Code Section Group

Welfare and Institutions Code - WIC

DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.8]

  ( Division 9 added by Stats. 1965, Ch. 1784. )

PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771]

  ( Part 3 added by Stats. 1965, Ch. 1784. )

CHAPTER 7. Basic Health Care [14000 - 14199.67]

  ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )

ARTICLE 2.95. Primary Care Provider Enrollment [14092 - 14092.35]
  ( Article 2.95 added by Stats. 1992, Ch. 722, Sec. 85. )

14092.
  

It is the purpose of this article to ensure that the Medi-Cal program is operated in the most cost-effective and efficient manner possible by assuring that beneficiaries have early and ongoing access to identified sources of quality primary care who have agreed to accept Medi-Cal patients. In so doing, it is intended to optimally realize the quality of care and health care financing benefits demonstrated by the experience of successful commercial managed care plans when patients affiliate with a single, specified primary care provider and management of patient care is placed within the control of the responsible primary care provider.

(Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

14092.05.
  

For purposes of this article “primary care provider” is defined as set forth in paragraph (1) of subdivision (a) of Section 14088.

(Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

14092.1.
  

The department shall seek all federal waivers necessary to allow federal financial participation in expenditures under this article.

(Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

14092.15.
  

The director shall investigate and may to the extent feasible require that:

(a) Primary care providers specify their capacity to accept Medi-Cal Patients and obtain a primary care provider project code under which fee-for-service Medi-Cal beneficiaries may enroll with the provider as their exclusive primary care source.

(b) Each primary care provider accept and enroll fee-for-service beneficiaries up to the provider’s specified capacity.

(c) Any managed care contractor serving children with conditions eligible under the California Children’s Services 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) 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. If the managed care contractor is paid according to a capitated or risk-based payment methodology, there shall be a separate actuarially sound rate 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) Beneficiaries enroll with or are assigned to a primary care provider who will be the exclusive source of fee-for-service primary care for the beneficiary. However, enrollment under this article shall be subordinated to any legal requirement that a beneficiary enroll in a Medi-Cal managed care plan contracting under this chapter or (Chapter 8 (commencing with Section 14200)).

(Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

14092.2.
  

The director may establish policy and procedures that assure that outpatient physician’s services, and any other Medi-Cal services the director may designate, provided by a source other than the primary care provider with whom a beneficiary is enrolled under this article, shall not be covered under the Medi-Cal program unless they are provided on an emergency basis or authorized by the responsible primary care provider.

(Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

14092.25.
  

In areas where a Medi-Cal beneficiary has the opportunity to enroll in a Medi-Cal managed care plan or to enroll with a primary care provider under this article, the director may require a beneficiary who is certified pursuant to subdivision (c) of Section 14016.5 that he or she has an established relationship with a provider, to enroll in a managed care plan, a pilot project, or a primary care provider under this article, if the beneficiary relies on care provided by hospital emergency departments for nonemergency care.

(Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

14092.3.
  

In implementing this article, the director has discretion to extend administrative or reimbursement flexibilities to participating primary care providers.

(Added by Stats. 1992, Ch. 722, Sec. 85. Effective September 15, 1992.)

14092.35.
  

To the extent that this article proves to be effective in reducing the cost of uncoordinated primary care delivered in the hospital emergency room or the costs of duplicative, unnecessary, or avoidable services, program savings may be shared with primary care providers who enroll beneficiaries under this article.

(Amended by Stats. 2006, Ch. 538, Sec. 704. Effective January 1, 2007.)

WICWelfare and Institutions Code - WIC2.95