Article 3 - Administration

California Welfare and Institutions Code — §§ 14100-14124.16

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Sections (194)

Repealed and added by Stats. 1965, 2nd Ex. Sess., Ch. 4.

The administration of this chapter shall be carried out by the same agents as are authorized by the several boards of supervisors to administer the public assistance programs.

§ 14100.1

Amended by Stats. 1978, Ch. 429.

For purposes of administering this chapter and Chapter 8 (commencing with Section 14200) of this part, the director shall have those powers and duties necessary to conform to requirements for securing approval of a state plan under the provisions of the applicable federal law, and the department shall be the single state agency for purposes of Title XIX of the federal Social Security Act.

§ 14100.2

Amended by Stats. 2008, Ch. 673, Sec. 4. Effective January 1, 2009.

(a)Except as provided in subdivision (i), all types of information, whether written or oral, concerning a person, made or kept by any public officer or agency in connection with the administration of any provision of this chapter, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520) and for which a grant-in-aid is received by this state from the United States government pursuant to Title XIX of the Social Security Act shall be confidential, and shall not be open to examination other than for purposes

directly connected with the administration of the Medi-Cal program. However, in the context of a petition for the appointment of a conservator for a person with respect to whom this information is made or kept, and in the context of a criminal prosecution for a violation of Section 368 of Penal Code with respect to such a person, all of the following shall apply:

A public officer or employee of any such agency may answer truthfully, at any proceeding related to the petition or prosecution, when asked if he or she is aware of information that he or she believes is related to the legal mental capacity of that aid recipient or the need for a conservatorship for that aid recipient. If the officer or employee states that he or she is aware of this information, the court may order the officer or employee to testify about his or her observations and to disclose any relevant agency records if the court has an other independent reason to believe that the officer or employee

has information that would facilitate the resolution of the matter.

(b)Except as provided in this section, and to the extent permitted by federal law or regulation, all information about applicants and recipients as provided for in subdivision (a) to be safeguarded includes, but is not limited to, names and addresses, medical services provided, social and economic conditions or circumstances, agency evaluation of personal information, and medical data, including diagnosis and past history of disease or disability.

(c)Purposes directly connected with the administration of the Medi-Cal program, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520) encompass those administrative activities and responsibilities in which the department and its agents are required to engage to insure effective program operations. These activities include, but are

not limited to: establishing eligibility and methods of reimbursement; determining the amount of medical assistance; providing services for recipients; conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the Medi-Cal program; and conducting or assisting a legislative investigation or audit related to the administration of the Medi-Cal program.

(d)Any officer, agent, or employee of the department or of any public agency shall provide the Joint Legislative Audit Committee and the State Auditor with any and all the information described in subdivision (b) within a reasonable period of time as determined by the committee in consultation with the department, after receipt of a request from the committee approved by a majority of the members of the committee. The Joint Legislative Audit Committee and the State Auditor may use that information only for the purpose of investigating or

auditing the administration of the Medi-Cal program, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520), and shall not use that information for commercial or political purposes. In any case where disclosure of information is authorized by this section, the Joint Legislative Audit Committee or the State Auditor shall not disclose the identity of any applicant or recipient, except in the case of a criminal or civil proceeding conducted in connection with the administration of the Medi-Cal program.

(e)The access to information provided in subdivision (d) shall be permitted only to the extent and under the conditions provided by federal law and regulations governing the release of such information.

(f)The department may make rules and regulations governing the custody, use, and preservation of all records, papers, files, and communications

pertaining to the administration of the laws relating to the Medi-Cal program, Chapter 8 (commencing with Section 14200), or Chapter 8.7 (commencing with Section 14520). The rules and regulations shall be binding on all departments, officials, and employees of the state, or of any political subdivision of the state and may provide for giving information to or exchanging information with agencies, public, or political subdivisions of the state, and may provide for giving information to or exchanging information with agencies, public or private, which are engaged in planning, providing, or securing such services for or in behalf of recipients or applicants; and for making case records available for research purposes, provided that that research will not result in the disclosure of the identity of applicants for or recipients of those services.

(g)Upon request, the department shall release to the negotiator established pursuant to Article 2.6

(commencing with Section 14081) all computer tapes and any modifications thereto, including paid claims, connected with the administration of the Medi-Cal program which are in the possession or under the control of the department, including tapes prepared prior to the effective date of this section.

To ensure compliance with federal law and regulations, the department shall make the minimum necessary modifications to its computer tapes prior to releasing the tapes to the negotiator in order to assure the confidentiality of the identity of all applicants for, or recipients of, those services. The department shall not make any modifications to paid claims tapes that affect information regarding beneficiaries’ aid categories or counties of origin.

(h)Any person who knowingly releases or possesses confidential information concerning persons who have applied for or who have been granted any form of

Medi-Cal benefits or benefits under Chapter 8 (commencing with Section 14200) or Chapter 8.7 (commencing with Section 14520) for which state or federal funds are made available in violation of this section is guilty of a misdemeanor.

(i)(1) To the extent federal funds are made available from the United States Department of Agriculture, the department may do both of the following:

(A) To the extent permitted by federal law, exercise its option under Section 1396a(a)(7)(B) of Title 42 of the United States Code, in coordination with the State Department of Education, to exchange the information necessary to perform direct verification of the eligibility of children for free or reduced price meals.

(B) To the extent permitted by federal law, in coordination with the State Department of Education,

exchange the information necessary to perform direct certification for enrolling children to receive free or reduced price meals.

(2)To the extent permitted by state and federal law, the department and the State Department of Education may review the data only for the purposes of improving the effectiveness of the data matches made pursuant to Sections 49561 and 49562 of the Education Code.

§ 14100.3

Added by Stats. 2013, Ch. 23, Sec. 56. (AB 82) Effective June 27, 2013.

(a)The State Department of Health Care Services shall post on its Internet Web site all submitted state plan amendments and all federal waiver applications and requests for new waivers, waiver amendments, and waiver renewals and extensions, within 10 business days from the date the department submits these documents for approval to the federal Centers for Medicare and Medicaid Services (CMS).

(b)The department shall post on its Internet Web site final approval or denial letters and accompanying documents for all submitted state plan amendments and federal waiver applications and requests within 10 business days from the date the department receives notification of final approval or denial from

CMS.

(c)If the department notifies CMS of the withdrawal of a submitted state plan amendment or federal waiver application or request, as described in subdivisions (a) and (b), the department shall post on its Internet Web site the withdrawal notification within 10 business days from the date the department notifies CMS of the withdrawal.

(d)Unless already posted on the Internet Web site pursuant to subdivisions (a) to (c), inclusive, the department shall post on its Internet Web site all pending submitted state plan amendments and federal waiver applications and requests, that the department submitted to CMS in 2009 and every year thereafter.

§ 14100.5

Repealed (in Sec. 133) and added by Stats. 2023, Ch. 42, Sec. 134. (AB 118) Effective July 10, 2023. Operative July 1, 2023, by its own provisions.

(a)The department shall prepare and submit Medi-Cal program assumptions and estimates to the Department of Finance. The purpose of the assumptions and estimates shall be to clearly identify changes within the Medi-Cal program which have policy or fiscal implications, and to produce reliable forecasts of Medi-Cal expenditures.

(b)(1) Beginning with the estimates for the 2024–25 fiscal year, Medi-Cal program assumptions and estimates shall be organized by and correspond to Budget Act or Budget Bill item numbers, separately identifying expenditures for all of the following:

(A) Purchase of medical care and services.

(B) County and other local assistance administration.

(2)Estimates and assumptions shall indicate state and federal, as well as total, funds expended.

(c)The department shall submit, by September 10 and March 1 of each year, to the Department of Finance for its approval, all assumptions underlying all Medi-Cal program estimates. The Department of Finance shall approve or modify, in writing, the assumptions underlying all estimates within 15 working days of their receipt. If the Department of Finance does not so approve or modify the assumptions by that date, the assumptions, as presented by the department, shall be deemed to be approved by the Department of Finance as of that date.

(d)The department shall submit an estimate of Medi-Cal program expenditures to the Department of Finance by November 1 and April 20 of each year. All approved estimates and supporting data provided by the department or developed independently by the Department of Finance, shall be made available to the legislative fiscal committees following approval by the Department of Finance. However, departmental estimates with supporting data shall be forwarded to the legislative fiscal committees on or about January 10 and May 15 of each year in the event this information has not been released earlier.

(e)Each Medi-Cal assumption shall contain a clear narrative description of the statutory, regulatory, or policy change, or other change, that has occurred or will occur which affects Medi-Cal program expenditures or which is of policy importance. Each assumption shall include a cost estimate which contains relevant workload, caseload, unit

cost and other data or information needed to support the estimate.

(f)The assumptions related to purchase of medical care and services shall include a section with a nontechnical description of the major variables used to produce a base projection. This section shall further contain an estimate of the fiscal impact of the use of these variables. The estimates related to purchase of medical care and services shall include current and budget year base projections of eligibles, users, expenditures and cost per user by quarter with sufficient past actual data to permit evaluation of the projections. The projections shall be prepared by service category and aid category.

(g)Assumptions or estimates related to Medi-Cal county and other local assistance administration costs shall contain a narrative description of how the forecast was prepared. The estimates shall compare past actual

and projected workload and expenditures in a format which will permit evaluation of forecasts. Unallocated funds and funds for special projects or special problems shall be separately identified.

(h)The estimates shall compare budgeted to implemented rate increases for the current year. The comparisons shall be by provider category and shall compare budgeted to implemented increases in terms of percentage increases, date of implementation, and revised estimated cost.

(i)This section shall become operative on July 1, 2023.

§ 14100.51

Added by Stats. 2013, Ch. 23, Sec. 57. (AB 82) Effective June 27, 2013.

(a)Each year, by no later than January 10 and concurrently with the release of the May Revision, the State Department of Health Care Services shall provide to the fiscal committees of the Legislature supplemental fiscal information for the Medi-Cal Specialty Mental Health Services Program. This supplemental fiscal information shall include service-type descriptions, children’s and adults’ caseload and fiscal forecast by service type, a detailed explanation of changes to these forecasts, fiscal charts containing children’s and adults’ claim costs and unduplicated client counts, and summary fiscal charts with current-year and budget-year proposals.

(b)For purposes of making the information described

in subdivision (a) available to the public, the department shall post this information on its Internet Web site.

§ 14100.52

Added by Stats. 2013, Ch. 23, Sec. 58. (AB 82) Effective June 27, 2013.

(b)For purposes of making the information described in subdivision (a) available to the public, the department shall post this information on its Internet Web site.

§ 14100.6

Added by Stats. 1991, Ch. 560, Sec. 1.

The department, in cooperation with the Controller, shall establish a method of providing to the Controller, periodically, updated information regarding changes in the roster of Medi-Cal providers.

§ 14100.7

Amended by Stats. 1998, Ch. 310, Sec. 81. Effective August 19, 1998.

(a)Any Medi-Cal provider of incontinence supplies or medical supplies, or both, shall provide, to the department, a bond, or other security satisfactory to the department, of not less than twenty-five thousand dollars ($25,000), pursuant to regulations adopted by the department.

(b)(1) After three years of continuous operation as a provider of incontinence supplies or medical supplies, or both, a Medi-Cal provider may apply to the department for an

exemption from the requirements of subdivision (a).

(2)The department shall adopt regulations establishing conditions for the approval or denial of applications for exemption pursuant to paragraph (1).

(c)For purposes of this section, “incontinence supplies” and “medical supplies” mean items prescribed by a licensed practitioner to meet medical needs of the patient, and which are eligible for reimbursement pursuant to this chapter.

(d)Subdivisions (a), (b), and (c) do not apply to individuals who are licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.

§ 14100.75

Amended by Stats. 2000, Ch. 322, Sec. 26. Effective January 1, 2001.

(a)(1) Each provider and each applicant, as defined in Section 14043.1, when applying for enrollment and continued enrollment, shall provide, to the department, a bond, or other security satisfactory to the department, of an amount determined by the department, pursuant to regulations adopted by the department.

(2)The department, in determining the amount of bond or security required by paragraph (1), shall base the determination on the level of

estimated billings, and shall not be less than twenty-five thousand dollars ($25,000).

(3)This subdivision shall become operative only if the director executes a declaration, that shall be retained by the director, stating that the surety bonds described in this paragraph are commercially offered throughout the state and by more than one vendor.

(b)(1) After three years of continuous operation as a provider, a Medi-Cal provider may apply to the department for an exemption from the requirements of subdivision (a).

(2)The department shall adopt regulations establishing conditions for the approval or denial of applications for exemption pursuant to paragraph (1).

(c)The department shall establish a mechanism to track rates of

participation among providers who are subject to the requirement of subdivision (a) to determine if the requirement is a deterrent to Medi-Cal program participation among provider applicants.

(d)Subdivisions (a) and (b) shall not apply to natural persons licensed or certified pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act, or to any clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code, or exempt from licensure under subdivision (c) of Section 1206 of the Health and Safety Code, to any health facility licensed under Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, or to any provider that is operated by a city, county, school district, county office of education, or state special school, or any professional corporation practicing pursuant to the Moscone-Knox

Professional Corporation Act provided for pursuant to Part 4 (commencing with Section 13400) of Division 3 of Title 1 of the Corporations Code.

(e)Nothing in this section shall relieve an applicant or provider of durable medical equipment or home health agency services from complying with subdivisions (a) and (b) of Sections 14100.8 and 14100.9, as applicable.

§ 14100.8

Added by Stats. 1998, Ch. 310, Sec. 82. Effective August 19, 1998.

(a)For purposes of this section, “provider of home health agency services” means a home health agency that is licensed by the department under Section 1726 of the Health and Safety Code that meets the requirements for the medicaid program under Subpart A (commencing with Sec. 441.10) of Part 441 of Title 42 of the Code of Federal Regulations, as amended, that meets the requirements for the Medicare program under Part 484 (commencing with Sec. 481.1) and Part 489 (commencing with Sec. 489.1) of Title 42 of the Code of Federal Regulations,

as amended, and that is enrolled as a provider in the Medi-Cal program. In the event of inconsistent requirements between the medicaid and Medicare programs, medicaid requirements shall take precedence.

(b)Within 90 days after the effective date of a final federal regulation requiring that a provider of home health agency services must acquire a surety bond in order to participate in the medicaid or Medicare program, each provider of home health agency services shall obtain, and thereafter maintain, a surety bond meeting the requirements of the final federal regulation, as amended, as a condition of participation in the Medi-Cal program.

(c)Any entity that has applied to become a provider of home health agency services less than 90 days prior to the date that the final federal regulation described in subdivision (b) becomes effective shall submit a surety bond within 90 days of

the effective date of the regulation.

(d)Failure of a provider of home health agency services to obtain and maintain a surety bond as required in this section shall result in denial or recoupment of Medi-Cal reimbursement for services provided during the period for which a surety bond should have been in effect.

(e)Failure of a provider of home health agency services to obtain and maintain a surety bond as required in this section shall result in automatic termination of the provider’s participation in the Medi-Cal program.

§ 14100.9

Added by Stats. 1998, Ch. 310, Sec. 83. Effective August 19, 1998.

(a)For purposes of this section, “provider of durable medical equipment” means any person or entity that furnishes medical equipment and medical supplies, meets state and local laws applicable to the furnishing of medical equipment and medical supplies, and that is enrolled as a provider in the Medi-Cal program.

(b)Within 90 days after the effective date of a final federal regulation requiring that a provider of durable medical equipment must acquire a surety bond in order

to participate in the medicaid or Medicare program, each provider of durable medical equipment shall obtain, and thereafter maintain, a surety bond meeting the requirements of the final federal regulation, as amended, as a condition of participation in the Medi-Cal program.

(c)Any person or entity that has applied to become a provider of durable medical equipment less than 90 days prior to the date that the final federal regulation described in subdivision (b) becomes effective shall submit a surety bond within 90 days of the effective date of the regulation.

(d)Failure of a provider of durable medical equipment to obtain and maintain a surety bond as required in this section shall result in denial or recoupment of Medi-Cal reimbursement for services provided during the period for which a surety bond should have been in effect.

(e)Failure of a provider of durable medical equipment to obtain and maintain a surety bond as required in this section shall result in automatic termination of the provider’s participation in the Medi-Cal program.

(f)Subdivisions (a), (b), (c), (d), and (e) do not apply to individuals who are licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.

§ 14101

Amended by Stats. 1978, Ch. 429.

The director may contract with other state agencies for services in connection with the administration of 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.

§ 14101.1

Added by Stats. 1976, Ch. 504.

The department shall enter into an agreement with the Secretary of Health, Education and Welfare under which such secretary will determine eligibility for Medi-Cal in the case of aged, blind or disabled persons under this state’s medical assistance plan approved under Title XIX of the Social Security Act. The state shall pay the Secretary of Health, Education and Welfare an amount equal to one-half of the cost of carrying out the agreement, but in computing such cost with respect to individuals eligible for benefits under Title XVI of the Social Security Act, such payment shall include only those costs which are additional to the costs incurred in carrying out such

title.

§ 14101.5

Amended by Stats. 1977, Ch. 1252.

The department and the State Department of Social Services shall provide to the other any information necessary for the performance of such department’s duties under this chapter.

§ 14101.7

Added by Stats. 1981, Ch. 102, Sec. 115. Effective June 28, 1981.

The Workers’ Compensation Appeals Board and the department shall exchange information and cooperate to assure that health services provided by Medi-Cal which are reimbursable by Workers’ Compensation are identified, and that Workers’ Compensation reimburses the department for those services.

§ 14102

Repealed and added by Stats. 2017, Ch. 52, Sec. 25. (SB 97) Effective July 10, 2017. Conditionally inoperative, by its own provisions. Repealed on January 1 following inoperative date, by its own provisions.

(a)If any program under the Medi-Cal program that provides full-scope Medi-Cal benefits to an applicable individual is not statutorily specified in Section 5000A of the Internal Revenue Code (26 U.S.C. 5000A), nor designated as minimum essential coverage in federal regulations, such as Section 1.5000A-2 of Title 26 of the Code of Federal Regulations, then the department shall apply to the United States Secretary of Health and Human Services for the program to be recognized as minimum essential coverage. Any recognition of minimum essential coverage obtained by the department pursuant to this subdivision shall apply in accordance with the federal approvals received and shall be effective on the first day of the month following the receipt of federal approval unless an earlier effective date is provided in the

applicable federal approval.

(b)If the requirement to maintain minimum essential coverage under Section 5000A of the Internal Revenue Code (26 U.S.C. 5000A) is repealed and no similar provision that would cause Medi-Cal beneficiaries to incur a tax penalty for the failure to maintain minimum essential coverage is implemented, this section shall become inoperative, and shall be repealed the following January 1.

(c)For purposes of this section, “applicable individual” shall have the same meaning as that term is defined in Section 5000A(d) of the Internal Revenue Code (26 U.S.C. 5000A(d)).

§ 14102.5

Amended by Stats. 2017, Ch. 511, Sec. 24. (AB 1688) Effective January 1, 2018.

(a)The department shall, in collaboration with the Exchange, the counties, consumer advocates, and the Statewide Automated Welfare System consortia, develop and prepare one or more reports that shall be issued on at least a biannual basis and shall be made publicly available within 90 days following the end of each reporting period, for the purpose of informing the California Health and Human Services Agency, the Exchange, the Legislature, and the public about the enrollment process for all insurance affordability programs. The data within the reports shall be aggregated and calculated on at least a quarterly basis. The reports shall comply with federal reporting requirements and shall, at a minimum, include the following information,

to be derived from, as appropriate depending on the data element, CalHEERS, MEDS, or the Statewide Automated Welfare System:

(1)For applications received for insurance affordability programs through any venue, all of the following:

(A)The number of applications received through each venue.

(B)The number of applicants included on those applications.

(C)Applicant demographics, including, but not limited to, gender, age, race, ethnicity, and primary language.

(D)The disposition of applications, including all of the following:

(i)The

number of eligibility determinations that resulted in an approval for coverage.

(ii) The program or programs for which the individuals in clause (i) were determined eligible.

(iii) The number of applications that were denied for any coverage and the reason or reasons for the denials.

(E) The number of days for eligibility determinations to be completed.

(2)With regard to health plan selection, all of the following:

(A)The health plans that are selected by applicants enrolled in an insurance affordability program, reported by the program.

(B)The number of Medi-Cal enrollees who do not select a health plan but are defaulted into a plan.

(3)For annual redeterminations conducted for beneficiaries, all of the following:

(A)The number of redeterminations processed.

(B)The number of redeterminations that resulted in continued eligibility for the same insurance affordability program.

(C)The number of redeterminations that resulted in a change in eligibility to a different insurance affordability program.

(D)The number of redeterminations that resulted in a finding of ineligibility for any program and the reason or reasons for the findings

of ineligibility.

(E)The number of days for redeterminations to be completed.

(4)With regard to disenrollments not related to a redetermination of eligibility, all of the following:

(A)The number of beneficiary disenrollments.

(B)The reasons for the disenrollments.

(C)The number of disenrollments that are caused by an individual disenrolling from one insurance affordability program and enrolling into another.

(5)The number of applications for insurance affordability programs that were filed with the help of an assister or navigator.

(6)The total number of grievances and appeals filed by applicants and enrollees regarding eligibility for insurance affordability programs, the basis for the grievance, and the outcomes of the appeals.

(b)The department shall collect the information necessary for these reports and develop these reports using data obtained from the Statewide Automated Welfare System, CalHEERS, MEDS, and any other appropriate state information management systems.

(c)For purposes of this section, the following definitions shall apply:

(1)“CalHEERS” means the California Healthcare Eligibility, Enrollment, and Retention System developed under Section 15926.

(2)“Exchange” means the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code.

(3)“Statewide Automated Welfare System” means the system developed pursuant to Section 10823.

(4)“MEDS” means the Medi-Cal Eligibility Data System that is maintained by the department.

§ 14103

Added by Stats. 2013, 1st Ex. Sess., Ch. 4, Sec. 26. (SB 1 1x) Effective September 30, 2013.

(a)The implementation of the optional expansion of Medi-Cal benefits to adults who meet the eligibility requirements of Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), shall be contingent upon the following:

(1)If the federal medical assistance percentage payable to the state under the ACA for the optional expansion of Medi-Cal benefits to adults is reduced below 90 percent, that reduction shall be addressed in a timely manner through the annual state budget or legislative process. Upon receiving notification of any reduction in federal assistance pursuant to this paragraph, the Director of Finance shall immediately notify the

Chairpersons of the Senate and Assembly Health Committees and the Chairperson of the Joint Legislative Budget Committee.

(2)If, prior to January 1, 2018, the federal medical assistance percentage payable to the state under the ACA for the optional expansion of Medi-Cal benefits to adults is reduced to 70 percent or less, the implementation of any provision in this chapter authorizing the optional expansion of Medi-Cal benefits to adults shall cease 12 months after the effective date of the federal law or other action reducing the federal medical assistance percentage.

(b)For purposes of this section, “ACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148) as originally enacted and as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) and any subsequent

amendments.

§ 14103.2

Amended by Stats. 2001, Ch. 745, Sec. 249. Effective October 12, 2001.

Whenever the director determines that the services or products of a provider cost the program in excess of reasonable value received, the provider shall thereafter be disqualified from participation in the program. The disqualification shall not become effective until an opportunity for a public hearing has been granted.

The department shall conduct a continuing review of reimbursements to all hospitals participating in the program in order to determine if any reimbursements are in excess of reasonable value

received.

§ 14103.4