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.)
Last modified: October 25, 2018