California Code
PART 3 - AID AND MEDICAL ASSISTANCE
CHAPTER 8 - Prepaid Plans

ARTICLE 1 - General Provisions

Section 14200. - 14200. This chapter shall be known and may be cited...

Section 14200.1. - 14200.1. The purpose of this chapter is to afford persons...

Section 14201. - 14201. The intent of the Legislature is to provide, to...

Section 14203. - 14203. (a) For purposes of administering this chapter and Chapter...

Section 14204. - 14204. (a) Pursuant to the provisions of this chapter, the...

Section 14205. - 14205. Except where the context otherwise requires, or where specific...

Section 14206. - 14206. (a) No prepaid health plan or pilot program shall...

ARTICLE 2 - Definitions

Section 14250. - 14250. Unless the context otherwise requires, the definitions set forth...

Section 14251. - 14251. (a) (1) “Prepaid health plan” means a plan that...

Section 14252. - 14252. “Medi-Cal beneficiary” means a person who is eligible to...

Section 14253. - 14253. “Subcontract” means an agreement entered into by the prepaid...

Section 14254. - 14254. (a) “Primary care physician” is a physician who has...

Section 14255. - 14255. “Specialist” means a physician who is board certified or...

Section 14256. - 14256. The “basic scope of health care benefits” means: (a)...

Section 14257. - 14257. Nothing in this act shall preclude the director from...

Section 14258. - 14258. “Service area” means a geographical area designated by the...

Section 14259. - 14259. “Director” means the State Director of Health Services. (Amended...

Section 14260. - 14260. “Department” means the State Department of Health Services. (Amended...

Section 14261. - 14261. “Vendor” means any person who provides services or supplies...

Section 14263. - 14263. “Marketing” means any activity conducted by or on behalf...

Section 14264. - 14264. “Marketing organization” means any subcontractor who agrees to provide...

Section 14265. - 14265. “Marketing representative” means any person who engages in marketing...

ARTICLE 3 - Administration

Section 14300. - 14300. The department shall publish a notice of intent to...

Section 14301. - 14301. (a) The department shall determine, by actuarial methods, prospective...

Section 14301.1. - 14301.1. (a) For rates established on or after August 1,...

Section 14301.11. - 14301.11. (a) Notwithstanding any law, and subject to subdivisions (e)...

Section 14301.2. - 14301.2. (a) The director may defer fee-for-service payments or payments...

Section 14301.3. - 14301.3. The department shall ensure that Medi-Cal managed care plans...

Section 14301.4. - 14301.4. (a) It is the intent of the Legislature, to...

Section 14301.5. - 14301.5. (a) (1) To the extent federal financial participation is...

Section 14302. - 14302. Except as provided in Section 14490, the duration of...

Section 14302.1. - 14302.1. (a) (1) Once it is determined that a contract...

Section 14303. - 14303. No contract between the department and the prepaid health...

Section 14303.1. - 14303.1. The department shall have authority to amend a prepaid...

Section 14303.2. - 14303.2. The department shall have authority to amend a prepaid...

Section 14303.3. - 14303.3. The department shall renew a contract unless good cause...

Section 14304.5. - 14304.5. Each prepaid health plan shall provide directly or through...

Section 14305. - 14305. The department may limit the scope of health care...

Section 14308. - 14308. (a) Each prepaid health plan shall furnish to the...

Section 14309. - 14309. The department shall provide for a continuing study of...

Section 14311. - 14311. Prepaid health plans, the services they provide, and the...

Section 14312. - 14312. The director shall adopt all necessary rules and regulations...

Section 14314. - 14314. The director may recover a due and payable overpayment...

Section 14315. - 14315. When it has been determined that a prepaid health...

Section 14316. - 14316. Notwithstanding any other provisions of law, contracts with plans...

ARTICLE 4 - Enrollment and Disenrollment

Section 14400. - 14400. Every prepaid health plan shall have an open enrollment...

Section 14401. - 14401. No Medi-Cal beneficiary shall be enrolled in a prepaid...

Section 14402. - 14402. The prepaid health plan shall enroll only those Medi-Cal...

Section 14403. - 14403. No Medi-Cal beneficiary shall be enrolled in more than...

Section 14406. - 14406. (a) Within seven days after the effective date of...

Section 14407. - 14407. Enrollment in a prepaid health plan shall be voluntary...

Section 14407.1. - 14407.1. (a) A contractor that has entered into a contract...

Section 14407.6. - 14407.6. (a) Notwithstanding Section 14407.5, the department shall, to the...

Section 14408. - 14408. (a) Except as otherwise prohibited by law, a contractor...

Section 14408.5. - 14408.5. A prepaid health plan that contracts with Medi-Cal managed...

Section 14409. - 14409. (a) No prepaid health plan, marketing representative, or marketing...

Section 14410. - 14410. No prepaid health plan or marketing representative shall adopt...

Section 14411. - 14411. (a) No prepaid health plan or marketing organization shall...

Section 14412. - 14412. (a) The enrollment of a Medi-Cal beneficiary in the...

Section 14413. - 14413. (a) Requests for disenrollment shall be made to an...

ARTICLE 5 - Standards for Prepaid Health Plans

Section 14450. - 14450. (a) No contract between the department and a prepaid...

Section 14450.5. - 14450.5. (a) No contract between the department and a prepaid...

Section 14451. - 14451. Services under a prepaid health plan contract shall be...

Section 14451.5. - 14451.5. (a) A prepaid health plan contractor may not enter...

Section 14452. - 14452. (a) All subcontracts shall be entered into pursuant to...

Section 14452.3. - 14452.3. Each prepaid health plan shall provide the services of...

Section 14452.4. - 14452.4. Where the prepaid health plan agrees to provide dental...

Section 14452.5. - 14452.5. Each prepaid health plan shall provide the services of...

Section 14452.6. - 14452.6. Prepaid health plans, or their subcontractors, shall not bill...

Section 14453. - 14453. In compensating directors and officers, the prepaid health plan...

Section 14454. - 14454. (a) The prepaid health plan shall be liable for...

Section 14455. - 14455. The prepaid health plan shall maintain a complete unit...

Section 14456. - 14456. The department shall conduct annual medical audits of each...

Section 14456.3. - 14456.3. (a) The department shall share with the Department of...

Section 14456.5. - 14456.5. (a) For purposes of this section, Medi-Cal managed care...

Section 14457. - 14457. In addition to the reviews required or authorized by...

Section 14458. - 14458. The prepaid health plan shall establish procedures for continuously...

Section 14459. - 14459. (a) The prepaid health plan shall maintain financial records...

Section 14459.5. - 14459.5. (a) As delegated by the federal government, the department...

Section 14459.6. - 14459.6. (a) The department shall establish a list of performance...

Section 14459.7. - 14459.7. (a) The department shall implement a Management Information System/Decision...

Section 14459.8. - 14459.8. (a) By no later than March 15, 2013, with...

Section 14460. - 14460. A schedule of reviews, visits, and audits shall be...

Section 14461. - 14461. Upon request by the department, each prepaid health plan...

Section 14462. - 14462. In accordance with Section 14081.5, the provisions of Section...

Section 14463. - 14463. (a) Except as otherwise provided in this chapter, each...

Section 14464. - 14464. (a) The department may negotiate and establish an individual...

ARTICLE 5.3 - Provision of Medical Care by Nonplan Providers to Enrollees of Prepaid Health Plans

Section 14465. - 14465. For purposes of this article and Section 14454, “emergency...

Section 14466. - 14466. The plan shall make a request to the department...

ARTICLE 6 - Conflict of Interest

Section 14475. - 14475. (a) No prepaid health plan or pilot program contract...

Section 14476. - 14476. The chief executive, sole proprietor, or managing partner of...

Section 14477. - 14477. (a) For purposes of this article, “state officer” means...

Section 14478. - 14478. (a) As used in this chapter, “substantial financial interest”...

Section 14479. - 14479. (a) No prepaid health plan or pilot program contract...

Section 14480. - 14480. No prepaid health plan or pilot program contract with...

Section 14481. - 14481. No prepaid health plan or pilot program contract shall...

Section 14482. - 14482. No prepaid health plan shall contract with any subcontractor...

ARTICLE 7 - Pilot Programs

Section 14490. - 14490. In providing benefits under this chapter and Chapter 7...

Section 14491. - 14491. The director shall pursue the feasibility of establishing the...

Section 14493. - 14493. The director shall also consider programs which demonstrate an...

Section 14494. - 14494. The director may enter into other contracts under this...

Section 14495. - 14495. In establishing pilot programs, the director may do the...

Section 14495.10. - 14495.10. (a) The department shall establish a pilot program to...

Section 14496. - 14496. (a) Alternate methods of payment for a pilot program...

Section 14497. - 14497. The director shall call a public hearing pursuant to...

Section 14499.5. - 14499.5. (a) (1) In carrying out the intent of this...

Section 14499.6. - 14499.6. (a) The Santa Barbara Regional Health Authority may arrange...

ARTICLE 8 - Medi-Cal At-Risk Fiscal Intermediaries

Section 14499.7. - 14499.7. The department may contract with one or more fiscal...

Section 14499.71. - 14499.71. For the purposes of this article, “fiscal intermediary” means...

Section 14499.73. - 14499.73. A contract entered into under this article shall provide...

Section 14499.74. - 14499.74. In determining the capitated rates to be paid to...

Section 14499.75. - 14499.75. A fiscal intermediary may contract for the provision of...

Section 14499.77. - 14499.77. All services, except those specified for exclusion by the...