California Welfare and Institutions Code ARTICLE 4 - The Medi-Cal Benefits Program

Section 14131.
The Medi-Cal Benefits Program comprises a department-administered uniform schedule of health care benefits. Notwithstanding any other provision of this chapter, “health care services” shall be...
Section 14131.05.
(a) Notwithstanding any other provision of this chapter or Chapter 8 (commencing with Section 14200), optional hearing aid benefits are subject to per beneficiary benefit cap...
Section 14131.10.
(a) Notwithstanding any other provision of this chapter, Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591), in order to implement changes...
Section 14131.11.
(a) Notwithstanding any other provision of this chapter or Chapter 8 (commencing with Section 14200), any increase in the amount charged to the Medi-Cal program for...
Section 14131.15.
(a) In geographic areas in which Medi-Cal managed care plans contracting under this chapter or Chapter 8 (commencing with Section 14200) are operating with capacity to...
Section 14132.
The following is the schedule of benefits under this chapter:(a) Outpatient services are covered as follows:Physician, hospital or clinic outpatient, surgical center, respiratory care, optometric, chiropractic,...
Section 14132.01.
(a) Notwithstanding any other provision of law, a community clinic or free clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety...
Section 14132.02.
(a) The department shall seek approval from the United States Secretary of Health and Human Services to provide individuals made eligible pursuant to Section 14005.60 with...
Section 14132.03.
(a) The following shall be covered Medi-Cal benefits effective January 1, 2014:(1) Mental health services included in the essential health benefits package adopted by the state pursuant...
Section 14132.05.
The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of their submittal to the federal Health Care Financing...
Section 14132.06.
(a) Services specified in this section that are provided by a local educational agency are covered Medi-Cal benefits, to the extent federal financial participation is available,...
Section 14132.07.
(a) A Medi-Cal managed care plan shall not restrict the choice of the qualified provider from whom a beneficiary enrolled in the managed care plan may...
Section 14132.1.
As used in this chapter “surgical center” means a surgical clinic that is licensed under Section 1203 of the Health and Safety Code. Pursuant to...
Section 14132.10.a.
(a) Pediatric day health care provided by a health facility licensed under paragraph (11) of subdivision (a) of Section 1250.1 of the Health and Safety Code...
Section 14132.100.a.
(a) The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.(b) The rural health clinic services...
Section 14132.101.
(a) Notwithstanding paragraphs (4) and (5) of subdivision (e) of Section 14132.100, a scope-of-service change request, whether mandatory or permissive, shall be timely when filed within...
Section 14132.102.
(a) With the exception of clinics and hospital outpatient departments that are subject to Section 14105.24, federally qualified health centers (FQHCs) that are receiving cost-based reimbursement...
Section 14132.107.
Claims for reimbursement under subdivision (e) of Section 14132.100 shall be finalized by the department within 150 days of receipt of the claims for reimbursement....
Section 14132.108.
Notwithstanding any other provision of law, requests for rate adjustments for scope-of-service rate changes under paragraph (4) of subdivision (e) of Section 14132.100 for an...
Section 14132.15.
For purposes of subdivision (p) of Section 14132, “rehabilitation services” means services intended to assist physically or cognitively impaired persons to achieve or regain their...
Section 14132.16.
Mammography for screening or diagnostic purposes upon the referral of a patient’s physician shall be covered under this chapter on or after January 1, 1988,...
Section 14132.17.
Annual cervical cancer tests for screening or diagnostic purposes, upon the referral of a patient’s physician, is a covered benefit under this chapter, on or...
Section 14132.18.
(a) Community supported living arrangement services approved by the United States Department of Health and Human Services in accordance with Section 1396v of Title 42 of...
Section 14132.19.
(a) (1) The department, in consultation with the State Department of Social Services, county mental health experts, managed care plan experts, behavioral health experts, child welfare experts,...
Section 14132.20.
(a) The department shall establish a program to provide continuous skilled nursing care to persons with developmental disabilities as a benefit of the Medi-Cal program, when...
Section 14132.21.
The department shall assess the feasibility of applying to the federal Health Care Financing Administration for a Medicaid State Plan amendment to provide targeted case...
Section 14132.22.
(a) For purposes of this section, dental restorative materials are limited to composite resin, glass ionomer cement, resin ionomer cement, and amalgam, as described on the...
Section 14132.23.
(a) (1) Except as set forth in paragraph (2), and notwithstanding any other provision of law or regulation, the active and retentive phases of orthodontic treatment covered...
Section 14132.24.
(a) The department shall develop and implement a program to provide a community-living support benefit to eligible Medi-Cal beneficiaries. The department shall submit any waiver application,...
Section 14132.25.
(a) On or before July 1, 1983, the State Department of Health Care Services shall establish a subacute care program in health facilities in order to...
Section 14132.26.
(a) The department shall develop a program that requires a waiver of federal law to test the efficacy of providing an assisted living benefit to beneficiaries...
Section 14132.27.
(a) (1) The department shall apply for a waiver of federal law pursuant to Section 1396n of Title 42 of the United States Code to test the...
Section 14132.275.
(a) The department shall seek federal approval to establish the demonstration project described in this section pursuant to a Medicare or a Medicaid demonstration project or...
Section 14132.276.
For nursing facility services provided under the demonstration project as established in Section 14132.275, to the extent these provisions are authorized under the memorandum of...
Section 14132.277.
(a) For purposes of this section, the following definitions apply:(1) “Alternate health care service plan” means a prepaid health plan that is a nonprofit health care service...
Section 14132.28.
(a) If the department decides to terminate or not renew a health facility’s subacute care services provider contract, the department shall notify the health facility 30...
Section 14132.29.
(a) A health facility that has a subacute services provider contract with the department under this chapter shall comply with the patient transfer and discharge requirements...
Section 14132.3.
In addition to any other criteria as provided in subdivision (p) of Section 14132, no reimbursement shall be made pursuant to this chapter for any...
Section 14132.34.
(a) Human milk and human milk derivatives supplied by a mothers’ milk bank for human consumption are a covered service under this chapter.(b) For purposes of this...
Section 14132.35.
(a) Outpatient rehabilitation services are covered under this chapter, subject to utilization controls.(b) The department and the Medi-Cal field offices shall not discriminate against elderly recipients in...
Section 14132.39.
Midwifery services provided by a licensed midwife shall be covered under this chapter, to the extent that federal financial participation is available, and, subject to...
Section 14132.4.
Nurse-midwifery services provided by a certified nurse-midwife shall be covered under the provisions of this chapter, to the extent required by federal law, subject to...
Section 14132.41.
(a) Services provided by a certified nurse practitioner shall be covered under this chapter to the extent authorized by federal law, and subject to utilization controls....
Section 14132.42.
Benefits under this chapter shall not be restricted for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery...
Section 14132.44.
(a) Targeted case management (TCM), pursuant to Section 1915(g) of the Social Security Act as amended by Public Law 99-272 (42 U.S.C. Sec. 1396n(g)), shall be...
Section 14132.45.
Regulations implementing, interpreting, or making specific the provisions of subdivision (z) of Section 14132 shall not be subject to Chapter 3.5 (commencing with Section 11340)...
Section 14132.46.
Pursuant to Sections 14024 and 14124.90, the Director of Health Services may recover for the cost of targeted case management services rendered under Section 14132.44...
Section 14132.47.
(a) It is the intent of the Legislature to provide local governmental agencies the choice of participating in either or both of the Targeted Case Management...
Section 14132.48.
Targeted case management services to which Sections 14132.44 and 14132.47 does not apply, and as specified in Section 1915(g) of the federal Social Security Act,...
Section 14132.49.
(a) Upon federal approval of the state plan amendments made pursuant to Section 14021.7 for federal financial assistance, targeted case management, pursuant to subdivision (g) of...
Section 14132.55.
For the purposes of reimbursement under the Medi-Cal program, a speech pathologist or audiologist shall be licensed by the Speech-Language Pathology and Audiology Examining Committee...
Section 14132.56.
(a) (1) Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT) shall be...
Section 14132.6.
External prostheses constructed of silicon or other comparable materials, prosthetic implants, and reconstructive surgery incident to mastectomy shall be deemed medically necessary and shall be...
Section 14132.62.
(a) Reconstructive surgery shall be covered under this chapter, as defined in subdivision (c), when necessary to achieve the purposes specified in paragraphs (1) or (2)...
Section 14132.63.
(a) An orthotist or prosthetist providing services under this chapter shall be required to be certified in orthotics or prosthetics by either the Board for Orthotist...
Section 14132.69.
(a) Notwithstanding any other provision of law, donor and recipient organ transplant surgeries are covered under the Medi-Cal program when an organ transplant is provided to...
Section 14132.70.
(a) A Medi-Cal beneficiary shall remain eligible to receive Medi-Cal coverage for antirejection medication for up to two years following an organ transplant, unless during that...
Section 14132.71.
(a) For purposes of donor and recipient organ transplant surgeries, the department shall establish standards as to both the circumstances and the criteria that the department...
Section 14132.72.
(a) For purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply.(b) It is the intent of...
Section 14132.725.
(a) To the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal...
Section 14132.73.
The State Department of Health Care Services shall allow psychiatrists to receive fee-for-service Medi-Cal reimbursement for services provided through telehealth in accordance with the Medicaid...
Section 14132.74.
(a) The department, in consultation with interested stakeholders, shall develop, as a pilot project, a pediatric palliative care benefit to evaluate whether, and to what extent,...
Section 14132.75.
(a) In enacting this section, it is the intent of the Legislature that palliative care include, but not be limited to, all of the following:(1) Specialized medical...
Section 14132.765.
(a) No treatment authorization request shall be required for the provision of prosthetic devices or for the replacement or repair of prosthetic devices, if the cost...
Section 14132.77.
(a) (1) Any rural hospital may request to participate in a two-year pilot project to perform delegated acute inpatient hospital treatment authorization review under the Medi-Cal program.(2) Any...
Section 14132.8.
Services covered under this chapter shall include rehabilitative services for the physically or cognitively impaired stroke patient, or a patient who has brain injury for...
Section 14132.81.
(a) The purchase of identification bracelets for eligible recipients under the Medi-Cal program who have Alzheimer’s Disease or some other cognitive defect, or medication allergies that...
Section 14132.86.
(a) Notwithstanding subdivision (ab) of Section 14132, effective May 1, 2014, purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral...
Section 14132.88.
(a) Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made available in the annual Budget Act for this purpose, the following are...
Section 14132.89.
(a) Notwithstanding subdivision (h) of Section 14132, effective May 1, 2014, or the effective date of any necessary federal approvals as required by subdivision (d), all...
Section 14132.9.
Notwithstanding subdivision (h) of Section 14132, any utilization controls imposed under such subdivision shall not include mandatory examination by any person not licensed as a...
Section 14132.905.
(a) Day care habilitative services, pursuant to subdivision (c) of Section 14021, shall be provided only to alcohol- and drug-exposed pregnant women and women in the...
Section 14132.91.
(a) Subject to the availability of funding, the department shall conduct a dental outreach and education program for Medi-Cal beneficiaries. The program shall inform Medi-Cal beneficiaries...
Section 14132.915.
(a) (1) The department shall establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required by the department. The...
Section 14132.92.
(a) Notwithstanding subdivision (a) of Section 4512, or any other provision of this chapter or Chapter 8 (commencing with Section 14200), services provided on or after...
Section 14132.925.
(a) (1) Notwithstanding any other provision of law or regulation to the contrary, to the extent federal financial participation is available, in furtherance of Section 14105.06 and...
Section 14132.93.
It is the intent of the Legislature that if services meeting the conditions of subdivision (a) of Section 14132.92 have been provided to a Medi-Cal...
Section 14132.94.
(a) Subject to approval by the Centers for Medicare and Medicaid Services of a medicaid state plan amendment electing the Programs of All-Inclusive Care for the...
Section 14132.95.
(a) Personal care services, when provided to a categorically needy person as defined in Section 14050.1 is a covered benefit to the extent federal financial participation...
Section 14132.951.
(a) It is the intent of the Legislature that the State Department of Health Services seek approval of a Medicaid waiver under the federal Social Security...
Section 14132.952.
(a) The department shall seek approval of an amendment to the Medicaid state plan pursuant to Section 1396n(j) of Title 42 of the United States Code...
Section 14132.955.
Personal care services that are provided pursuant to Section 14132.95 shall include services in the recipient’s place of employment if both of the following conditions...
Section 14132.956.
(a) The department shall assess and determine whether it would be cost efficient for the state to exercise the option made available under Section 1915(k) of...
Section 14132.96.
Medi-Cal personal care services provider rates established as provided in the state plan under Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title...
Section 14132.966.
(a) Services provided by a physician assistant are a covered benefit under this chapter to the extent authorized by federal law and subject to utilization controls.(b) Subject...
Section 14132.968.
(a) (1) Pharmacist services are a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services.(2) The department shall establish a...
Section 14132.97.
(a) (1) For purposes of this section, “waiver personal care services” means personal care services authorized by the department for persons who are eligible for either nursing...
Section 14132.98.
(a) For a beneficiary diagnosed with cancer and accepted into a phase I, phase II, phase III, or phase IV clinical trial for cancer, the Medi-Cal...
Section 14132.985.
For services provided pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9, Section 14499.5, or Chapter 1 (commencing with Section...
Section 14132.99.
(a) For the purposes of this section, “facility residents” means individuals who are currently residing in a nursing facility and whose care is paid for by...
Section 14132.991.
(a) When renewing the Nursing Facility/Acute Hospital Transition and Diversion Waiver, as authorized by subdivision (t) of Section 14132, the director may take the following actions,...
Section 14132.992.
(a) (1) By March 15, 2011, the department shall submit to the federal Centers for Medicare and Medicaid Services a home- and community-based services waiver application pursuant...
Section 14132aa.
(a) Services provided by facilities licensed as congregate living health facilities to individuals diagnosed as having acquired immune deficiency syndrome (AIDS), are a covered benefit under...
Section 14133.
Utilization controls that may be applied to the services set forth in Section 14132 which are subject to utilization controls shall be limited to:(a) Prior authorization,...
Section 14133.01.
(a) Notwithstanding any other law, the director or his or her designee may apply prior authorization by designing a sampling methodology that will result in a...
Section 14133.05.
(a) Notwithstanding any other provision of law, a request for a treatment authorization received by the department shall be reviewed for medical necessity only.(b) Any claim for...
Section 14133.07.
(a) Prior authorization for podiatric services provided on an outpatient or inpatient basis shall not be required when all of the following conditions are met:(1) The services...
Section 14133.1.
(a) The director shall determine which of the utilization controls in Section 14133 shall be applied to any specific service or group of services which are...
Section 14133.10.a.
(a) Where it is expected to be cost-effective, the director may, in conducting Medi-Cal acute care inpatient hospital utilization control, establish a program of aggressive case...
Section 14133.12.
(a) The director shall apply utilization controls to continuous skilled nursing care services provided pursuant to the pilot program established under Section 14495.10, including, but not...
Section 14133.14.
The criteria that the department shall use to identify providers to be placed on prior authorization for noninvasive testing procedures shall include, but not be...
Section 14133.15.
(a) The provision of services to beneficiaries eligible for medical assistance benefits may be subject to utilization controls, as provided for in Section 50793 of Title...
Section 14133.16.
(a) Notwithstanding subdivision (l) of Section 14132, hearing aids are covered when supplied by a hearing aid dispenser on prescription of an otolaryngologist, or the attending...
Section 14133.2.
(a) The director shall include in the Medi-Cal list of contract drugs any drug approved for the treatment of cancer by the federal Food and Drug...
Section 14133.22.
(a) Prescribed drugs shall be limited to no more than six per month, unless prior authorization is obtained.(b) The limit in subdivision (a) shall not apply to...
Section 14133.225.
Notwithstanding any other law, the department shall not provide or pay for any prescription drug or other therapy to treat erectile dysfunction for any person...
Section 14133.23.
(a) To the extent that federal financial participation is not available, the provision of drug benefits under this chapter to full-benefit dual eligible beneficiaries who are...
Section 14133.25.
(a) The director shall identify those surgical and medical procedures capable of outpatient performance and establish conditions for assuring performance in an outpatient rather than inpatient...
Section 14133.3.
(a) The director shall require fully documented medical justification from providers that the requested services are medically necessary to prevent significant illness, to alleviate severe pain,...
Section 14133.37.
For drugs covered under this chapter requiring prior authorization, the department shall ensure the timely and efficient processing of authorization requests by doing all of...
Section 14133.4.
Notwithstanding any other provision of law, utilization controls adopted by the State Department of Health Services shall not include prior authorization for portable X-ray services...
Section 14133.45.
(a) Utilization controls adopted by the department shall not include prior authorization for renal dialysis treatment provided to eligible recipients for the treatment of end stage...
Section 14133.6.
In acting upon prior authorization requests for nonemergency medical transportation services, the department shall consider all relevant information in its possession regarding the beneficiary for...
Section 14133.65.
Prior authorization for the use of nonemergency medical transportation services by patients to and from dialysis treatment shall be approved for a period of up...
Section 14133.7.
The department shall not require emergency certification statements for hospital inpatient claims which have been reviewed and approved by the department for appropriateness of emergency...
Section 14133.8.
(a) A bone marrow transplant for the treatment of cancer for beneficiaries who are eligible for full-scope benefits under this chapter, shall be reimbursable under this...
Section 14133.85.
(a) (1) Except as otherwise provided in this subdivision, prior authorization shall not be required for hospice services.(2) Paragraph (1) shall not apply to any admission which violates...
Section 14133.9.
The implementation of prior authorization permitted by subdivision (a) of Section 14133 shall be subject to all of the following provisions:(a) The department shall secure a...
Section 14134.
(a) Except for any prescription, refill, visit, service, device, or item for which the program’s payment is ten dollars ($10) or less, in which case no...
Section 14134.1.
(a) Except as provided in paragraph (2) of subdivision (a) of Section 14134, no provider under this chapter may deny care or services to an individual...
Section 14134.2.
The reimbursement rate for any three or more laboratory services for the same patient on the same day, which are commonly performed in an automated...
Section 14134.25.
(a) Tobacco cessation services are covered benefits under the Medi-Cal program, subject to utilization controls. Tobacco cessation services shall include all intervention recommendations, as periodically updated,...
Section 14134.5.
All of the following provisions apply to the provision of services pursuant to subdivision (u) of Section 14132:(a) “Comprehensive perinatal provider” means any general practice physician,...
Section 14134.55.
The department shall streamline and simplify existing Medi-Cal program procedures in order to improve access to lactation supports and breast pumps among Medi-Cal recipients.(Added by...
Section 14134.6.
Long-term health care facilities may charge a resident only the actual price paid by the facility for goods and services actually supplied to the resident...
Section 14135.
To assure maximum federal financial participation under this chapter, the director shall establish an enrollment fee, premium or similar charge to the extent required by...
Section 14136.
(a) No city or county shall establish equipment and personnel standards for the furnishing of nonemergency medical transportation services for eligible Medi-Cal beneficiaries which are in...
Section 14136.1.
It is the intent of the Legislature that, in order for payment to be made to a medical transportation service provider, a patient who requires...
Section 14136.3.
No prior authorization shall be necessary for the provision of nonemergency medical transportation services to Medi-Cal beneficiaries when the beneficiary is being transported from an...
Section 14136.4.
A written treatment authorization request for nonemergency medical transportation services for which a department employed medical consultant had provided conditional prior authorization to the provider...
Section 14136.5.
No entity which has received funds under paragraph (2) of subsection (b) of Section 1601 of the federal Urban Mass Transportation Act shall receive reimbursement...
Section 14136.8.
No reimbursement shall be made for medical transportation services provided pursuant to subdivision (i) of Section 14132 when the services are prescribed or ordered by...
Section 14137.
The State Department of Health Services, following review and approval from the State Health and Welfare Agency, shall seek all necessary waivers from the United...
Section 14137.6.
(a) Notwithstanding any other provision of law, and subject to federal financial participation, covered services under this chapter shall include, subject to utilization controls, medically necessary...
Section 14137.8.
Approval of a request for acute inpatient care shall be solely dependent upon the medical necessity for this care, as documented in the proposed treatment...
Section 14138.
(a) To the extent permitted by federal law, the department shall purchase vaccines and biological products in bulk from the Centers for Disease Control or any...

Last modified: October 22, 2018