§ 53800. General Provisions.

(a) In regions designated by the department, eligible Medi-Cal beneficiaries shall receive health care services through one of two prepaid health plans, except as provided in subsection (c) below.

(b) The two prepaid health plans in the designated regions shall be selected as follows:

(1) The department shall award one contract through a competitive bid process.

(2) The department shall award one contract to a prepaid health plan which is:

(A) Organized by the county government(s) or by stakeholders of a region designated by the director under the Two-Plan Model, or

(B) Designated by the county government(s) or by stakeholders of a region designated by the director under the Two-Plan Model, and approved by the department at the department's sole discretion.

(C) As a condition of contract award, the prepaid health plan shall agree:

1. To include in its health care delivery system under the contract any safety net provider as defined in Section 53810(ii) physically located and operating within the designated region, as defined in Section 53810(n), that is willing to agree to provide services under the same terms and conditions that the plan requires of any other similar provider to be included in the health care delivery system under the contract, and

2. To establish participation standards for any provider of medical or hospital services, physically located and operating within the region, that will ensure the opportunity for substantial participation of traditional providers, as defined in Section 53810(kk), in the health care delivery system under the contract. Nothing in this subsection shall be construed to prevent federally qualified health centers from requesting cost-based reimbursement consistent with federal law in seeking to enter into a subcontracting relationship with a plan in a designated region.

3. If no health care service plan is willing or able to contract with the department pursuant to subsection (b)(2), the department may award two contracts pursuant to subsection (b)(1). The two prepaid health plans shall agree to offer subcontracts to safety net providers physically located and operating within the designated region in accordance with policies developed by each prepaid health plan and approved by the department prior to commencement of plan operation.

(c) To promote continuity of care, preserve access to providers, and maintain physician-patient relationships, the department has the authority to contract with an Alternate Health Care Service Plan (AHCSP). To the extent allowable under the law, the department has the authority to enter into either one contract for all geographic areas where the AHCSP operates or enter into multiple contracts to serve the different geographic areas.

(1) The following beneficiaries enrolling in Medi-Cal managed care shall be eligible to enroll in an AHCSP which contracts with the department:

(A) An existing member of the AHCSP transitioning into Medi-Cal managed care;

(B) A beneficiary who has been enrolled in the AHCSP at any time during the twelve (12) months immediately prior to the beneficiary's Medi-Cal eligibility; or

(C) A beneficiary with an AHCSP family member linkage.

(2) A beneficiary who is eligible to enroll in the AHCSP but chooses not to enroll in the AHCSP shall be assigned to a plan through the enrollment processes set forth in Sections 53845, 53882, and 53883, except as otherwise provided by law.

(3) The assignment system described in Section 53884 shall not apply to the AHCSP, except as otherwise provided by law.

(4) An AHCSP shall meet all of the requirements of this chapter.

HISTORY

1. New article 8 (sections 53800-53830) and section filed 5-14-93 as an emergency; operative 5-14-93. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 93, No. 20).

2. Repealer of article 8 heading, new chapter 4.1 and article 1 headings, and amendment of subsections (a) and (b)(3) filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

3. Amendment filed 10-30-96 as an emergency; operative 10-30-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 46).

4. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

5. Amendment of subsection (b)(2)(C)(1) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).

6. Amendment of section and Note filed 2-26-2014; operative 4-1-2014 (Register 2014, No. 9).

Note

Note: Authority cited: Section 20, Health and Safety Code; Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4 and 14201, Welfare and Institutions Code.