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Code
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Effective
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ParaReg Text
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580-1
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Federal regulations provide, in pertinent part, that:
(b) A state plan must—
(1) Specify a single State agency established or designated to administer or
supervise the administration of the plan; and
(2) Include a certification by the State Attorney General, citing the legal
authority for the single State agency to—
(i) Administer or supervise the administration of
the plan; and
(ii) Make rules and regulations that it follows in administering the plan or
that are binding upon local agencies that administer the plan.
(c) Determination of eligibility. (1) The plan must specify whether the
agency that determines eligibility for families and for individuals under 21
is—
(i) The Medicaid agency; or
(ii) The single State agency for the financial assistance program under Title
IV-A (in the 50 States or the District of Columbia).
(2) The plan must specify whether the agency that determines eligibility for
the aged, blind, or disabled is—
(i) The Medicaid agency;
(ii) The single State agency for the financial assistance program under Title
IV-A (in the 50 States or the District of Columbia); or
(iii) The Federal agency administering the supplemental security income
program under Title XVI (SSI). In this case, the plan must also specify
whether the Medicaid agency or the Title IV-A agency
determines eligibility for any groups whose eligibility is not determined by
the Federal agency.
(e) Authority of the single State agency. In order for an agency to qualify
as the Medicaid agency—
(1) The agency must not delegate, to other than its own officials, authority
to—
(i) Exercise administrative discretion in the
administration or supervision of the plan, or
(ii) Issue policies, rules, and regulations on program matters.
(2) The authority of the agency must not be impaired if any of its rules,
regulations, or decisions are subject to review, clearance, or similar action
by other offices or agencies of the State.
(3) If other State or local agencies or offices perform services for the
Medicaid agency, they must not have the authority to change or disapprove any
administrative decision of that agency, or otherwise substitute their
judgment for that of the Medicaid agency with respect to the application of
policies, rules, and regulations issued by the Medicaid agency.
(42 Code of Federal Regulations §431.10)
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581-1
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"Contract" means the written agreement entered into
between a health care service plan (as defined in §1345, Health and Safety
Code) and the Department and approved by appropriate state agencies to
provide health care services to members under the provisions of the
Waxman-Duffy Pre-paid Health Plan (PHP) Act, §14200, et seq., Welfare and
Institutions Code. (§53108)
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581-2
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"Disenrollment" means the
process by which a member's entitlement to receive services from a PHP is
terminated. (§53114)
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581-3
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Except as provided in §53440, PHP membership shall continue
indefinitely after enrollment. Membership shall be contingent upon the
member's retention of Medi-Cal eligibility as well
as eligibility for enrollment in the plan under the terms of the plan
contract. (§53426)
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581-4
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Each prepaid health plan shall establish and maintain a
procedure for submittal, processing and resolution of all member complaints.
This section provides that such procedures shall be approved by the
Department and shall provide for the processing of disenrollment
requests through the grievance procedure. (§53260(a))
State law provides that the enrollment of a Medi-Cal
beneficiary in a prepaid health plan shall not be terminated except for loss
of eligibility, for good cause as determined by the Department, or at the
request of the beneficiary. (Welfare and Institutions Code (W&IC)
§14412(a))
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583-1
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State law permits the Director of the CDHS to designate any
benefit or service included in the Medi-Cal
Program, at state option under federal Medicaid rules, as a covered benefit
only when provided by a Medi-Cal managed care plan
to a Medi-Cal enrollee of the plan. (Welfare and
Institutions Code (W&IC) §14131.15(a))
Where benefits and services have been designated by the Director under the
above paragraph, beneficiaries who are eligible to enroll in and reside in
the service area of a managed care plan, and who desire coverage for such
benefits and services, must enroll in a Medi-Cal
managed care plan to receive them. These beneficiaries shall, to the maximum
extent permitted under federal law, remain enrolled in the plan. (W&IC
§14131.15(b))
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584-1
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Enrollment in GMC is mandatory for eligible beneficiaries who
meet all of the following criteria:
1. Are eligible for full scope Medi-Cal;
2. Have a zero SOC;
3. Do not qualify to select an alternative to GMC, under §53923.5;
4. Are eligible for AFDC, or linked to AFDC, to Foster Care, or to the MI
program for children under age 21.
(§53906(a))
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584-2
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The CDHS or the GMC enrollment contractor shall mail an
enrollment form and GMC plan information to each eligible beneficiary
described in §53906(a). The mailing shall include GMC options presentation
information and instructions to enroll in a GMC plan within thirty days of
the postmark date on the mailing envelope. (§53921(c)) Each eligible
beneficiary described in §53906(a) shall enroll in a GMC plan within thirty
days of receipt of an enrollment form with instructions from the department or
the GMC enrollment contractor to select a GMC plan. Under Subsection (1), in
the event an eligible beneficiary described in §53906(a) does not enroll in a
GMC plan within thirty days, the GMC enrollment contractor shall assign the
eligible beneficiary to a GMC plan, in accordance with §53921.5. (§53921(d))
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584-3
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Each eligible beneficiary, prior to or upon either signing an
enrollment application or being assigned to a GMC plan in accordance with
§53921.5, shall be informed in writing by the department or the GMC
enrollment contractor of at least the following:
(1) There will be a 15 to 45 day processing time between the date of
application and the effective date of enrollment in a GMC plan.
(2) Until GMC plan enrollment is effective, the beneficiary may receive Medi-Cal covered health care services from any Medi-Cal provider licensed to provide the services.
(3) An alternative to GMC plan enrollment exists.
(4) Disenrollment from certain GMC plans, specified
in §53925.5, is restricted during the second through sixth month of
enrollment.
(§53926.5(a))
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584-4
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Each GMC plan shall provide in writing, in addition to those
items of information required by W&IC §14406, the following to each
member within seven days after the effective date of enrollment in the plan:
(1) The effective date of enrollment.
(2) A description of all available services and an explanation of any
applicable service limitations, exclusions from coverage or charges for
services.
(3) The name, telephone number and service site address of the primary care
provider selected by the member or instructions to select a primary care
provider within thirty days or be assigned to one.
(4) An enrollment/disenrollment form and an
explanation that it must be used to disenroll from
the GMC plan, in the event disenrollment is
requested by the member.
(5) Information concerning non-medical transportation available to the
beneficiary under the Medi-Cal program, or offered
by the GMC plan, if applicable, and how to receive it.
(§53926.5(b))
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584-5
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Each eligible beneficiary enrolling in a GMC plan shall enroll
in one dental plan and either one PHP or one PCCM plan. (§53921(e))
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584-6
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The GMC enrollment contractor shall assign an eligible
beneficiary described in §53906(a) to a GMC plan, from which to receive
health care services, in the following situations:
(1) In the event the eligible beneficiary does not select a PHP or PCCM plan
and a dental plan within thirty days of receiving an enrollment form pursuant
to §53921(c).
(2) In the event a member requests and is granted disenrollment
from a GMC plan (pursuant to §53925.5) but does not select a different GMC
plan (pursuant to §53925.5) in which to enroll: Unless that member was
granted approval by the GMC enrollment contractor to receive health care
services through the fee-for-service Medi-Cal
program (pursuant to §53923.5).
(§53921.5(a))
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584-7
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No member who is assigned to a GMC plan under §53921.5 shall be
denied a request for disenrollment if all primary
health care services through that assigned GMC plan are more than 10 miles
from the beneficiary's residence. (§53922.5(a))
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584-8
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An eligible beneficiary specified in §53906(a) who meets the
requirements of (a) or (b) may request from the GMC enrollment contractor an
alternative to GMC plan enrollment.
(a) An eligible beneficiary who is an Indian, is a member of an Indian
household, or has written acceptance from an Indian Health Service program
facility to receive health care services through that facility, may, as an
alternative to GMC plan enrollment and upon request, choose to receive health
care services through an Indian Health Service program facility.
(b) An eligible beneficiary who is receiving treatment or services for a
complex medical situation from a physician who is participating in the Medi-Cal program, but is not a contracted provider of any
GMC plan, may request continued fee-for-service Medi-Cal
for the purposes of continuity of care. The department may approve continued
treatment under the fee-for-service Medi-Cal program
for any eligible beneficiary whose diagnosis or treatment needs are verified
in writing by the beneficiary's Medi-Cal provider
and who meets one of the criteria below in 1 though 3 for continued
fee-for-service Medi-Cal.
(1) The eligible beneficiary is under the care of a physician specialist:
(A) For treatment of a condition that is within the specialist's scope of
practice, pursuant to the Business and Professions Code;
(B) That specialty is not practiced by any physician within the available
providers of any GMC plan; and
(C) That specialist is a participating Medi-Cal
provider, but is not a contracted provider of any GMC plan.
(2) The eligible beneficiary is in a complex, high risk medical treatment
plan:
(A) Under the supervision of a physician who is a participating Medi-Cal provider, but is not a contracted provider of
any GMC plan; and
(B) May experience deleterious medical effects if that treatment were to be
disrupted by leaving the care of that physician to begin receiving care from
a GMC plan physician.
(3) The eligible beneficiary is a woman who is pregnant and under the care of
a physician who is a participating Medi-Cal
provider, but is not a contracted provider of any GMC plan.
(c) Any eligible beneficiary granted continued fee-for-service Medi-Cal under (b)(1) or (2) may
remain with that fee-for-service physician only until the medical condition
has stabilized to a level that would enable the eligible beneficiary to
change physicians and begin receiving care from a GMC plan physician without
deleterious medical effects. An eligible beneficiary granted continued
fee-for-service Medi-Cal under (b)(3)
may remain with that physician through delivery and the end of the month in
which ninety days post-partum occurs.
(§53923.5)
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584-9
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State regulations require that:
(a) Each GMC plan shall have a mechanism in place and approved in writing by
the department to ensure that each member is assigned to a primary care
provider, by either:
(1) Allowing each member to select a primary care provider from the GMC
plan’s network of affiliated providers, if the member chooses to do so; or
(2) Assigning a primary care provider to each member within forty days from
the effective date of enrollment, if the member does not select one within
the first thirty days of the effective date of enrollment in the GMC plan.
(A) Assignment conducted pursuant to (a)(2) shall
meet both 1 and 2:
1. The member shall be assigned to a primary care provider no more than 10
miles from the beneficiary's residence.
2. If available within the GMC plan, the member shall be assigned to a
primary care provider who is or has office staff who are linguistically and
culturally competent to communicate with the member or have the ability to
interpret in the provision of health care services and related activities
during the member's office visits or contacts, if the language or cultural
needs of the member are known to the GMC plan.
(b) Any member dissatisfied with the primary care provider selected or
assigned shall be allowed to select or be assigned to another primary care
provider. Each GMC plan shall assist its members in changing primary care
providers if that change is requested by the member. Any GMC plan physician
or dentist dissatisfied with the professional relationship with any member
may request that the member select or be assigned to another primary care
provider.
(§53925)
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