2009 California Welfare and Institutions Code - Section 14499.7-14499.77 :: Article 8. Medi-cal At-risk Fiscal Intermediaries

14499.7.  The department may contract with one or more fiscal
intermediaries in order to pay for benefits authorized under this
chapter and Chapter 7 (commencing with Section 14000). Contracts
entered into pursuant to this article may be awarded on a bid or
nonbid basis.

14499.71.  For the purposes of this article, "fiscal intermediary"
means an entity that agrees to pay for covered services provided to
Medi-Cal eligibles in exchange for a premium, subscription charge, or
capitation payment; to assume an underwriting risk; and is either
licensed by the Director of the Department of Managed Health Care
under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter
2.2 (commencing with Section 1340) of Division 2 of the Health and
Safety Code) or is licensed as a nonprofit hospital service plan by
the Insurance Commissioner pursuant to subdivision (e) of Section
11493 of the Insurance Code and Sections 11501 to 11505, inclusive,
of the Insurance Code.

14499.73.  A contract entered into under this article shall provide
that a fiscal intermediary meets both of the following criteria:
   (a) The fiscal intermediary shall provide or arrange for an
adequate number of primary care physicians and supportive specialty
care physicians.
   (b) The fiscal intermediary shall implement a management and
information reporting system in order to determine the costs of each
type of health care service rendered to Medi-Cal recipients.

14499.74.  In determining the capitated rates to be paid to a fiscal
intermediary during the first year of contracting under this
article, the department shall utilize an acceptable actuarial process
and historical data concerning Medi-Cal recipients in the
geographical area which will, or is being, served by the fiscal
intermediary. During the remaining years of the contract with the
fiscal intermediary, the department shall utilize data concerning
Medi-Cal expenditures for delivery of services based on the
fee-for-service experience in comparable geographic areas. The
capitated rates shall not exceed the total per capita amount
(including the cost of adjustments to provide actuarial equivalence)
which would be payable for all services and requirements covered
under the fiscal intermediary contract adopted pursuant to this
article if all those services and requirements were to be furnished
to Medi-Cal beneficiaries under the fee-for-service Medi-Cal program
provided for by Chapter 7 (commencing with Section 14000).

14499.75.  A fiscal intermediary may contract for the provision of
services with any provider who would be eligible to provide services
if services were to be provided on a fee-for-service basis without
the use of a fiscal intermediary pursuant to this article.

14499.77.  All services, except those specified for exclusion by the
department, received by Medi-Cal recipients residing in the
geographical area served by the fiscal intermediary shall be paid for
by the fiscal intermediary. Services shall be provided only by
providers which have entered into agreements with the fiscal
intermediary, unless authorized by the fiscal intermediary.