from a county
organized health system due to an out-of-county placement, the county
child welfare agency or probation department with responsibility for
the care and placement of the child shall request that the child be
disenrolled from the county organized health system. The request
shall be made to the entity designated by the State Department of
Health Care Services to receive requests for disenrollment or to the
department, if the department has no designee, no later than one
working day after either of the following occurs:
   (1) The out-of-county placement begins.
   (2) It is determined that a child who initially remained enrolled
in the county organized health system following the out-of-county
placement, pursuant to subdivision (a), should subsequently be
disenrolled.
   (c) The State Department of Health Care Services shall, in
consultation with other agencies and organizations interested in
health care access for foster children, establish for county
organized health systems urgent disenrollment procedures that provide
for disenrollment of foster children in out-of-county placements
within two working days of receipt by the department's designee or by
the department, if the department has no designee, of a request for
disenrollment made by the county child welfare services agency, the
county probation department, the foster caregiver, or any other
person authorized to make medical decisions on behalf of the foster
child.
   (d) The department shall issue all-county letters or similar
instructions to implement subdivision (c) no later than January 1,
2009, and thereafter shall adopt any necessary implementing
regulations.