Unless the context otherwise requires, the definitions set forth in this article govern the construction of this chapter.

For purposes of this chapter, “categorically needy person” means a person whose coverage is mandatory under Title XIX of the Social Security Act including, but not limited to, the individuals covered pursuant to Section 1396a(a)(10)(A)(i) of Title 42 of the United States Code.

For the purposes of this chapter “aid” means financial assistance provided to or in behalf of needy persons under the provisions of Chapters 2 (commencing with Section 11200), 3 (commencing with Section 12000), and 5 (commencing with Section 13000) of this part.

“A person in long-term care” means a person who is an inpatient in a medical facility for more than the month of admission who is expected to remain for the full month after the month of admission.

“Post-eligibility treatment of income” means the determination of long-term care patient liability for each month in which the patient is described in Section 14050.3 or as an institutionalized spouse described in Section 14002.5 determined in accordance with Section 435.725 of Title 42 of the Code of Federal Regulations, without regard to paragraph (1) of subsection (b) of that section, and Sections 435.832, and 435.845 of Title 42 of the Code of Federal Regulations, as appropriate.

“Long-term care patient liability” is the term given to the result of the post-eligibility treatment of income calculation under Section 14051.7. The person in long-term care or an institutionalized spouse shall incur or expect to incur an amount of medical expenses that equal this amount pursuant to subdivision (d) of Section 14005.12.

“State-only Medi-Cal person” means a person who resides in a nursing facility or any category of intermediate care facility for the developmentally disabled, and who meets all of the following requirements:

“Cuban-Haitian entrant or refugee” means a person eligible under the Cuban-Haitian Entrant Program or Refugee Resettlement Program, as defined in federal regulations.

screening, diagnosis, and treatment for any individual under 21 years of age.

services provided to individuals 21 to 64 years of age, inclusive, in an institution for mental diseases operating under a consolidated license with a general acute care hospital pursuant to Section 1250.8 of the Health and Safety Code, unless federal financial participation is available for such inpatient services.

Notwithstanding Section 14053, ancillary outpatient services, pursuant to Section 14132, for any eligible individual who is 21 years of age or over, and has not attained 65 years of age and who is a patient in an institution for mental diseases shall be covered regardless of the availability of federal financial participation.

counties are financially responsible for specialty mental health services and related ancillary services provided to persons through county mental health programs when Medi-Cal reimbursement is not available, when it is determined that Medi-Cal reimbursement has been paid for ancillary services for residents of IMDs, both the federal financial participation reimbursement and any state funds paid for the ancillary services provided to residents of IMDs shall be recovered from counties by the department in accordance with applicable state and federal statutes and regulations.

For the purposes of the Medi-Cal Act, the terms “prescribed drug” and “prescription drug” shall not include any drug which, because of differing prices charged by the manufacturer on a discriminatory basis or discriminatory refusal to sell by the manufacturer, or both, is not available on the same terms and conditions to all providers of prescription services, or any drug which is found to be overpriced in comparison to another drug which has an equivalent therapeutic effect, unless the director determines that the drug is vital to the program and no acceptable substitute is available.

Before the director determines that any drug has an equivalent therapeutic effect in comparison to another drug, or is vital to the program and no acceptable substitute is available, he must have received a report to that effect from the Medi-Cal Contract Drug Advisory Committee.

Nothing in this section shall be construed to apply to quantity or other nondiscriminatory discounts available on the same terms and conditions to all providers of prescription services, to sales by competitive bidding to federal, state or local governmental agencies, or to sales to wholesalers so long as the manufacturer does not require or induce the wholesalers to make the drug available other than on the same terms and conditions to all providers of prescription services.

This section shall not be construed to deny reimbursement to hospitals for prescribed drugs furnished to inpatients or, unless the

regulations provide to the contrary, to registered outpatients.

Prior to including or excluding any drug from the program, the director shall give adequate notice to those California associations of health professionals and those recognized national associations of pharmaceutical manufacturers that are affected by such action and shall seek and consider the advice of those associations.

inmates made eligible for services under this section or in accordance with Section 5072 of the Penal Code from Medi-Cal managed care health plans, and may exempt inmates from enrollment into new or existing plans.

incarcerated in county facilities and who are otherwise eligible for Medi-Cal pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9, the county shall be responsible for the nonfederal share of the reimbursement.

if and to the extent that existing levels of federal financial participation are not otherwise jeopardized. To the extent that the department determines that existing levels of federal financial participation are jeopardized, this section shall no longer be implemented.

this section or in accord with Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the hospitals used to provide acute inpatient hospital services to inmates.

terms have the following meanings:

section

shall not be construed to alter or abrogate any obligation of the state pursuant to an administrative action or a court order that is final and no longer subject to appeal to reimburse counties for any acute inpatient hospital services or inpatient psychiatric services provided to a juvenile inmate.

shall consult with counties in the development of the process pursuant to this section.

section. This section shall be implemented only if and to the extent that any necessary federal approvals have been obtained, and only to the extent that federal financial participation is available.

services and inpatient psychiatric services provided to eligible juvenile inmates described in subdivision (a).

this section that is inconsistent with the final judicial or CMS determination shall have no force or effect.

are admitted as inpatients in a medical institution off the grounds of the correctional facility, and who, but for their institutional status as juvenile inmates, are otherwise eligible for Medi-Cal benefits pursuant to this chapter. This process shall be coordinated, to the extent possible, with the processes and procedures established pursuant to Section 14053.7 of this code and Section 5072 of the Penal Code.

administration of this section and the nonfederal share of expenditures for acute inpatient hospital services and inpatient psychiatric services provided off the grounds of the correctional facility to any juvenile inmate of the Division of Juvenile Facilities who is eligible for Medi-Cal benefits pursuant to this section.

court of appellate jurisdiction that is not further appealed, in any action by any party, or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services (CMS), that disallows, defers, or alters the implementation of this section or, to the extent applicable, Section 14053.7 of this code or Section 5072 of the Penal Code, including the rate methodology or payment process established by the department that limits or affects the department’s authority to select the facilities used to provide acute inpatient hospital services and inpatient psychiatric services to juvenile inmates in the Division of Juvenile Facilities, then any provision of this section that is inconsistent with the final judicial or CMS determination shall have no force or effect.

determination.

certified by the department as specified in Section 14018.

“Elective services” means any treatment service which generally can be postponed without seriously affecting the health of the person requiring the service.

identified in paragraph (1), even after the marriage is terminated by death or divorce or the domestic partnership has been legally terminated.

“Minimum coverage” means prescribed drugs for public assistance recipients as established by the director, and care or coverage specified in paragraphs (1), (2), (3), (4), (5), and (10) of Section 14053, except that it shall not include elective services.

100500) of the Government Code, with advance payment of the premium tax credit established under Section 36B of the Internal Revenue Code.

“Contract hospital” means a nonprofit medical facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, with which the board of supervisors of a county which does not maintain a county hospital has executed a contract, currently in effect, to care for medically indigent individuals.

Health care provided under this chapter may include diagnostic, preventive, corrective, and curative services and supplies essential thereto, provided by qualified medical and related personnel for conditions that cause suffering, endanger life, result in illness or infirmity, interfere with capacity for normal activity including employment, or for conditions which may develop into some significant handicap.

Medical care shall include, but is not limited to, other remedial care, not necessarily medical. Other remedial care shall include, without being limited to, treatment by prayer or healing by spiritual means in the practice of

the religion of any church or religious denomination.

medical necessity standard for coverage for individuals under 21 years of age is accurately reflected in all materials.

behavioral health delivery system, as defined in subdivision (i) of Section 14184.101.

Every recipient who is entitled to visual care under this chapter, which may be rendered either by an optometrist or a physician, may select a duly licensed member of either profession to render the service.

As used in this chapter, “director” means the State Director of Health Services.

As used in this chapter, “department” means the State Department of Health Services.

As used in this chapter, “Medi-Cal” means the California Medical Assistance Program.

As used in this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7 (commencing with Section 14520) of this part, the terms “Director of Health” and “Director of Benefit Payments” shall be construed to refer to and mean the State Director of Health Services.

As used in this chapter, Chapter 8 (commencing with Section 14200), Chapter 8.5 (commencing with Section 14500), and Chapter 8.7 (commencing with Section 14520) of this part, the terms “Department of Health,” “State Department of Health,” “Department of Benefit Payments,” and “State Department of Benefit Payments” shall be construed to refer to and mean the State Department of Health Services.

with, various entities and programs that serve children, including, but not limited to, the State Department of Education, counties, Women, Infants, and Children program agencies, Head Start and Healthy Start programs, and community-based organizations that deal with potentially eligible families and children to assist in the outreach, education, and application completion process. The department shall implement the campaign if funding is provided for this purpose by an appropriation in the annual Budget Act or other statute.

or the Healthy Families Program, proxy measures for rates of eligible children may be used. These measures may include, but are not limited to, the number of children in families with gross annual household incomes at or below the federal poverty levels pertinent to the programs.

(ii) Ability to work effectively with populations that have disproportionately low enrollment rates.

(iii) Organizational experiences in helping families learn about, and enroll in, the Medi-Cal program and Healthy Families Program. Organizations that do not have experience helping families learn about, and enroll in, the

Medi-Cal program and Healthy Families Program shall be eligible only to the extent that they support and collaborate with the outreach and enrollment activities of entities with that experience.

(C) Effectiveness of the outreach and education plan, including, but not limited to, all of the following:

(ii) Strategies to identify and address barriers to enrollment, such as transportation limitations and community perceptions regarding the Medi-Cal program and Healthy Families Program.

(iii) Coordination with other outreach efforts in the community, including the statewide Healthy Families Program and Medi-Cal program outreach campaign, the state and federally funded county

Medi-Cal outreach program, and any other Medi-Cal program and Healthy Families Program outreach projects in the target community.

(iv) Collaboration with other local organizations that serve families of eligible children.

(vi) Plans to inform families about all available health care programs and services.

program, and the highest number of Medi-Cal program and Healthy Families Program cases for children. This number shall be weighted to emphasize those who appear eligible, but are not currently enrolled in the programs.

paragraph (2). The director shall establish the procedures and format for submission to the department of all county allocation plans.

following:

(ii) The current application, enrollment, retention, and utilization activities.

(iii) How the allocation funds awarded under this section will be used to supplement and not supplant existing application, enrollment, retention, and utilization activities.

(E) A detailed proposed budget of all expenditures for the relevant fiscal year or years for the county’s outreach and enrollment plan activities, expenses, services, materials, and support.

the department, on the progress made in achieving the objectives of the allocation plan.

Managed Risk Medical Insurance Board shall seek approval of any amendments to the state plan necessary to implement this section for purposes of funding under Titles XIX and XXI of the federal Social Security Act (42 U.S.C. Secs. 1396 et seq. and 1397aa et seq., respectively). This section shall be implemented only when federal approvals have been obtained and only to the extent federal financial participation is available.

The department shall encourage counties to outstation additional Medi-Cal eligibility workers in nontraditional sites, such as schools, private hospitals, clinics, mental health centers, sites providing services under California Supplemental Food Program for Women, Infants, and Children sites, and community-based organizations. The department shall permit counties to redirect a portion of existing funding for Medi-Cal eligibility administration for this purpose. The department shall require counties that redirect funds to provide an annual report on the cost of

the additional outstationed workers and their effectiveness in increasing or facilitating Medi-Cal enrollment. Expenditures under this section shall be subject to the availability of federal financial participation, and shall not cause an increase in the allocation of funds for the administration of the Medi-Cal program.

In conducting outreach activities for the enrollment of special needs populations into a Medi-Cal managed care program, the department and its contractors, as deemed applicable by the department, shall work with state, local, and regional organizations with the ability to target low-income seniors and individuals with disabilities in the communities where they live. This shall include, but not be limited to, all applicable state departments that serve these individuals, regional centers, seniors’ organizations, local health consumer centers, and other

consumer-focused organizations that are engaging in providing assistance to this population.