ARTICLE 2.5. Physicians Costs [14075 - 14080.5]
( Article 2.5 added by Stats. 1976, Ch. 1207. )
The Legislature intends that Medi-Cal recipients have reasonable access to medical care services and especially to primary and maternity care services. In order to obtain such access, the Legislature intends that, to the extent feasible and permitted by federal law, physicians be reimbursed equally statewide for comparable services, at a rate sufficient to provide Medi-Cal recipients with such reasonable access, and also intends that higher rates be paid, relatively, for providing primary and maternity care services.
(Added by Stats. 1976, Ch. 1207.)
As used in this article:
(a) “Medically underserved area” means a county, standard metropolitan statistical area, or other area within the state in which the director determines that Medi-Cal recipients do not have access to an adequate number of physicians.
(b) “Primary care services” means those general medical services, as determined by the director, which are not performed on an emergency, referral, or consulting basis.
(c) “Maternity care services” are prenatal, postnatal,
perinatal, and neonatal services.
(Added by Stats. 1976, Ch. 1207.)
Notwithstanding any other provisions of this chapter the director shall establish, within 15 days of the effective date of this act a statewide, uniform schedule for reimbursing physician services to Medi-Cal patients provided on or after July 1, 1976; except that, the director may establish physician reimbursement rates higher than the statewide rates for; (a) areas which the director determines to be medically underserved: and (b) other problems of equity in payment levels which adversely affect the accessibility of physician services to Medi-Cal recipients. Nothing in this section shall be construed to prevent the director from adopting physician reimbursement rates for
primary care services and maternity care services which are relatively higher than the rates paid for other types of physician services.
(Added by Stats. 1976, Ch. 1207.)
The director shall establish, at the time he or she establishes the statewide rate for physician services required by Section 14077, a level of reimbursement for physician services which represents at least an average increase over the statewide average amounts paid under the Medi-Cal program for the three-month period ending February 29, 1976, of 9.5 percent for all physician services except primary care services and maternity care services; of 20 percent for primary care services; and of 30 percent for maternity care services.
(Added by Stats. 1976, Ch. 1207.)
(a) The director shall periodically review the reimbursement levels for physician and dental services in the Medi-Cal fee-for-service delivery system, and shall periodically revise the rates of reimbursement to physicians and dentists to the extent the director deems necessary to comply with applicable federal Medicaid program requirements, including provisions on reasonable access to physician and dental services for Medi-Cal beneficiaries.
(b) To the extent consistent with the department’s federally approved access monitoring plan, or any successor methodology for monitoring reasonable access to Medi-Cal covered services, as
described in Section 1396a(a)(30)(A) of Title 42 of the United States Code, this periodic review, as it relates to rates for physician services, shall take into account at least the following factors:
(1) Annual cost increases for physicians as reflected by the Consumer Price Index.
(2) Physician reimbursement levels under the Medicare Program.
(3) Prevailing customary physician charges within the state and in various geographical areas.
(4) Characteristics of the current population of Medi-Cal beneficiaries and the medical services needed.
(Amended by Stats. 2020, Ch. 12, Sec. 56. (AB 80) Effective June 29, 2020.)
Rates of reimbursement established pursuant to this chapter shall make no distinction based on whether a particular service is provided by a physician or a dentist. The director shall not reduce any rate of reimbursement for physician services in order to comply with this section.
(Added by Stats. 1981, Ch. 995, Sec. 1.)
(a) Notwithstanding any other provision of this chapter, reimbursement to providers for dental services provided to individuals 21 years of age or older at the time of services shall be limited to not more than one thousand eight hundred dollars ($1,800) per beneficiary in any calendar year, commencing January 1, 2006. This limitation shall not apply to any of the following:
(1) Emergency dental services within the scope of covered dental benefits defined as a dental condition
manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
(2) Services that are federally mandated under Part 440 (commencing with Section 440.1) of Title 42 of the Code of Federal Regulations, including pregnancy-related services and services for other conditions that might complicate the pregnancy.
(3) Dentures.
(4) Maxillofacial and complex oral surgery.
(5) Maxillofacial services, including dental implants and implant-retained prostheses.
(6) Services provided in long-term care facilities.
(b) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, provider bulletins, or similar instructions. No later than January 1, 2008, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(c) The department shall pursue any state plan amendment or other federal approval necessary in order to effectuate this section. This section shall be implemented only to the extent that federal financial participation is available.
(Amended by Stats. 2008, Ch. 758, Sec. 35. Effective September 30, 2008.)
Notwithstanding any other provision of this article, no increase in the reimbursement levels for physician and dental services under Medi-Cal shall be made for the period from July 1, 1982, to September 30, 1982, inclusive, except to the extent funds may be provided therefor by the Budget Act of 1982.
(Added by Stats. 1982, Ch. 115, Sec. 51. Effective March 13, 1982.)