§ 53851. Scope of Services.

(a) Each plan in a designated region shall provide or arrange for the provision of all Medi-Cal covered services to be delivered, unless excluded under the contract, in accordance with the terms and conditions of the contract between the plan and the department.

(b) The scope of services available to Medi-Cal members shall include:

(1) An initial health assessment, unless the member's primary care physician determines that the member's medical record contains complete information, updated within the previous 12 months, consistent with the assessment requirements stated below, and with the requirements of section 53840(c)(7). The assessment, at a minimum shall include, a history of the member's physical and mental health, an identification of risks, an assessment of need for preventive screens or services and health education, and the diagnosis and plan for treatment of any diseases. The plan shall ensure that care for pregnant women is initiated at the earliest time possible.

(2) Health education.

(3) Preventive services.

(4) Primary and specialty care.

(5) Case management and coordination of care as defined in section 53810(f).

(6) Emergency care.

(c) Each plan shall refer and coordinate care for those services that are excluded under the contract, whether or not covered under the Medi-Cal program, pursuant to the requirements of the contract between the plan and the department.

(d) No plan shall withhold medically necessary Medi-Cal covered services not specifically excluded under the contract, due to a dispute with the department over capitation rates, service costs or any other reason. The plan shall pursue a remedy in accordance with the provisions of the contract.

(e) Each plan shall ensure that information, services or presentations required under this section, shall be provided in: language that is easy to understand, the preferred language of the beneficiary, a culturally appropriate manner, and a way that is fully accessible to beneficiaries with disabilities.

HISTORY

1. New section 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).

2. 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).

Note

Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3 and 14087.4, Welfare and Institutions Code.