SB 912: Comprehensive perinatal services.
- Session Year: 2025-2026
- House: Senate
- Latest Version Date: 2026-04-27
Current Status:
In Progress
(2026-05-14: May 14 hearing: Held in committee and under submission.)
Introduced
In Committee
Awaiting First Chamber Vote
Passed First Chamber
In Committee
Awaiting Second Chamber Vote
Passed Second Chamber
Enacted
Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes a schedule of benefits under the Medi-Cal program and provides for various services, including comprehensive perinatal services and federally qualified health center (FQHC) and rural health clinic (RHC) services, that are rendered by Medi-Cal enrolled providers. Under existing law, FQHCs and RHCs receive a per-visit prospective payment system (PPS) rate for each visit.
Existing law establishes the Comprehensive Perinatal Services Program, the goals of which are to decrease and maintain the decreased level of perinatal, maternal, and infant mortality and morbidity in the State of California and to support methods of providing comprehensive prenatal care that prevent prematurity and the incidence of low birth weight infants. Under the program, the State Department of Public Health is required to develop and maintain a statewide comprehensive community-based perinatal services program and enter into contracts, grants, or agreements with health care providers to deliver these services in a coordinated effort. Existing law also requires the department to monitor the delivery of services under those contracts, grants, and agreements through a uniform health data collection system that utilizes epidemiologic methodology.
This bill would instead require the State Department of Health Care Services to oversee a statewide comprehensive community-based perinatal services program and enroll health care providers to deliver these services to Medi-Cal members and make conforming changes, but would maintain the State Department of Public Healths role with related contracts, grants, and agreements. The bill would specify that any participation by the State Department of Public Health does not change the State Department of Health Care Services authority to implement comprehensive community-based perinatal services for purposes of the Medi-Cal program. By January 1, 2028, the bill would require the State Department of Health Care Services, in consultation with the State Department of Public Health, to clarify each departments roles and responsibilities regarding comprehensive perinatal services by regulation. The bill would, among other things, require the State Department of Health Care Services to develop a training on administering the informational and educational materials on comprehensive perinatal services, require all perinatal providers providing perinatal care to Medi-Cal members to attend the training, services by January 1, 2028, and require all Medi-Cal managed care plans to ensure providers receive the training. disseminate the materials, as specified. The bill would require the State Department of Health Care Services, no later than July 15, 2027, to submit to the Assembly Committee on Health and the Senate Committee on Health, and post on its internet website, a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services from January 1, 2022, to January 1, 2025, inclusive. The bill would also require the State Department of Health Care Services, commencing January 1, July 15, 2028, and every 3 years thereafter, to submit to those committees, and post on its internet website, a report that identify the number of pregnant and postpartum individuals that received and were offered comprehensive perinatal services during the previous 3 calendar years.
This bill would require a Medi-Cal provider providing pregnancy care managed care plan to inform each Medi-Cal member treated during the perinatal period regarding the availability of and access to comprehensive perinatal services. On an effective date designated by the State Department of Health Care Services that is no sooner than January 1, 2027, the bill would prohibit a PPS billable visit from including an encounter with a comprehensive perinatal practitioner who is not otherwise a PPS billable health professional. The bill would authorize the department to implement an alternative payment methodology for FQHCs and RHCs to obtain reimbursement for encounters with community health workers at no less than the applicable Medi-Cal fee-for-service rate when provided either on the same day or different day as a PPS billable visit.
Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes a schedule of benefits under the Medi-Cal program and provides for various services, including comprehensive perinatal services and federally qualified health center (FQHC) and rural health clinic (RHC) services, that are rendered by Medi-Cal enrolled providers. Under existing law, FQHCs and RHCs receive a per-visit prospective payment system (PPS) rate for each visit.
Existing law establishes the Comprehensive Perinatal Services Program, the goals of which are to decrease and maintain the decreased level of perinatal, maternal, and infant mortality and morbidity in the State of California and to support methods of providing comprehensive prenatal care that prevent prematurity and the incidence of low birth weight infants. Under the program, the State Department of Public Health is required to develop and maintain a statewide comprehensive community-based perinatal services program and enter into contracts, grants, or agreements with health care providers to deliver these services in a coordinated effort. Existing law also requires the department to monitor the delivery of services under those contracts, grants, and agreements through a uniform health data collection system that utilizes epidemiologic methodology.
This bill would instead require the State Department of Health Care Services to oversee a statewide comprehensive community-based perinatal services program and enroll health care providers to deliver these services to Medi-Cal members and make conforming changes, but would maintain the State Department of Public Healths role with related contracts, grants, and agreements. The bill would specify that any participation by the State Department of Public Health does not change the State Department of Health Care Services authority to implement comprehensive community-based perinatal services for purposes of the Medi-Cal program. By January 1, 2028, the bill would require the State Department of Health Care Services, in consultation with the State Department of Public Health, to clarify each departments roles and responsibilities regarding comprehensive perinatal services by regulation. The bill would, among other things, require the State Department of Health Care Services to develop a training on administering the comprehensive perinatal services, require all perinatal providers providing perinatal care to Medi-Cal members to attend the training, and require all Medi-Cal managed care plans to ensure providers receive the training. The bill would require the State Department of Health Care Services, no later than July 15, 2027, to submit to the Assembly Committee on Health and the Senate Committee on Health, and post on its internet website, a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services from January 1, 2022, to January 1, 2025, inclusive. The bill would also require the State Department of Health Care Services, commencing January 1, 2028, and every 3 years thereafter, to submit to those committees, and post on its internet website, a report that identify the number of pregnant and postpartum individuals that received and were offered comprehensive perinatal services during the previous 3 years.
This bill would require a Medi-Cal provider providing pregnancy care to inform each Medi-Cal member treated during the perinatal period regarding the availability of and access to comprehensive perinatal services. On an effective date designated by the State Department of Health Care Services that is no sooner than January 1, 2027, the bill would prohibit a PPS billable visit from including an encounter with a comprehensive perinatal practitioner who is not otherwise a PPS billable health professional. The bill would authorize the department to implement an alternative payment methodology for FQHCs and RHCs to obtain reimbursement for encounters with community health workers at no less than the applicable Medi-Cal fee-for-service rate when provided either on the same day or different day as a PPS billable visit.
It is the intent of the Legislature to enact legislation implementing several recommendations made in California State Auditor Report 2023-103: The Comprehensive Perinatal Services Program to enhance monitoring and oversight and do all of the following:
(a)Clarify that the State Department of Health Care Services is responsible for the delivery of the comprehensive perinatal services benefit as the single state agency pursuant to Section 10740 of the Welfare and Institutions Code that oversees the Medi-Cal program. It is the intent of the Legislature that the State Department of Health Care Services collaborate with the State Department of Public Health when appropriate.
(b)Require the State Department of Health Care Services to collaborate with the State Department of Public Health on updated regulations related to comprehensive perinatal services.
(c)Require the State Department of Health Care Services to modify an existing system or develop a new system of oversight to monitor and publicly report comprehensive perinatal services utilization data for comprehensive perinatal services for eligible Medi-Cal members.
SEC. 2.Section 123486 is added to the Health and Safety Code, to read:123486.Any participation in administration of the program by the State Department of Public Health, including administrative services pursuant to a contract or other collaboration with the State Department of Health Care Services, shall not supplant, create concurrent, nor supersede the State Department of Health Care Services authority as the designated single state agency for the administration of the federal Medicaid program pursuant to Section 10740 of the Welfare and Institutions Code and as designated in Californias Medicaid state plan. As such, the State Department of Health Care Services is ultimately responsible for the implementation of this benefit for the purposes of the Medi-Cal program.
SEC. 3.Section 123487 is added to the Health and Safety Code, to read:123487.(a)The State Department of Health Care Services shall collaborate with the State Department of Public Health to update the regulations related to comprehensive perinatal services to clarify the roles and responsibilities from each department and make adjustments to the current monitoring and oversights systems, including the monitoring of managed care plans and fee-for-service providers, by January 1, 2028.
(b)The By January 1, 2028, the State Department of Health Care Services, with collaboration from the State Department of Public Health, shall develop a training on administering informational and educational materials on comprehensive perinatal services. By January 1, 2028, the services for providers and recipients. The State Department of Health Care Services shall require that all providers providing perinatal care to Medi-Cal members complete the training, including managed care plan and fee-for-service providers. do all of the following regarding the materials:
(1)Post the materials on its internet website and inform providers through a provider bulletin.
(2)Require managed care plans to annually disseminate provider materials to network providers providing perinatal care.
(3)Require managed care plans to disseminate recipient materials once to pregnant or postpartum members when pregnancy or postpartum status is initially identified.
(4)Annually disseminate materials to Medi-Cal fee-for-service providers who are not also managed care providers.
(5)Disseminate recipient materials to pregnant or postpartum members in the fee-for-service system when the pregnancy or postpartum status is initially identified.
SEC. 4.Section 123490 of the Health and Safety Code is repealed.SEC. 5.Section 123490 is added to the Health and Safety Code, to read:123490.The State Department of Health Care Services shall oversee a statewide comprehensive community-based perinatal services program and enroll health care providers to deliver these services to Medi-Cal members.
SEC. 6.Section 123491 of the Health and Safety Code is amended to read:123491.(a) There is hereby established a voluntary nurse home visiting grant program for expectant first-time mothers, their children, and their families, to be administered by the State Department of Public Health pursuant to Section 123492. The program may be cited as the Nurse-Family Partnership program.
(b)The goals and objectives of the program shall be the same as, but shall not be limited to, those in the community-based comprehensive perinatal health care system as set forth in Section 123505.
(c)The State Department of Public Health shall adopt regulations for the implementation of this section in accordance with Section 123516.
SEC. 7.Section 123492 of the Health and Safety Code is amended to read:123492.The State Department of Public Health shall develop a grant application and award grants on a competitive basis to counties for the startup, continuation, and expansion of the program established pursuant to Section 123491. To be eligible to receive a grant for purposes of that section, a county shall agree to all of the following:
(a)Serve through the program only pregnant, low-income women who have had no previous live births. Notwithstanding subdivision (b) of Section 123485, women who are juvenile offenders or who are clients of the juvenile system shall be deemed eligible for services under the program.
(b)Enroll women in the program while they are still pregnant, before the 28th week of gestation, and preferably before the 16th week of gestation, and continue those women in the program through the first two years of the childs life.
(c)Use as home visitors only registered nurses who have been licensed in the state.
(d)Have nurse home visitors undergo training according to the program and follow the home visit guidelines developed by the Nurse-Family Partnership program.
(e)Have nurse home visitors specially trained in prenatal care and early child development.
(f)Have nurse home visitors follow a visit schedule keyed to the developmental stages of pregnancy and early childhood.
(g)Ensure that, to the extent possible, services shall be rendered in a culturally and linguistically competent manner.
(h)Limit a nurse home visitors caseload to no more than 25 active families at any given time.
(i)Provide for every eight nurse home visitors a full-time nurse supervisor who holds at least a bachelors degree in nursing and has substantial experience in community health nursing.
(j)Have nurse home visitors and nurse supervisors trained in effective home visitation techniques by qualified trainers.
(k)Have nurse home visitors and nurse supervisors trained in the method of assessing early infant development and parent-child interaction in a manner consistent with the program.
(l)Provide data on operations, results, and expenditures in the formats and with the frequencies specified by the State Department of Public Health.
(m)Collaborate with other home visiting and family support programs in the community to avoid duplication of services and complement and integrate with existing services to the extent practicable.
(n)Demonstrate that adoption of the Nurse-Family Partnership program is supported by a local governmental or government-affiliated community planning board, decisionmaking board, or advisory body responsible for assuring the availability of effective, coordinated services for families and children in the community.
(o)Provide cash or in-kind matching funds in the amount of 100 percent of the grant award.
(p)Prohibit the use of moneys received for the program as a match for grants currently administered by the State Department of Public Health.
SEC. 8.Section 123493 of the Health and Safety Code is amended to read:123493.(a)The State Department of Public Health may accept voluntary contributions, in cash or in-kind, to pay for the costs in the implementation of the program under Section 123492. These private donations shall be deposited into the California Families and Children Account, which is hereby created in the State Treasury, in which, notwithstanding Section 13340 of the Government Code, is hereby continuously appropriated to the State Department of Public Health for purposes of implementing Section 123492. State funds shall not be used in implementing Section 123492.
(b)The State Department of Public Health shall only distribute grants established under Section 123492 if the Director of Finance determines, in writing, that there are sufficient funds from private donations available in the account for expenditure for the purposes of the program.
(c)The State Department of Public Healths administration costs shall not exceed 5 percent of the moneys in the account created under subdivision (a). Any costs to the State Department of Public Health incurred prior to the account receiving funds shall be reimbursed to the State Department of Public Health from funds in the account.
(d)The State Department of Public Health shall not apply for grants or solicit private funds.
(e)If, as of January 1, 2009, the Director of Finance determines pursuant to subdivision (a) that there are insufficient funds on deposit in the account to implement the voluntary nurse home visiting grant program, the account shall cease to exist.
SEC. 9.Section 123501 is added to the Health and Safety Code, to read:123501.(a)The State Department of Health Care Services shall require all Medi-Cal managed care plans to include information on comprehensive perinatal services in the plan member handbooks.
(b)The State Department of Health Care Services shall require all Medi-Cal managed care plans to ensure that their network providers have received the training described in Section 123487.(c)(b)No later than January 1, 2028, the State Department of Health Care Services shall update an existing system or implement a new system to monitor and publicly report deidentified comprehensive perinatal services utilization data for eligible Medi-Cal members. members, consistent with state and federal privacy laws.
(d)(c)The State Department of Health Care Services shall require Medi-Cal managed care plans, as defined in Section 14184.101 of the Welfare and Institutions Code, to conduct site reviews on perinatal providers at least once every three years, starting in January 1, 2027, to ensure that eligible Medi-Cal managed care plan members receive comprehensive perinatal services.
SEC. 10.Section 123516 of the Health and Safety Code is amended to read:123516.(a)The State Department of Public Health, in consultation with the program administrators, may contract with one or more qualified organizations to assist the State Department of Public Health in ensuring that grantees implement the program as established under Section 123491 and to conduct an annual evaluation of the implementation of the grant program on a statewide basis. The first evaluation shall be due 12 months after the award of grants pursuant to Section 123492.
(b)(1)In conducting its monitoring and evaluation activities, the State Department of Public Health shall be guided by program performance standards developed by the State Department of Public Health in consultation with the Nurse-Family Partnership program.
(2)The annual evaluation shall contain, but not be limited to, the extent to which each grantee participating in the program has done each of the following:
(A)Recruited a population of low-income, first-time mothers.
(B)Enrolled families early in pregnancy and followed them through the second birthday of the child.
(C)Conducted visits that are of comparable frequency, duration, and content as those delivered in the randomized clinical trials of the program.
(D)Assessed the health and well-being of the mothers and children enrolled in the program according to common indicators of maternal, child, and family health.
SEC. 11.Section 123520 of the Health and Safety Code is amended to read:123520.(a) In developing a comprehensive system, health care providers funded under this article may perform the following activities to ensure that a full range of program components of a comprehensive, community-based health care system are available, accessible, and utilized by pregnant women and infants:
(1) Coordinate specific linkages with one another.
(2) Subcontract the services specified in this article.
(3) Provide additional services not specifically listed in this article. These additional services shall include, but shall not be limited to the Women, Infants, and Children (WIC) food supplement program, services offered by local health departments, and public and private social welfare agencies. Nothing contained in this article shall be construed to prohibit a subcontractor from being reimbursed pursuant to a fee for service, capitation, or other payment mechanism.
(b) All services and educational materials shall be provided in the primary languages of the clients served, provided that there are at least 5 percent or 100 persons, whichever is less, of the total member population served annually by each facility, who share language other than English and who are limited-English speaking. Limited-English speaking means a person who uses a language other than English in order to communicate effectively.
(c) Health care providers applying for a contract, grant, or agreement under this article shall indicate the manner in which their service elements will be coordinated with existing community resources and services and with hospitals of all levels in the area to ensure each client receives the appropriate level or care at the appropriate time. The State Department of Public Health may require written agreements between contractors and hospital or hospitals in the area regarding delivery services, and protocols for referral and transfer when special treatment services are required. The State Department of Public Health may, when requested by the grantee or contractor, assist in achieving coordination and written agreements pertaining to the delivery of these services.
SEC. 12.Section 123521 is added to the Health and Safety Code, to read:123521.(a)(1)The State Department of Health Care Services shall, no later than July 15, 2027, submit to the Assembly Committee on Health and the Senate Committee on Health, and post on its internet website, a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services from January 1, 2022, to January 1, 2025, inclusive.
(2)Commencing January 1, July 15, 2028, and every three years thereafter, the State Department of Health Care Services shall submit to the Assembly Committee on Health and the Senate Committee on Health, and post on its internet website, a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services during the previous three calendar years.
(b)A report to be submitted pursuant to subdivision (a) shall be submitted in compliance with Section 9795 of the Government Code.
SEC. 13.Section 131051 of the Health and Safety Code is amended to read:131051.The duties, powers, functions, jurisdiction, and responsibilities transferred to the State Department of Public Health shall, pursuant to the act that added this section, include all of the following previously performed by the former State Department of Health Services:
(a)Under the jurisdiction of the Deputy Director for Prevention Services:
(1)The Office of AIDS, including but not limited to:
(A)The AIDS Drug Assistance Program (Chapter 6 (commencing with Section 120950) of Part 4 of Division 105).
(B)The AIDS Early Intervention Program (Chapter 4 (commencing with Section 120900) of Part 4 of Division 105).
(C)The CARE Services Program, provided for pursuant to the federal Ryan White CARE Act, 42 U.S.C. Section 300ff.
(D)The CARE/Health Insurance Premium Payment Program (federal Ryan White CARE Act, 42 U.S.C. Sec. 300ff).
(E)The Housing Opportunities for Persons with AIDS Program (Section 100119).
(F)The Residential AIDS Licensed Facilities Program (former Section 100119; Chapter 2 (commencing with Section 120815) of Part 4 of Division 105).
(G)The AIDS Case Management Program (federal Ryan White CARE Act, 42 U.S.C. Sec. 300ff; Chapter 2 (commencing with Section 120815) of Part 4 of Division 105).
(H)The AIDS Medi-Cal Waiver Program (former Section 100119; 42 U.S.C. Sec. 1396n(c)).
(I)The Bridge Project (former Section 100119).
(J)The HIV Therapeutic Monitoring Program (Chapter 16 (commencing with Section 121345) of Part 4 of Division 105).
(K)The Learning Immune Function Enhancement program (former Section 100119).
(L)The San Ysidro Prevention Project (Section 113019).
(M)The California Statewide Treatment Education Program (former Section 100119).
(N)The HIV Counseling and Testing Program (Section 113019).
(O)The Neighborhood Intervention Geared Toward High-Risk Testing program (former Section 100119).
(P)The Perinatal Transmission Prevention Project (Section 113019).
(Q)The California AIDS Clearinghouse (Section 113019).
(R)The California Disclosure Assistance and Partner Services/Partner Counseling and Referral Services (Section 113019).
(S)The African-American HIV Initiative (Section 113019; Chapter 13.7 (commencing with Section 120290) of Part 4 of Division 105).
(T)The Injection Drug User HIV Testing Utilizing Hepatitis C Testing High-Risk Initiative (Section 113019).
(U)The Prevention with Positives High-Risk Initiative (Section 113019).
(V)The Statewide Technical Assistance Initiatives (Section 113019).
(W)The HIV/AIDS Case Registry (Sections 113019, 120125, and 120130).
(2)The Office of Binational Border Health, including, but not limited to, all of the following:
(A)The California-Mexico Health Initiative (Part 3 (commencing with Section 475) of Division 1).
(B)The Early Warning Infectious Disease Surveillance Program (Chapter 2 (commencing with Section 1250) of Division 2; Chapter 2 (commencing with Section 120130) of Part 1 of Division 105).
(3)The Division of Communicable Disease Control, including, but not limited to, all of the following:
(A)The Infant Botulism Treatment and Prevention Program (Article 2.5 (commencing with Section 123700) of Chapter 3 of Part 2 of Division 106).
(B)The Sexually Transmitted Disease Control Program (Part 3 (commencing with Section 120500) of Division 105).
(C)The Infectious Disease Program (Chapter 2 (commencing with Section 120130) of Part 1 of Division 105).
(D)The Bioterrorism Epidemiology Program.
(E)The Vector Borne Disease (Part 11 (commencing with Section 116100) of Division 104).
(F)The Tuberculosis Control Program (Part 5 (commencing with Section 121350) of Division 105).
(G)The Microbial Diseases Laboratory (Chapter 2 (commencing with Section 100250) of Division 101).
(H)The Viral and Rickettsial Disease Laboratory (Chapter 2 (commencing with Section 100250) of Division 101).
(I)The West Nile Human Surveillance Program (Chapter 2 (commencing with Section 116110) of Part 11 of Division 104).
(J)The Immunization Program (Part 2 (commencing with Section 120325) of Division 105).
(K)The Vaccines for Children Program (Part 2 (commencing with Section 120325) of Division 105).
(4)The Division of Chronic Disease and Injury Control, including, but not limited to, all of the following:
(A)The IMPACT Prostate Cancer Treatment Program (Chapter 7 (commencing with Section 104322) of Part 1 of Division 103), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this program are hereby with the State Department of Health Care Services.
(B)The Every Woman Counts program (Breast and Cervical Cancer Screening Program) (Article 1.3 (commencing with Section 104150) of Chapter 2 of Part 1 of Division 103; Section 30461.6 of the Revenue and Taxation Code), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this program are hereby with the State Department of Health Care Services.
(C)The Well-Integrated Screening and Evaluation for Women Across the Nation Demonstration Project (Article 1.3 (commencing with Section 104150) of Chapter 2 of Part 1 of Division 103).
(D)The California Nutrition Network (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(E)The Cancer Research Program (Article 2 (commencing with Section 104175) of Chapter 2 of Part 1 of Division 103).
(F)The Translational Cancer Research and Technology Transfer Program (Article 2 (commencing with Section 104175) of Chapter 2 of Part 1 of Division 103).
(G)The Ken Maddy California Cancer Registry (Chapter 2 (commencing with Section 103875) of Part 2 of Division 102).
(H)The California Osteoporosis Prevention and Education Program (Chapter 1 (commencing with Section 125700) of Part 8 of Division 106).
(I)The Preventive Health Care for the Aging Program (Part 4 (commencing with Section 104900) of Division 103).
(J)The California Arthritis Prevention Program (former Section 100185).
(K)The Office of Oral Health (Chapter 3 (commencing with Section 104750) of Part 3 of Division 103).
(L)The Childrens Dental Disease Prevention Program (Article 3 (commencing with Section 104770) of Chapter 3 of Part 3 of Division 103).
(M)The Community Water Fluoridation Program (Article 3.5 (commencing with Section 116409) of Chapter 4 of Part 12 of Division 104).
(N)The California Asthma Public Health Initiative (Chapter 6.5 (commencing with Section 104316) of Part 1 of Division 103).
(O)The California Obesity Prevention Initiative (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(P)The School Health Connections program (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(Q)The California Project LEAN (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(R)The California Center for Physical Activity (Section 131085).
(S)The California Diabetes Program (Section 131085).
(T)The Preventive Medicine Residency Program (Section 131090).
(U)The California Epidemiologic Investigation Service (Article 4 (commencing with Section 100325) of Chapter 2 of Part 1 of Division 101).
(V)The Continuing Professional Education Program (Section 131090).
(W)The Injury Surveillance and Epidemiology Program (Part 2 (commencing with Section 104325) of Division 103).
(X)The State and Local Injury Control Program (Chapter 1 (commencing with Section 104325) of Part 2 of Division 103).
(Y)The Office on Disability and Health (former Section 100185).
(Z)The Alzheimers Disease Program (Article 4 (commencing with Section 125275) of Chapter 2 of Part 5 of Division 106).
(AA)The California Tobacco Control Program (Chapter 1 (commencing with Section 104350) of Part 3 of Division 103).
(5)The Division of Drinking Water and Environmental Management, including, but not limited to, all of the following:
(A)The Medical Waste Management Program (Part 14 (commencing with Section 117600) of Division 104).
(B)The Department of Defense Oversight Program (Radiologic Guidance and Approvals) (Part 9 (commencing with Section 114650) of Division 104).
(C)The Nuclear Emergency Response Program (Part 9 (commencing with Section 114650) of Division 104).
(D)The Institutions Program (Environmental Surveys) (Article 5 (commencing with Section 116025) of Chapter 5 of Part 10 of Division 104).
(E)The Drinking Water Field Management program (Chapter 4 (commencing with Section 116270) of Part 12 of Division 104).
(F)The Environmental Health Specialist Registration Program (Article 1 (commencing with Section 106600) of Chapter 4 of Part 1 of Division 104).
(G)The Sanitation and Radiation Laboratory (Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101); Chapter 4 (commencing with Section 116270) of Part 12 of Division 104).
(H)The Radon Program (Chapter 7 (commencing with Section 105400) of Part 5 of Division 103; Chapter 4 (commencing with Section 116270) of Part 12, and Article 2 (commencing with Section 106750) of Chapter 4 of Part 1, of Division 104).
(I)The Shellfish Sanitation Program (Chapter 5 (commencing with Section 112150) of Part 6 of Division 104).
(J)The Ocean Beach Safety Programs (Article 2 (commencing with Section 115875) of Chapter 5 of Part 10 of Division 104).
(K)The Bioterrorism Planning and Response for Drinking Water, Medical Waste, and Environmental Health program (Article 6 (commencing with Section 101315) of Chapter 3 of Part 3 of Division 101).
(L)The Safe Drinking Water State Revolving Fund (Chapter 4.5 (commencing with Section 116760) of Part 12 of Division 104).
(M)The Drinking Water Technical Programs (Chapter 4 (commencing with Section 16270) of Part 12 of Division 104; Chapter 4.5 (commencing with Section 116760) of Part 12 of Division 104; Article 3 (commencing with Section 106875) of Chapter 4 of Part 1 of Division 104; Chapter 5 (commencing with Section 116775) of Part 12 of Division 104; Chapter 5 (commencing with Section 115825) of Part 10 of Division 104; Chapter 7 (commencing with Section 13500) of Division 7 of the Water Code; Section 13411 of the Water Code).
(N)The Water Security, Clean Drinking Water, Coastal and Beach Protection Act of 2002 (Proposition 50) (Division 26.5 (commencing with Section 79500) of the Water Code).
(6)The Division of Environmental and Occupational Disease Control, including, but not limited to, all of the following:
(A)The California Birth Defect Monitoring Program (Chapter 1 (commencing with Section 103825) of Part 2 of Division 102).
(B)The Childhood Lead Poisoning Prevention Program (Chapter 5 (commencing with Section 105275) of Part 5 of Division 103; Article 7 (commencing with Section 124125) of Chapter 3 of Part 2 of Division 106).
(C)The Lead Related Construction Program (Chapter 4 (commencing with Section 105250) of Part 5 of Division 103).
(D)The Epidemiology Studies Laboratory (Sections 25416, former Section 100170, Section 100325, and Section 104324.25).
(E)The Center for Autism and Developmental Disabilities Research and Epidemiology (former Section 100170).
(F)The Cancer Cluster/Environmental Investigations (former Section 100170).
(G)The Toxic Mold Program (Chapter 18 (commencing with Section 26100) of Division 20).
(H)The Federal Agency for Toxic Substances and Disease Registry Health Assessments, Education and Investigations program (former Section 100170).
(I)The Fish Contamination Outreach and Education program (former Section 100170).
(J)The Air Pollution and Cardiovascular Disease in the California Teachers Study Cohort Project (former Section 100170).
(K)The Delta Watershed Fish Project (outreach, education, and training to reduce exposures to mercury in fish) (former Section 100170).
(L)The Environmental Health Laboratory (former Section 100170; Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101).
(M)The Indoor Air Quality program (Chapter 7 (commencing with Section 105400) of Part 5 of Division 103).
(N)The Outdoor Air Quality program (Section 60.9 of the Labor Code).
(O)The Laboratory Response Network for Chemical Terrorism program (former Section 100170; Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101).
(P)The Air Quality and Human Monitoring Support Program (former Section 100170).
(Q)The Hazard Evaluation System and Information Service Program (Article 1 (commencing with Section 105175) of Chapter 2 of Part 5 of Division 103; Section 147.2 of the Labor Code).
(R)The Occupational Health Surveillance and Evaluation Program (Article 1 (commencing with Section 105175) of Chapter 2 of Part 5 of Division 103).
(S)The Occupational Lead Poisoning Prevention Program (Article 2 (commencing with Section 105185) of Chapter 2 of Part 5 of Division 103).
(T)The Occupational Blood Lead Registry (Article 2 (commencing with Section 105185) of Chapter 2 of Part 5 of Division 103).
(7)The Division of Food, Drug and Radiation Safety, including, but not limited to, all of the following:
(A)The Drug Licensing Program (Article 6 (commencing with Section 111615) of Chapter 6 of Part 5 of Division 104).
(B)The Consumer Product Safety Program (Part 3 (commencing with Section 108100) of Division 104).
(C)The Export Program (Article 2 (commencing with Section 110190) of Chapter 2 of Part 5 of Division 104).
(D)The Food Safety Inspection Program (Part 5 (commencing with Section 109875) and Part 6 (commencing with Section 111940) of Division 104).
(E)The Foodborne Illness and Tampering Emergency Response Program (Part 5 (commencing with Section 109875) of Division 104).
(F)The Retail Food Safety Program (Part 7 (commencing with Section 113700) of Division 104).
(G)The Food Safety Industry Education and Training Program (pursuant to Section 110485).
(H)The Medical Device Licensing Program (Article 6 (commencing with Section 111615) of Chapter 6 of Part 5 of Division 104).
(I)The Medical Device Safety Program (Part 5 (commencing with Section 109875) of Division 104).
(J)The Stop Tobacco Access to Kids Enforcement Program (STAKE) (Division 8.5 (commencing with Section 22950) of the Business and Professions Code).
(K)The Food and Drug Laboratory (Chapter 2 (commencing with Section 100250) of Division 101).
(L)The Drug Safety Program (Part 4 (commencing with Section 109250) and Part 5 (commencing with Section 109875) of Division 104).
(M)The General Food Safety Program (Part 5 (commencing with Section 109875) and Part 6 (commencing with Section 111940) of Division 104).
(N)The Food Testing Program (Chapter 2 (commencing with Section 100250) of Division 101).
(O)The Forensic Alcohol Testing Program (Article 2 (commencing with Section 100700) of Chapter 4 of Part 1 of Division 101).
(P)The Methadone Laboratory Regulating Program (Article 2 (commencing with Section 11839.23) of Chapter 10 of Part 2 of Division 10.5).
(Q)The Radiologic Health Program (Part 9 (commencing with Section 114650) of Division 104).
(R)The Mammography Program (Chapter 6 (commencing with Section 114840) of Part 9 of Division 104).
(S)The Radioactive Materials Licensing and Inspection Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(T)The Radiological Technologist Certification Program (Article 5 (commencing with Section 106955) of Part 1, and Article 3 (commencing with Section 114855) of Chapter 6 of Part 9 of Division 104).
(U)The Radioactive Waste Tracking Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(V)The Radioactive Waste Minimization Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(W)The Low Level Radioactive Waste Management, Treatment and Disposal Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(X)The Statewide Environmental Radiation Monitoring Program (pursuant to Section 114755).
(Y)The Department of Energy Oversight Program (Part 9 (commencing with Section 114650) of Division 104).
(Z)The X-Ray Machine Inspection and Registration and Mammography Quality Standards Act Inspection Program (Article 5 (commencing with Section 106955) of Part 1, and Article 3 (commencing with Section 114855) of Chapter 6 of Part 9 of Division 104).
(8)The Deputy Director for Laboratory Science, including, but not limited to, all of the following:
(A)The Environmental Laboratory Accreditation Program (Article 3 (commencing with Section 100825) of Chapter 4 of Part 1 of Division 101).
(B)The Laboratory Central Services Program (Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101).
(C)The National Laboratory Training Network (Section 131085).
(D)The Laboratory Field Services program (Chapter 3 (commencing with Section 1200) of Division 2 of the Business and Professions Code).
(b)Under the jurisdiction of the Deputy Director for Licensing and Certification:
(1)The General Acute Care Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(2)The Acute Psychiatric Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(3)The Special Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(4)The Chemical Dependency Recovery Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(5)The Skilled Nursing Facilities Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(6)The Intermediate Care Facilities Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(7)The Intermediate Care Facilities-Developmentally Disabled Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(8)The Intermediate Care Facilities-Developmentally Disabled-Habilitative Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(9)The Intermediate Care Facility-Developmentally Disabled-Nursing Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(10)The Home Health Agencies Licensing Program (Chapter 8 (commencing with Section 1725) of Division 2).
(11)The Referral Agencies Licensing Program (Chapter 2.3 (commencing with Section 1400) of Division 2).
(12)The Adult Day Health Centers Licensing Program (Chapter 3.3 (commencing with Section 1570) of Division 2).
(13)The Congregate Living Health Facilities (Chapter 2 (commencing with Section 1250) of Division 2).
(14)The Psychology Clinics Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(15)The Primary ClinicsCommunity and Free Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(16)The Specialty ClinicsRehab Clinics Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(17)The Dialysis Clinics Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(18)The Pediatric Day Health/Respite Care Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(19)The Alternative Birthing Centers Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(20)The Hospice Licensing Program (Chapter 2 (commencing with Section 1339.30) of Division 2).
(21)The Correctional Treatment Centers Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(22)The Medicare/Medi-Cal Certification Program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
(23)The Nursing Home Administrator Professional Certification Program (Chapter 2.35 (commencing with Section 1416) of Division 2).
(24)The Certified Nursing Assistants Professional Certification Program (Chapter 2 (commencing with Section 1337) of Division 2).
(25)The Home Health Aides Professional Certification Program (Chapter 8 (commencing with Section 1725) of Division 2).
(26)The Hemodialysis Technicians Professional Certification Program (Chapter 3 (commencing with Section 1247) of Division 2 of the Business and Professions Code; Chapter 10 (commencing with Section 1794) of Division 2).
(27)The Criminal Background Clearance Program (Chapter 2 (commencing with Section 1337), Chapter 3 (commencing with Section 1520), Chapter 3.01 (commencing with Section 1569.15), Chapter 3.4 (commencing with Section 1496.80) of Division 2, and Chapter 4 (commencing with Section 11150) of Division 8).
(c)Under the jurisdiction of the Deputy Director for Health Information and Strategic Planning:
(1)The Refugee Health Program (Subpart G of Part 400 of Title 45 of the Code of Federal Regulations).
(2)The Office of County Health Services (Article 5 (commencing with Section 101300) of Chapter 3 of Part 3 of Division 101; Part 4.7 (commencing with Section 16900) of Division 9 of the Welfare and Institutions Code).
(3)The Medically Indigent Services Program (Article 5 (commencing with Section 101300) of Chapter 3 of Part 3 of Division 101).
(4)The Office of Vital Records (Part 1 (commencing with Section 102100) of Division 102).
(5)The Office of Health Information and Research (Article 1 (commencing with Section 102175) of Chapter 2 of Part 1 of Division 102; Section 128730).
(6)The Local Public Health Services Program (Article 5 (commencing with Section 101300) of Chapter 3 of Part 3 of Division 101).
(7)The Center for Health Statistics (Part 1 (commencing with Section 102100) of Division 102; Section 128730).
(8)The Medical Marijuana Program (Article 2.5 (commencing with Section 11362.7) of Chapter 6 of Division 10 of the Health and Safety Code).
(d)Under the jurisdiction of the Deputy Director for Primary Care and Family Health:
(1)The Maternal, Child and Adolescent Health program (Part 2 (commencing with Section 123225) of Division 106).
(2)The Adolescent Family Life Program (Article 1 (commencing with Section 124175) of Chapter 4 of Part 2 of Division 106).
(3)The Advanced Practice Nurse Training program (Part 2 (commencing with Section 123225) of Division 106).
(4)The Black Infant Health Program (Part 2 (commencing with Section 123225) of Division 106).
(5)The Breastfeeding Program (Article 3 (commencing with Section 123360) of Chapter 1 of Part 2 of Division 6).
(6)The California Diabetes and Pregnancy Program (Part 2 (commencing with Section 123225) of Division 106).
(7)The California Initiative to Improve Adolescent Health (Part 2 (commencing with Section 123225) of Division 106).
(8)The Childhood Injury Prevention Program (Article 4 (commencing with Section 100325) of Chapter 2 of Division 101).
(9)The Fetal and Infant Mortality Review Program (Article 1 (commencing with Section 123650) of Chapter 3 of Part 2 of Division 106).
(10)The Human Stem Cell Research Program (Chapter 3 (commencing with Section 125290.10) of Part 5 of Division 106; Chapter 1 (commencing with Section 125300) of Part 5.5 of Division 106).
(11)The Local Health Department Maternal, Child and Adolescent Health Program (Section 123255).
(12)The Maternal Mortality Review Program (Article 4 (commencing with Section 100325) of Chapter 2 of Division 101).
(13)The Oral Health Program (Part 2 (commencing with Section 123225) of Division 106).
(14)The Preconception Health and Health Care Initiative (Part 2 (commencing with Section 123225) of Division 106).
(15)The Regional Perinatal Programs of California (Article 4 (commencing with Section 123550) of Chapter 2 of Part 2 of Division 106).
(16)The Perinatal Dispatch Centers Outreach and Education Program (Article 4 (commencing with Section 123750) of Chapter 3 of Part 2 of Division 106).
(17)The State Early Childhood Comprehensive Services program (Part 2 (commencing with Section 123225) of Division 106).
(18)The Sudden Infant Death Syndrome Program (Article 3 (commencing with Section 123725) of Chapter 3 of Part 2 of Division 106).
(19)The Youth Pilot Program (Chapter 12.85 (commencing with Section 18987) of Part 6 of Division 9 of the Welfare and Institutions Code).
(20)The Office of Family Planning (Chapter 8.5 (commencing with Section 14500) of Part 3 of Division 9 of the Welfare and Institutions Code; Division 24 (commencing with Section 24000) of the Welfare and Institutions Code), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this office are hereby with the State Department of Health Care Services.
(21)The Community Challenge Grant Program (Section 14504.1 of the Welfare and Institutions Code, and Chapter 14 (commencing with Section 18993) of Part 6 of Division 9 of the Welfare and Institutions Code).
(22)The Information and Education Program (Section 14504.3 of the Welfare and Institutions Code).
(23)The Family PACT Program (subdivision (aa) of Section 14132 and Section 24005 of the Welfare and Institutions Code), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this program are hereby with the State Department of Health Care Services.
(24)The Male Involvement Program (Section 14504 of the Welfare and Institutions Code).
(25)The TeenSMART Outreach Program (Section 14504.2 of the Welfare and Institutions Code).
(26)The Battered Women Shelter Program (Chapter 6 (commencing with Section 124250) of Part 2 of Division 106).
(27)The Women, Infants and Children Program (Article 1 (commencing with Section 123275) of Chapter 1 of Part 2 of Division 106).
(28)The WIC Supplemental Nutrition Program (Article 1 (commencing with Section 123275) of Chapter 1 of Part 2 of Division 106).
(29)The Farmers Market Nutrition Program (Section 123279).
(30)Genetic Disease Program (Chapter 1 (commencing with Section 124975) of Part 5 of Division 106).
(31)The Newborn Screening Program (Chapter 1 (commencing with Section 124975) of Part 5 of Division 106).
(32)The Prenatal Screening Program (Chapter 1 (commencing with Section 124975) of Part 5 of Division 106).
SEC. 14.Section 14132 of the Welfare and Institutions Code is amended to read:14132.The following is the schedule of benefits under this chapter:
(a)Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center, respiratory care, optometric, chiropractic, psychology, podiatric, occupational therapy, physical therapy, speech therapy, audiology, acupuncture to the extent federal matching funds are provided for acupuncture, and services of persons rendering treatment by prayer or healing by spiritual means in the practice of any church or religious denomination insofar as these can be encompassed by federal participation under an approved plan, subject to utilization controls.
(b)(1)Inpatient hospital services, including, but not limited to, physician and podiatric services, physical therapy, and occupational therapy, are covered subject to utilization controls.
(2)For a Medi-Cal fee-for-service member, emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition. This paragraph does not change the obligation of Medi-Cal managed care plans to provide emergency services and care. For the purposes of this paragraph, emergency services and care and emergency medical condition have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.
(c)Nursing facility services, subacute care services, and services provided by any category of intermediate care facility for the developmentally disabled, including podiatry, physician, nurse practitioner services, and prescribed drugs, as described in subdivision (d), are covered subject to utilization controls. Respiratory care, physical therapy, occupational therapy, speech therapy, and audiology services for patients in nursing facilities and any category of intermediate care facility for persons with developmental disabilities are covered subject to utilization controls.
(d)(1)Purchase of prescribed drugs is covered subject to the Medi-Cal List of Contract Drugs and utilization controls.
(2)Purchase of drugs used to treat erectile dysfunction or any off-label uses of those drugs are covered only to the extent that federal financial participation is available.
(3)(A)To the extent required by federal law, the purchase of outpatient prescribed drugs, for which the prescription is executed by a prescriber in written, nonelectronic form on or after April 1, 2008, is covered only when executed on a tamper resistant prescription form. The implementation of this paragraph shall conform to the guidance issued by the federal Centers for Medicare and Medicaid Services, but shall not conflict with state statutes on the characteristics of tamper resistant prescriptions for controlled substances, including Section 11162.1 of the Health and Safety Code. The department shall provide providers and members with as much flexibility in implementing these rules as allowed by the federal government. The department shall notify and consult with appropriate stakeholders in implementing, interpreting, or making specific this paragraph.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instructions without taking regulatory action.
(4)(A)(i)For the purposes of this paragraph, nonlegend has the same meaning as defined in subdivision (a) of Section 14105.45.
(ii)Nonlegend acetaminophen-containing products, including childrens acetaminophen-containing products, selected by the department are covered benefits.
(iii)Nonlegend cough and cold products selected by the department are covered benefits.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instruction without taking regulatory action.
(e)Outpatient dialysis services and home hemodialysis services, including physician services, medical supplies, drugs, and equipment required for dialysis, are covered, subject to utilization controls.
(f)Anesthesiologist services when provided as part of an outpatient medical procedure, nurse anesthetist services when rendered in an inpatient or outpatient setting under conditions set forth by the director, outpatient laboratory services, and x-ray services are covered, subject to utilization controls. This subdivision does not require prior authorization for anesthesiologist services provided as part of an outpatient medical procedure or for portable x-ray services in a nursing facility or any category of intermediate care facility for the developmentally disabled.
(g)Blood and blood derivatives are covered.
(h)(1)Emergency and essential diagnostic and restorative dental services, except for orthodontic, fixed bridgework, and partial dentures that are not necessary for balance of a complete artificial denture, are covered, subject to utilization controls. The utilization controls shall allow emergency and essential diagnostic and restorative dental services and prostheses that are necessary to prevent a significant disability or to replace previously furnished prostheses that are lost or destroyed due to circumstances beyond the members control. Notwithstanding the foregoing, the director may by regulation provide for certain fixed artificial dentures necessary for obtaining employment or for medical conditions that preclude the use of removable dental prostheses, and for orthodontic services in cleft palate deformities administered by the departments California Childrens Services program.
(2)For persons 21 years of age or older, the services specified in paragraph (1) shall be provided subject to the following conditions:
(A)Periodontal treatment is not a benefit.
(B)Endodontic therapy is not a benefit except for vital pulpotomy.
(C)Laboratory processed crowns are not a benefit.
(D)Removable prosthetics shall be a benefit only for patients as a requirement for employment.
(E)The director may, by regulation, provide for the provision of fixed artificial dentures that are necessary for medical conditions that preclude the use of removable dental prostheses.
(F)Notwithstanding the conditions specified in subparagraphs (A) to (E), inclusive, the department may approve services for persons with special medical disorders subject to utilization review.
(3)Paragraph (2) shall become inoperative on July 1, 1995.
(i)Medical transportation is covered, subject to utilization controls.
(j)Home health care services are covered, subject to utilization controls.
(k)(1)Prosthetic and orthotic devices and eyeglasses are covered, subject to utilization controls. Utilization controls shall allow replacement of prosthetic and orthotic devices and eyeglasses necessary because of loss or destruction due to circumstances beyond the members control. Frame styles for eyeglasses replaced pursuant to this subdivision shall not change more than once every two years, unless the department so directs.
(2)Orthopedic and conventional shoes are covered when provided by a prosthetic and orthotic supplier on the prescription of a physician and when at least one of the shoes will be attached to a prosthesis or brace, subject to utilization controls. Modification of stock conventional or orthopedic shoes when medically indicated is covered, subject to utilization controls. If there is a clearly established medical need that cannot be satisfied by the modification of stock conventional or orthopedic shoes, custom-made orthopedic shoes are covered, subject to utilization controls.
(3)Therapeutic shoes and inserts are covered when provided to a member with a diagnosis of diabetes, subject to utilization controls, to the extent that federal financial participation is available.
(l)Hearing aids are covered, subject to utilization controls. Utilization controls shall allow replacement of hearing aids necessary because of loss or destruction due to circumstances beyond the members control.
(m)Durable medical equipment and medical supplies are covered, subject to utilization controls. The utilization controls shall allow the replacement of durable medical equipment and medical supplies when necessary because of loss or destruction due to circumstances beyond the members control. The utilization controls shall allow authorization of durable medical equipment needed to assist a disabled member in caring for a child for whom the disabled member is a parent, stepparent, foster parent, or legal guardian, subject to the availability of federal financial participation. The department shall adopt emergency regulations to define and establish criteria for assistive durable medical equipment in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(n)Family planning services are covered, subject to utilization controls. However, for Medi-Cal managed care plans, utilization controls shall be subject to Section 1367.25 of the Health and Safety Code.
(o)Inpatient intensive rehabilitation hospital services, including respiratory rehabilitation services, in a general acute care hospital are covered, subject to utilization controls, when either of the following criteria are met:
(1)A patient with a permanent disability or severe impairment requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to develop function beyond the limited amount that would occur in the normal course of recovery.
(2)A patient with a chronic or progressive disease requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to maintain the patients present functional level as long as possible.
(p)(1)Adult day health care is covered in accordance with Chapter 8.7 (commencing with Section 14520).
(2)Commencing 30 days after the effective date of the act that added this paragraph, and notwithstanding the number of days previously approved through a treatment authorization request, adult day health care is covered for a maximum of three days per week.
(3)As provided in accordance with paragraph (4), adult day health care is covered for a maximum of five days per week.
(4)As of the date that the director makes the declaration described in subdivision (g) of Section 14525.1, paragraph (2) shall become inoperative and paragraph (3) shall become operative.
(q)(1)Application of fluoride, or other appropriate fluoride treatment as defined by the department, and other prophylaxis treatment for children 17 years of age and under are covered.
(2)All dental hygiene services provided by a registered dental hygienist, registered dental hygienist in extended functions, and registered dental hygienist in alternative practice licensed pursuant to Sections 1753, 1917, 1918, and 1922 of the Business and Professions Code may be covered as long as they are within the scope of Denti-Cal benefits and they are necessary services provided by a registered dental hygienist, registered dental hygienist in extended functions, or registered dental hygienist in alternative practice.
(r)(1)Paramedic services performed by a city, county, or special district, or pursuant to a contract with a city, county, or special district, and pursuant to a program established under former Article 3 (commencing with Section 1480) of Chapter 2.5 of Division 2 of the Health and Safety Code by a paramedic certified pursuant to that article, and consisting of defibrillation and those services specified in subdivision (3) of former Section 1482 of the article.
(2)A provider enrolled under this subdivision shall satisfy all applicable statutory and regulatory requirements for becoming a Medi-Cal provider.
(3)This subdivision shall be implemented only to the extent funding is available under Section 14106.6.
(s)(1)In-home medical care services are covered when medically appropriate and subject to utilization controls, for a member who would otherwise require care for an extended period of time in an acute care hospital at a cost higher than in-home medical care services. The director shall have the authority under this section to contract with organizations qualified to provide in-home medical care services to those persons. These services may be provided to a patient placed in a shared or congregate living arrangement, if a home setting is not medically appropriate or available to the member.
(2)As used in this subdivision, in-home medical care service includes utility bills directly attributable to continuous, 24-hour operation of life-sustaining medical equipment, to the extent that federal financial participation is available.
(3)As used in this subdivision, in-home medical care services include, but are not limited to:
(A)Level-of-care and cost-of-care evaluations.
(B)Expenses, directly attributable to home care activities, for materials.
(C)Physician fees for home visits.
(D)Expenses directly attributable to home care activities for shelter and modification to shelter.
(E)Expenses directly attributable to additional costs of special diets, including tube feeding.
(F)Medically related personal services.
(G)Home nursing education.
(H)Emergency maintenance repair.
(I)Home health agency personnel benefits that permit coverage of care during periods when regular personnel are on vacation or using sick leave.
(J)All services needed to maintain antiseptic conditions at stoma or shunt sites on the body.
(K)Emergency and nonemergency medical transportation.
(L)Medical supplies.
(M)Medical equipment, including, but not limited to, scales, gurneys, and equipment racks suitable for paralyzed patients.
(N)Utility use directly attributable to the requirements of home care activities that are in addition to normal utility use.
(O)Special drugs and medications.
(P)Home health agency supervision of visiting staff that is medically necessary, but not included in the home health agency rate.
(Q)Therapy services.
(R)Household appliances and household utensil costs directly attributable to home care activities.
(S)Modification of medical equipment for home use.
(T)Training and orientation for use of life-support systems, including, but not limited to, support of respiratory functions.
(U)Respiratory care practitioner services as defined in Sections 3702 and 3703 of the Business and Professions Code, subject to prescription by a physician and surgeon.
(4)A member receiving in-home medical care services is entitled to the full range of services within the Medi-Cal scope of benefits as defined by this section, subject to medical necessity and applicable utilization control. Services provided pursuant to this subdivision, which are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with a home- and community-based services waiver.
(t)Home- and community-based services approved by the United States Department of Health and Human Services are covered to the extent that federal financial participation is available for those services under the state plan or waivers granted in accordance with Section 1315 or 1396n of Title 42 of the United States Code. The director may seek waivers for any or all home- and community-based services approvable under Section 1315 or 1396n of Title 42 of the United States Code. Coverage for those services shall be limited by the terms, conditions, and duration of the federal waivers.
(u)Comprehensive perinatal services meeting the standards developed by the department pursuant to Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to implement the provisions of this subdivision. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented. Provisions for which waivers are obtained or for which waivers are not required shall be implemented notwithstanding any inability to obtain federal waivers for the other provisions. No provision of this subdivision shall be implemented unless matching funds from Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code are available.
(v)Early and periodic screening, diagnosis, and treatment for any individual under 21 years of age is covered, consistent with the requirements of Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code.
(w)(1)Hospice services are covered, in accordance with Medicare requirements, and are subject to utilization controls. Coverage shall be available only to the extent that no additional net program costs are incurred.
(2)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(3)Notwithstanding any other law, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions.
(x)When a claim for treatment provided to a member includes both services that are authorized and reimbursable under this chapter and services that are not reimbursable under this chapter, that portion of the claim for the treatment and services authorized and reimbursable under this chapter shall be payable.
(y)Home- and community-based services approved by the United States Department of Health and Human Services for a member with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex, who requires intermediate care or a higher level of care.
Services provided pursuant to a waiver obtained from the Secretary of the United States Department of Health and Human Services pursuant to this subdivision, and that are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with the waiver, and subject to the terms, conditions, and duration of the waiver. These services shall be provided to a member in accordance with the clients needs as identified in the plan of care, and subject to medical necessity and applicable utilization control.
The director may, under this section, contract with organizations qualified to provide, directly or by subcontract, services provided for in this subdivision to an eligible member. Contracts or agreements entered into pursuant to this division shall not be subject to the Public Contract Code.
(z)Respiratory care when provided in organized health care systems as defined in Section 3701 of the Business and Professions Code, and as an in-home medical service as outlined in subdivision (s).
(aa)(1)There is hereby established in the department a program to provide comprehensive clinical family planning services to any person who has a family income at or below 200 percent of the federal poverty level, as revised annually, and who is eligible to receive these services pursuant to the waiver identified in paragraph (2). This program shall be known as the Family Planning, Access, Care, and Treatment (Family PACT) Program.
(2)The department shall seek a waiver in accordance with Section 1315 of Title 42 of the United States Code, or a state plan amendment adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code, which was added to Section 1396a of Title 42 of the United States Code by Section 2303(a)(2) of the federal Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148), for a program to provide comprehensive clinical family planning services as described in paragraph (8). Under the waiver, the program shall be operated only in accordance with the waiver and the statutes and regulations in paragraph (4) and subject to the terms, conditions, and duration of the waiver. Under the state plan amendment, which shall replace the waiver and shall be known as the Family PACT successor state plan amendment, the program shall be operated only in accordance with this subdivision and the statutes and regulations in paragraph (4). The state shall use the standards and processes imposed by the state on January 1, 2007, including the application of an eligibility discount factor to the extent required by the federal Centers for Medicare and Medicaid Services, for purposes of determining eligibility as permitted under Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the extent that federal financial participation is available, the program shall continue to conduct education, outreach, enrollment, service delivery, and evaluation services as specified under the waiver. The services shall be provided under the program only if the waiver and, when applicable, the successor state plan amendment are approved by the federal Centers for Medicare and Medicaid Services and only to the extent that federal financial participation is available for the services. This section does not prohibit the department from seeking the Family PACT successor state plan amendment during the operation of the waiver.
(3)Solely for the purposes of the waiver or Family PACT successor state plan amendment and notwithstanding any other law, the collection and use of an individuals social security number shall be necessary only to the extent required by federal law.
(4)Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and 24013, and any regulations adopted under these statutes shall apply to the program provided for under this subdivision. No other law under the Medi-Cal program or the State-Only Family Planning Program shall apply to the program provided for under this subdivision.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, without taking regulatory action, the provisions of the waiver after its approval by the federal Centers for Medicare and Medicaid Services and the provisions of this section by means of an all-county letter or similar instruction to providers. Thereafter, the department shall adopt regulations to implement this section and the approved waiver in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act adding this subdivision, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.
(6)If the Department of Finance determines that the program operated under the authority of the waiver described in paragraph (2) or the Family PACT successor state plan amendment is no longer cost effective, this subdivision shall become inoperative on the first day of the first month following the issuance of a 30-day notification of that determination in writing by the Department of Finance to the chairperson in each house that considers appropriations, the chairpersons of the committees, and the appropriate subcommittees in each house that considers the State Budget, and the Chairperson of the Joint Legislative Budget Committee.
(7)If this subdivision ceases to be operative, all persons who have received or are eligible to receive comprehensive clinical family planning services pursuant to the waiver described in paragraph (2) shall receive family planning services under the Medi-Cal program pursuant to subdivision (n) if they are otherwise eligible for Medi-Cal with no spend down of excess income, or shall receive comprehensive clinical family planning services under the program established in Division 24 (commencing with Section 24000) either if they are eligible for Medi-Cal with a spend down of excess income or if they are otherwise eligible under Section 24003.
(8)For purposes of this subdivision, comprehensive clinical family planning services means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, natural family planning, abstinence methods, and basic, limited fertility management. Comprehensive clinical family planning services include, but are not limited to, preconception counseling, maternal and fetal health counseling, general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, medical family planning treatment and procedures, including supplies and followup, and informational, counseling, and educational services. Comprehensive clinical family planning services shall not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care that is not incident to the diagnosis of pregnancy. Comprehensive clinical family planning services shall be subject to utilization control and include all of the following:
(A)Family planning related services and male and female sterilization. Family planning services for men and women shall include emergency services and services for complications directly related to the contraceptive method, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, and followup, consultation, and referral services, as indicated, which may require treatment authorization requests.
(B)All United States Department of Agriculture, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies that are in keeping with current standards of practice and from which the individual may choose.
(C)Culturally and linguistically appropriate health education and counseling services, including informed consent, that include all of the following:
(i)Psychosocial and medical aspects of contraception.
(ii)Sexuality.
(iii)Fertility.
(iv)Pregnancy.
(v)Parenthood.
(vi)Infertility.
(vii)Reproductive health care.
(viii)Preconception and nutrition counseling.
(ix)Prevention and treatment of sexually transmitted infection.
(x)Use of contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies.
(xi)Possible contraceptive consequences and followup.
(xii)Interpersonal communication and negotiation of relationships to assist individuals and couples in effective contraceptive method use and planning families.
(D)A comprehensive health history, updated at the next periodic visit (between 11 and 24 months after initial examination) that includes a complete obstetrical history, gynecological history, contraceptive history, personal medical history, health risk factors, and family health history, including genetic or hereditary conditions.
(E)A complete physical examination on initial and subsequent periodic visits.
(F)Services, drugs, devices, and supplies deemed by the federal Centers for Medicare and Medicaid Services to be appropriate for inclusion in the program.
(G)(i)Home test kits for sexually transmitted diseases, including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal or Family PACT clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(ii)For purposes of this subparagraph, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(iii)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Family PACT provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(9)In order to maximize the availability of federal financial participation under this subdivision, the director shall have the discretion to implement the Family PACT successor state plan amendment retroactively to July 1, 2010.
(ab)(1)Purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products and utilization controls.
(2)Purchase of enteral nutrition products is limited to those products to be administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube. A member under the Early and Periodic Screening, Diagnostic, and Treatment Program shall be exempt from this paragraph.
(3)Notwithstanding paragraph (2), the department may deem an enteral nutrition product, not administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube, a benefit for patients with diagnoses, including, but not limited to, malabsorption and inborn errors of metabolism, if the product has been shown to be neither investigational nor experimental when used as part of a therapeutic regimen to prevent serious disability or death.
(4)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the amendments to this subdivision made by the act that added this paragraph by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.
(5)The amendments made to this subdivision by the act that added this paragraph shall be implemented June 1, 2011, or on the first day of the first calendar month following 60 days after the date the department secures all necessary federal approvals to implement this section, whichever is later.
(ac)Diabetic testing supplies are covered when provided by a pharmacy, subject to utilization controls.
(ad)(1)Nonmedical transportation is covered, subject to utilization controls and permissible time and distance standards, for a member to obtain covered Medi-Cal services.
(2)(A)(i)Nonmedical transportation includes, at a minimum, round trip transportation for a member to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance, and mileage reimbursement when conveyance is in a private vehicle arranged by the member and not through a transportation broker, bus passes, taxi vouchers, or train tickets.
(ii)Nonmedical transportation does not include the transportation of a sick, injured, invalid, convalescent, infirm, or otherwise incapacitated member by ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations.
(B)Nonmedical transportation shall be provided for a member who can attest in a manner to be specified by the department that other currently available resources have been reasonably exhausted. For a member enrolled in a managed care plan, nonmedical transportation shall be provided by the members managed care plan. For a Medi-Cal fee-for-service member, the department shall provide nonmedical transportation when those services are not available to the member under Sections 14132.44 and 14132.47.
(3)Nonmedical transportation shall be provided in a form and manner that is accessible, in terms of physical and geographic accessibility, for the member and consistent with applicable state and federal disability rights laws.
(4)It is the intent of the Legislature in enacting this subdivision to affirm the requirement under Section 431.53 of Title 42 of the Code of Federal Regulations, in which the department is required to provide necessary transportation, including nonmedical transportation, for recipients to and from covered services. This subdivision shall not be interpreted to add a new benefit to the Medi-Cal program.
(5)The department shall seek any federal approvals that may be required to implement this subdivision, including, but not limited to, approval of revisions to the existing state plan that the department determines are necessary to implement this subdivision.
(6)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained.
(7)Prior to the effective date of any necessary federal approvals, nonmedical transportation was not a Medi-Cal managed care benefit with the exception of when provided as an Early and Periodic Screening, Diagnostic, and Treatment service.
(8)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing January 1, 2018, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(9)This subdivision shall not be implemented until July 1, 2017.
(ae)(1)No sooner than January 1, 2022, Rapid Whole Genome Sequencing, including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal member who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(af)(1)Home test kits for sexually transmitted diseases that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(2)For purposes of this subdivision, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(3)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Medi-Cal provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(4)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
(ag)(1)Violence prevention services are covered, subject to medical necessity and utilization controls.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(4)The department shall post on its internet website the date upon which violence prevention services may be provided and billed pursuant to this subdivision.
(5)Violence prevention services means evidence-based, trauma-informed, and culturally responsive preventive services provided to reduce the incidence of violent injury or reinjury, trauma, and related harms and promote trauma recovery, stabilization, and improved health outcomes.
SEC. 15.Section 14132.100 of the Welfare and Institutions Code, as added by Section 104 of Chapter 21 of the Statutes of 2025, is amended to read:14132.100.(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.(c)Federally qualified health center services and rural health clinic services that are eligible for federal financial participation shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.(B)A change in service due to amended regulatory requirements or rules.(C)A change in service resulting from relocating or remodeling an FQHC or RHC.(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).(3)A change in costs is not, in and of itself, a scope-of-service change, unless all of the following apply:(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.(4)A request shall be submitted for each affected year.(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.(6)The department shall notify the provider of the departments discretionary decision in writing.(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, or a visiting nurse that is eligible for federal financial participation. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit that is eligible for federal financial participation.(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist that is eligible for federal financial participation.(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.(C)An FQHC or RHC that does not provide dental hygienist or dental hygienist in alternative practice services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist that is eligible for federal financial participation.(4)(A)(i)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.(ii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.(iii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.(iv)(I)An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction.(II)Notwithstanding subclause (I), the department may provide for exceptions to the prohibition established by subclause (I), including, but not limited to, the exceptions described in sub-subclauses (ia) and (ib), which shall be developed in consultation with affected stakeholders and published in departmental guidance.(ia)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.(ib)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.(v)An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:(I)The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.(II)The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.(III)The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.(IV)An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.(B)(i)Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve member choice.(ii)The department may provide specific exceptions to the requirement specified in clause (i), based on an FQHCs or RHCs access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.(iii)Effective on the date designated by the department pursuant to clause (i), an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:(I)Offer those services via in-person, face-to-face contact.(II)Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.(iv)In addition to any existing law requiring member consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by an FQHC or RHC to a Medi-Cal member, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal member: an explanation that members have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal member without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for nonmedical transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the FQHC or RHC.(I)The FQHC or RHC shall document in the patient record the provision of this information and the patients verbal or written acknowledgment that the information was received.(II)The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subparagraph.(C)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.(D)This paragraph shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subparagraph (C), whichever is later. This paragraph shall not be construed to limit coverage of, and reimbursement for, covered telehealth services provided before the operative date of this paragraph.(E)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this paragraph by means of all-county letters, plan letters, provider manuals, information notices, provider bulletins, and similar instructions, without taking any further regulatory action.(F)Telehealth modalities authorized pursuant to this paragraph shall be subject to the billing, reimbursement, and utilization management policies imposed by the department.(G)Services delivered via telehealth modalities described in this paragraph shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid state plan, and any other applicable state and federal statutes and regulations.(5)For purposes of this section, physician shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor.(6)(A)Notwithstanding any other provision of this section, pursuant to an effective date designated by the department that is no sooner than January 1, 2027, a PPS billable visit shall not include an encounter with a comprehensive perinatal practitioner who is not otherwise a PPS billable health professional pursuant to paragraph (1).(B)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized. (C)This paragraph shall be implemented only for dates of service on or after the department implements the alternative payment methodology or other appropriate financing mechanism described in paragraph (7).(7)(A)Notwithstanding any other provision of this section, pursuant to an effective date designated by the department that is no sooner than January 1, 2027, the department may implement an alternative payment methodology or other appropriate financing mechanism that allows FQHCs and RHCs to obtain reimbursement for encounters with community health workers at no less than the applicable Medi-Cal fee-for-service rate when provided either on the same day or different day as a PPS-billable visit.(B)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.(i)(1)Provided that the following entities are not operating as intermittent clinics, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, each entity shall have its reimbursement rate established in accordance with one of the methods outlined in paragraph (2) or (3), as selected by the FQHC or RHC:(A)An entity that first qualifies as an FQHC or RHC in 2001 or later.(B)A newly licensed facility at a new location added to an existing FQHC or RHC.(C)An entity that is an existing FQHC or RHC that is relocated to a new site.(2)(A)An FQHC or RHC that adds a new licensed location to its existing primary care license under paragraph (1) of subdivision (b) of Section 1212 of the Health and Safety Code may elect to have the reimbursement rate for the new location established in accordance with paragraph (3), or notwithstanding subdivision (e), an FQHC or RHC may choose to have one PPS rate for all locations that appear on its primary care license determined by submitting a change in scope of service request if both of the following requirements are met:(i)The change in scope of service request includes the costs and visits for those locations for the first full fiscal year immediately following the date the new location is added to the FQHCs or RHCs existing licensee.(ii)The FQHC or RHC submits the change in scope of service request within 90 days after the FQHCs or RHCs first full fiscal year.(B)The FQHCs or RHCs single PPS rate for those locations shall be calculated based on the total costs and total visits of those locations and shall be determined based on the following:(i)An audit in accordance with Section 14170.(ii)Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successors.(iii)Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.(C)Except as specified in subdivision (j), this paragraph does not apply to a location that was added to an existing primary care clinic license by the State Department of Public Health, whether by a regional district office or the centralized application unit, prior to January 1, 2017.(3)If an FQHC or RHC does not elect to have the PPS rate determined by a change in scope of service request, the FQHC or RHC shall have the reimbursement rate established for any of the entities identified in paragraph (1) or (2) in accordance with one of the following methods at the election of the FQHC or RHC:(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.(4)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.(5)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.(j)(1)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, in a mobile unit as defined in subdivision (b) of Section 1765.105 of the Health and Safety Code, or at the election of the FQHC or RHC and subject to paragraph (2), a location added to an existing primary care clinic license by the State Department of Public Health prior to January 1, 2017, shall be billed by and reimbursed at the same rate as the FQHC or RHC that either established the intermittent clinic site or mobile unit, or that held the clinic license to which the location was added prior to January 1, 2017.(2)If an FQHC or RHC with at least one additional location on its primary care clinic license that was added by the State Department of Public Health prior to January 1, 2017, applies for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (e), all locations on the FQHCs or RHCs primary care clinic license shall be subject to a scope-of-service adjustment in accordance with either paragraph (2) or (3) of subdivision (i), as selected by the FQHC or RHC.(3)This subdivision does not preclude or otherwise limit the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).(l)Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.(1)An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).(2)(A)For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.(3)If the costs associated with providing Drug Medi-Cal services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.(B)An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.(C)The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.(F)For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).(4)Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).(A)In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.(B)In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.(5)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.(6)For purposes of this subdivision, the following definitions apply:(A)Drug Medi-Cal organized delivery system or DMC-ODS means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.(B)Special Terms and Conditions has the same meaning as set forth in subdivision (o) of Section 14184.10.(m)Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.(1)An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal members as part of the mental health plans network.(2)(A)For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.(3)If the costs associated with providing specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.(B)An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department is retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but the effective date shall not be earlier than January 1, 2018.(C)The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.(F)For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).(4)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.(n)The department shall seek any necessary federal approvals and issue appropriate guidance to allow an FQHC or RHC to bill, under a supervising licensed behavioral health practitioner, for an encounter between an FQHC or RHC patient and a psychological associate, associate professional clinical counselor, associate clinical social worker, or associate marriage and family therapist when all of the following conditions are met:(1)The psychological associate, associate professional clinical counselor, associate clinical social worker, or associate marriage and family therapist is supervised by the designated licensed behavioral health practitioner, as required by their applicable clinical licensing board.(2)The behavioral health visit is billed under the supervising licensed practitioner of the FQHC or RHC, pursuant to paragraph (1).(3)The FQHC or RHC is otherwise authorized to bill for services provided by the supervising licensed behavioral health practitioner as a separate visit.(o)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.(p)The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.(q)The department shall implement this section only to the extent that federal financial participation is available.(r)Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of this section, including all of the following:(1)Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days prior to the meeting described in paragraph (2).(2)Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.(3)Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.(4)Providing at least 60 days advance notice of the effective date of the proposed action or change.(s)This section shall become operative on July 1, 2026.SEC. 16.SEC. 15.Section 14134.5 of the Welfare and Institutions Code is repealed.SEC. 17.SEC. 16.Section 14134.5 is added to the Welfare and Institutions Code, to read:14134.5.(a)A Medi-Cal provider providing pregnancy care managed care plan shall inform each Medi-Cal member treated during the perinatal period regarding the availability of and access to comprehensive perinatal services, in accordance with this section.
(b)A Medi-Cal members participation in comprehensive perinatal services provided pursuant to subdivision (u) of Section 14132 and this section is voluntary.
(c)Comprehensive perinatal services shall, to the extent feasible, be provided in a manner that reflects the linguistic and cultural features of the populations served.
(d)The department shall do all of the following:
(1)Establish a method for reimbursement of comprehensive perinatal services that shall cover reasonable costs for the provision of comprehensive perinatal services, in accordance with subdivision (a) of Section 14105.05. The department may utilize fee schedules, capitated fees, or global fees to reimburse Medi-Cal providers providing comprehensive perinatal services.
(2)Develop systems for the monitoring and oversight of comprehensive perinatal services.
(3)Establish standards for comprehensive perinatal services rendered by a Medi-Cal provider pursuant to subdivision (u) of Section 14132 and this section.
(4)Adopt patient rights safeguards for recipients of the comprehensive perinatal services.
(5)Adopt regulations to implement this section, as determined to be necessary by the department.
(e)For purposes of this section and the provision of services pursuant to subdivision (u) of Section 14132:
(1)Comprehensive perinatal services includes the provision of the combination of Medi-Cal services and supports, as determined and defined by the department. Comprehensive perinatal services includes all of the following:
(A)A psychosocial assessment and, if appropriate, referral to counseling.
(B)Nutrition assessments and, if appropriate, referral to counseling on food supplement programs, vitamins, and breastfeeding.
(C)Health, childbirth, and parenting education.
(D)Assistance with scheduling visits with appropriate providers and followup to verify whether services have been received.
(2)Family physician means a primary care physician and surgeon who renders continued comprehensive and preventative health care services to individuals and families, and who has received specialized training in an approved family medicine residency for three years after graduation from an accredited medical school.(3)Medi-Cal provider providing pregnancy care means an obstetrician-gynecologist, a family physician, a certified nurse-midwife, or a licensed midwife enrolled in Medi-Cal pursuant to subdivision (b) of Section 438.602 of Title 42 of the Code of Federal Regulations or Chapter 7 (commencing with Section 14000) that directly, indirectly, or through a group, association, corporation, institution, entity, or clinic, provide outpatient care related to pregnancy to a Medi-Cal member. For the purposes of this definition, Medi-Cal provider providing pregnancy care also includes the clinic, group, association, corporation, institution, entity, or clinic through which the aforementioned providers provide pregnancy care.(4)(2)Perinatal means the period from the establishment of pregnancy through 12 months following the end of pregnancy.
(f)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar instructions.
(g)This section does not revise or expand the scope of practice of licensed midwives, as defined in Article 24 (commencing with Section 2505) of Chapter 5 of Division 2 of the Business and Professions Code.
It is the intent of the Legislature to enact legislation implementing several recommendations made in California State Auditor Report 2023-103: The Comprehensive Perinatal Services Program to enhance monitoring and oversight and do all of the following:
(a)Clarify that the State Department of Health Care Services is responsible for the delivery of the comprehensive perinatal services benefit as the single state agency pursuant to Section 10740 of the Welfare and Institutions Code that oversees the Medi-Cal program. It is the intent of the Legislature that the State Department of Health Care Services collaborate with the State Department of Public Health when appropriate.
(b)Require the State Department of Health Care Services to collaborate with the State Department of Public Health on updated regulations related to comprehensive perinatal services.
(c)Require the State Department of Health Care Services to modify an existing system or develop a new system of oversight to monitor and publicly report comprehensive perinatal services utilization data for comprehensive perinatal services for eligible Medi-Cal members.
SEC. 2.Section 123486 is added to the Health and Safety Code, to read:123486.Any participation in administration of the program by the State Department of Public Health, including administrative services pursuant to a contract or other collaboration with the State Department of Health Care Services, shall not supplant, create concurrent, nor supersede the State Department of Health Care Services authority as the designated single state agency for the administration of the federal Medicaid program pursuant to Section 10740 of the Welfare and Institutions Code and as designated in Californias Medicaid state plan. As such, the State Department of Health Care Services is ultimately responsible for the implementation of this benefit for the purposes of the Medi-Cal program.
SEC. 3.Section 123487 is added to the Health and Safety Code, to read:123487.(a)The State Department of Health Care Services shall collaborate with the State Department of Public Health to update the regulations related to comprehensive perinatal services to clarify the roles and responsibilities from each department and make adjustments to the current monitoring and oversights systems, including the monitoring of managed care plans and fee-for-service providers, by January 1, 2028.
(b)The State Department of Health Care Services, with collaboration from the State Department of Public Health, shall develop a training on administering comprehensive perinatal services. By January 1, 2028, the State Department of Health Care Services shall require that all providers providing perinatal care to Medi-Cal members complete the training, including managed care plan and fee-for-service providers.
SEC. 4.Section 123490 of the Health and Safety Code is repealed.123490.(a) The department shall develop and maintain a statewide comprehensive community-based perinatal services program and enter into contracts, grants, or agreements with health care providers to deliver these services in a coordinated effort to the extent permitted under federal law and regulation. These contracts, grants, or agreements shall be made in medically underserved areas or areas with demonstrated need. Nothing in this section shall be construed to prevent reallocation of resources or use of new moneys for the development of new community-based comprehensive perinatal systems in underserved areas or areas with demonstrated need, and supplementation of systems already in existence.(b) As a condition of receiving funds from the Maternal and Child Health program, contractors shall bill the Medi-Cal program for services provided to Medi-Cal recipients.SEC. 5.Section 123490 is added to the Health and Safety Code, to read:123490.The State Department of Health Care Services shall oversee a statewide comprehensive community-based perinatal services program and enroll health care providers to deliver these services to Medi-Cal members.
SEC. 6.Section 123491 of the Health and Safety Code is amended to read:123491.(a) There is hereby established a voluntary nurse home visiting grant program for expectant first-time mothers, their children, and their families, to be administered by the department State Department of Public Health pursuant to Section 123492. The program may be cited as the Nurse-Family Partnership program.
(b)The goals and objectives of the program shall be the same as, but shall not be limited to, those in the community-based comprehensive perinatal health care system as set forth in Section 123505.
(c)The department State Department of Public Health shall adopt regulations for the implementation of this section in accordance with Section 123516.
SEC. 7.Section 123492 of the Health and Safety Code is amended to read:123492.The department State Department of Public Health shall develop a grant application and award grants on a competitive basis to counties for the startup, continuation, and expansion of the program established pursuant to Section 123491. To be eligible to receive a grant for purposes of that section, a county shall agree to all of the following:
(a)Serve through the program only pregnant, low-income women who have had no previous live births. Notwithstanding subdivision (b) of Section 123485, women who are juvenile offenders or who are clients of the juvenile system shall be deemed eligible for services under the program.
(b)Enroll women in the program while they are still pregnant, before the 28th week of gestation, and preferably before the 16th week of gestation, and continue those women in the program through the first two years of the childs life.
(c)Use as home visitors only registered nurses who have been licensed in the state.
(d)Have nurse home visitors undergo training according to the program and follow the home visit guidelines developed by the Nurse-Family Partnership program.
(e)Have nurse home visitors specially trained in prenatal care and early child development.
(f)Have nurse home visitors follow a visit schedule keyed to the developmental stages of pregnancy and early childhood.
(g)Ensure that, to the extent possible, services shall be rendered in a culturally and linguistically competent manner.
(h)Limit a nurse home visitors caseload to no more than 25 active families at any given time.
(i)Provide for every eight nurse home visitors a full-time nurse supervisor who holds at least a bachelors degree in nursing and has substantial experience in community health nursing.
(j)Have nurse home visitors and nurse supervisors trained in effective home visitation techniques by qualified trainers.
(k)Have nurse home visitors and nurse supervisors trained in the method of assessing early infant development and parent-child interaction in a manner consistent with the program.
(l)Provide data on operations, results, and expenditures in the formats and with the frequencies specified by the department. State Department of Public Health.
(m)Collaborate with other home visiting and family support programs in the community to avoid duplication of services and complement and integrate with existing services to the extent practicable.
(n)Demonstrate that adoption of the Nurse-Family Partnership program is supported by a local governmental or government-affiliated community planning board, decisionmaking board, or advisory body responsible for assuring the availability of effective, coordinated services for families and children in the community.
(o)Provide cash or in-kind matching funds in the amount of 100 percent of the grant award.
(p)Prohibit the use of moneys received for the program as a match for grants currently administered by the department. State Department of Public Health.
SEC. 8.Section 123493 of the Health and Safety Code is amended to read:123493.(a)The department State Department of Public Health may accept voluntary contributions, in cash or in-kind, to pay for the costs in the implementation of the program under Section 123492. These private donations shall be deposited into the California Families and Children Account, which is hereby created in the State Treasury, in which, notwithstanding Section 13340 of the Government Code, is hereby continuously appropriated to the department State Department of Public Health for purposes of implementing Section 123492. No state funds shall State funds shall not be used in implementing Section 123492.
(b)The department State Department of Public Health shall only distribute grants established under Section 123492 if the Director of Finance determines, in writing, that there are sufficient funds from private donations available in the account for expenditure for the purposes of the program.
(c)The departments State Department of Public Healths administration costs shall not exceed 5 percent of the moneys in the account created under subdivision (a). Any costs to the department State Department of Public Health incurred prior to the account receiving funds shall be reimbursed to the department State Department of Public Health from funds in the account.
(d)The department State Department of Public Health shall not apply for grants or solicit private funds.
(e)If, as of January 1, 2009, the Director of Finance determines pursuant to subdivision (a) that there are insufficient funds on deposit in the account to implement the voluntary nurse home visiting grant program, the account shall cease to exist.
SEC. 9.Section 123501 is added to the Health and Safety Code, to read:123501.(a)The State Department of Health Care Services shall require all Medi-Cal managed care plans to include information on comprehensive perinatal services in the plan member handbooks.
(b)The State Department of Health Care Services shall require all Medi-Cal managed care plans to ensure that their network providers have received the training described in Section 123487.
(c)No later than January 1, 2028, the State Department of Health Care Services shall update an existing system or implement a new system to monitor and publicly report eligible Medi-Cal members.
(d)The State Department of Health Care Services shall require Medi-Cal managed care plans, as defined in Section 14184.101 of the Welfare and Institutions Code, to conduct site reviews on perinatal providers at least once every three years, starting in January 1, 2027, to ensure that eligible Medi-Cal managed care plan members receive comprehensive perinatal services.
SEC. 10.Section 123516 of the Health and Safety Code is amended to read:123516.(a)The department, State Department of Public Health, in consultation with the program administrators, may contract with one or more qualified organizations to assist the department State Department of Public Health in ensuring that grantees implement the program as established under Section 123491 and to conduct an annual evaluation of the implementation of the grant program on a statewide basis. The first evaluation shall be due 12 months after the award of grants pursuant to Section 123492.
(b)(1)In conducting its monitoring and evaluation activities, the department State Department of Public Health shall be guided by program performance standards developed by the department State Department of Public Health in consultation with the Nurse-Family Partnership program.
(2)The annual evaluation shall contain, but not be limited to, the extent to which each grantee participating in the program has done each of the following:
(A)Recruited a population of low-income, first-time mothers.
(B)Enrolled families early in pregnancy and followed them through the second birthday of the child.
(C)Conducted visits that are of comparable frequency, duration, and content as those delivered in the randomized clinical trials of the program.
(D)Assessed the health and well-being of the mothers and children enrolled in the program according to common indicators of maternal, child, and family health.
SEC. 11.Section 123520 of the Health and Safety Code is amended to read:123520.(a) In developing a comprehensive system, health care providers funded under this article may perform the following activities to ensure that a full range of program components of a comprehensive, community-based health care system are available, accessible, and utilized by pregnant women and infants:
(1) Coordinate specific linkages with one another.
(2) Subcontract the services specified in this article.
(3) Provide additional services not specifically listed in this article. These additional services shall include, but shall not be limited to the Women, Infants, and Children (WIC) food supplement program, services offered by local health departments, and public and private social welfare agencies. Nothing contained in this article shall be construed to prohibit a subcontractor from being reimbursed pursuant to a fee for service, capitation, or other payment mechanism.
(b) All services and educational materials shall be provided in the primary languages of the clients served, provided that there are at least 5 percent or 100 persons, whichever is less, of the total beneficiary member population served annually by each facility, who share language other than English and who are limited-English speaking. Limited-English speaking means a person who uses a language other than English in order to communicate effectively.
(c) Health care providers applying for a contract, grant, or agreement under this article shall indicate the manner in which their service elements will be coordinated with existing community resources and services and with hospitals of all levels in the area to ensure each client receives the appropriate level or care at the appropriate time. The department State Department of Public Health may require written agreements between contractors and hospital or hospitals in the area regarding delivery services, and protocols for referral and transfer when special treatment services are required. The department State Department of Public Health may, when requested by the grantee or contractor, assist in achieving coordination and written agreements pertaining to the delivery of these services.
SEC. 12.Section 123521 is added to the Health and Safety Code, to read:123521.(a)(1)The State Department of Health Care Services shall, no later than July 15, 2027, submit to the Assembly Committee on Health and the Senate Committee on Health, and post on its internet website, a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services from January 1, 2022, to January 1, 2025, inclusive.
(2)Commencing January 1, 2028, and every three years thereafter, the State Department of Health Care Services shall submit to the Assembly Committee on Health and the Senate Committee on Health, and post on its internet website, a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services during the previous three years.
(b)A report to be submitted pursuant to subdivision (a) shall be submitted in compliance with Section 9795 of the Government Code.
SEC. 13.Section 131051 of the Health and Safety Code is amended to read:131051.The duties, powers, functions, jurisdiction, and responsibilities transferred to the State Department of Public Health shall, pursuant to the act that added this section, include all of the following previously performed by the former State Department of Health Services:
(a)Under the jurisdiction of the Deputy Director for Prevention Services:
(1)The Office of AIDS, including but not limited to:
(A)The AIDS Drug Assistance Program (Chapter 6 (commencing with Section 120950) of Part 4 of Division 105).
(B)The AIDS Early Intervention Program (Chapter 4 (commencing with Section 120900) of Part 4 of Division 105).
(C)The CARE Services Program, provided for pursuant to the federal Ryan White CARE Act, 42 U.S.C. Section 300ff.
(D)The CARE/Health Insurance Premium Payment Program (federal Ryan White CARE Act, 42 U.S.C. Sec. 300ff).
(E)The Housing Opportunities for Persons with AIDS Program (Section 100119).
(F)The Residential AIDS Licensed Facilities Program (former Section 100119; Chapter 2 (commencing with Section 120815) of Part 4 of Division 105).
(G)The AIDS Case Management Program (federal Ryan White CARE Act, 42 U.S.C. Sec. 300ff; Chapter 2 (commencing with Section 120815) of Part 4 of Division 105).
(H)The AIDS Medi-Cal Waiver Program (former Section 100119; 42 U.S.C. Sec. 1396n(c)).
(I)The Bridge Project (former Section 100119).
(J)The HIV Therapeutic Monitoring Program (Chapter 16 (commencing with Section 121345) of Part 4 of Division 105).
(K)The Learning Immune Function Enhancement program (former Section 100119).
(L)The San Ysidro Prevention Project (Section 113019).
(M)The California Statewide Treatment Education Program (former Section 100119).
(N)The HIV Counseling and Testing Program (Section 113019).
(O)The Neighborhood Intervention Geared Toward High-Risk Testing program (former Section 100119).
(P)The Perinatal Transmission Prevention Project (Section 113019).
(Q)The California AIDS Clearinghouse (Section 113019).
(R)The California Disclosure Assistance and Partner Services/Partner Counseling and Referral Services (Section 113019).
(S)The African-American HIV Initiative (Section 113019; Chapter 13.7 (commencing with Section 120290) of Part 4 of Division 105).
(T)The Injection Drug User HIV Testing Utilizing Hepatitis C Testing High-Risk Initiative (Section 113019).
(U)The Prevention with Positives High-Risk Initiative (Section 113019).
(V)The Statewide Technical Assistance Initiatives (Section 113019).
(W)The HIV/AIDS Case Registry (Sections 113019, 120125, and 120130).
(2)The Office of Binational Border Health, including, but not limited to, all of the following:
(A)The California-Mexico Health Initiative (Part 3 (commencing with Section 475) of Division 1).
(B)The Early Warning Infectious Disease Surveillance Program (Chapter 2 (commencing with Section 1250) of Division 2; Chapter 2 (commencing with Section 120130) of Part 1 of Division 105).
(3)The Division of Communicable Disease Control, including, but not limited to, all of the following:
(A)The Infant Botulism Treatment and Prevention Program (Article 2.5 (commencing with Section 123700) of Chapter 3 of Part 2 of Division 106).
(B)The Sexually Transmitted Disease Control Program (Part 3 (commencing with Section 120500) of Division 105).
(C)The Infectious Disease Program (Chapter 2 (commencing with Section 120130) of Part 1 of Division 105).
(D)The Bioterrorism Epidemiology Program.
(E)The Vector Borne Disease (Part 11 (commencing with Section 116100) of Division 104).
(F)The Tuberculosis Control Program (Part 5 (commencing with Section 121350) of Division 105).
(G)The Microbial Diseases Laboratory (Chapter 2 (commencing with Section 100250) of Division 101).
(H)The Viral and Rickettsial Disease Laboratory (Chapter 2 (commencing with Section 100250) of Division 101).
(I)The West Nile Human Surveillance Program (Chapter 2 (commencing with Section 116110) of Part 11 of Division 104).
(J)The Immunization Program (Part 2 (commencing with Section 120325) of Division 105).
(K)The Vaccines for Children Program (Part 2 (commencing with Section 120325) of Division 105).
(4)The Division of Chronic Disease and Injury Control, including, but not limited to, all of the following:
(A)The IMPACT Prostate Cancer Treatment Program (Chapter 7 (commencing with Section 104322) of Part 1 of Division 103), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this program are hereby with the State Department of Health Care Services.
(B)The Every Woman Counts program (Breast and Cervical Cancer Screening Program) (Article 1.3 (commencing with Section 104150) of Chapter 2 of Part 1 of Division 103; Section 30461.6 of the Revenue and Taxation Code), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this program are hereby with the State Department of Health Care Services.
(C)The Well-Integrated Screening and Evaluation for Women Across the Nation Demonstration Project (Article 1.3 (commencing with Section 104150) of Chapter 2 of Part 1 of Division 103).
(D)The California Nutrition Network (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(E)The Cancer Research Program (Article 2 (commencing with Section 104175) of Chapter 2 of Part 1 of Division 103).
(F)The Translational Cancer Research and Technology Transfer Program (Article 2 (commencing with Section 104175) of Chapter 2 of Part 1 of Division 103).
(G)The Ken Maddy California Cancer Registry (Chapter 2 (commencing with Section 103875) of Part 2 of Division 102).
(H)The California Osteoporosis Prevention and Education Program (Chapter 1 (commencing with Section 125700) of Part 8 of Division 106).
(I)The Preventive Health Care for the Aging Program (Part 4 (commencing with Section 104900) of Division 103).
(J)The California Arthritis Prevention Program (former Section 100185).
(K)The Office of Oral Health (Chapter 3 (commencing with Section 104750) of Part 3 of Division 103).
(L)The Childrens Dental Disease Prevention Program (Article 3 (commencing with Section 104770) of Chapter 3 of Part 3 of Division 103).
(M)The Community Water Fluoridation Program (Article 3.5 (commencing with Section 116409) of Chapter 4 of Part 12 of Division 104).
(N)The California Asthma Public Health Initiative (Chapter 6.5 (commencing with Section 104316) of Part 1 of Division 103).
(O)The California Obesity Prevention Initiative (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(P)The School Health Connections program (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(Q)The California Project LEAN (Chapter 2 (commencing with Section 104575) of Part 3 of Division 103).
(R)The California Center for Physical Activity (Section 131085).
(S)The California Diabetes Program (Section 131085).
(T)The Preventive Medicine Residency Program (Section 131090).
(U)The California Epidemiologic Investigation Service (Article 4 (commencing with Section 100325) of Chapter 2 of Part 1 of Division 101).
(V)The Continuing Professional Education Program (Section 131090).
(W)The Injury Surveillance and Epidemiology Program (Part 2 (commencing with Section 104325) of Division 103).
(X)The State and Local Injury Control Program (Chapter 1 (commencing with Section 104325) of Part 2 of Division 103).
(Y)The Office on Disability and Health (former Section 100185).
(Z)The Alzheimers Disease Program (Article 4 (commencing with Section 125275) of Chapter 2 of Part 5 of Division 106).
(AA)The California Tobacco Control Program (Chapter 1 (commencing with Section 104350) of Part 3 of Division 103).
(5)The Division of Drinking Water and Environmental Management, including, but not limited to, all of the following:
(A)The Medical Waste Management Program (Part 14 (commencing with Section 117600) of Division 104).
(B)The Department of Defense Oversight Program (Radiologic Guidance and Approvals) (Part 9 (commencing with Section 114650) of Division 104).
(C)The Nuclear Emergency Response Program (Part 9 (commencing with Section 114650) of Division 104).
(D)The Institutions Program (Environmental Surveys) (Article 5 (commencing with Section 116025) of Chapter 5 of Part 10 of Division 104).
(E)The Drinking Water Field Management program (Chapter 4 (commencing with Section 116270) of Part 12 of Division 104).
(F)The Environmental Health Specialist Registration Program (Article 1 (commencing with Section 106600) of Chapter 4 of Part 1 of Division 104).
(G)The Sanitation and Radiation Laboratory (Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101); Chapter 4 (commencing with Section 116270) of Part 12 of Division 104).
(H)The Radon Program (Chapter 7 (commencing with Section 105400) of Part 5 of Division 103; Chapter 4 (commencing with Section 116270) of Part 12, and Article 2 (commencing with Section 106750) of Chapter 4 of Part 1, of Division 104).
(I)The Shellfish Sanitation Program (Chapter 5 (commencing with Section 112150) of Part 6 of Division 104).
(J)The Ocean Beach Safety Programs (Article 2 (commencing with Section 115875) of Chapter 5 of Part 10 of Division 104).
(K)The Bioterrorism Planning and Response for Drinking Water, Medical Waste, and Environmental Health program (Article 6 (commencing with Section 101315) of Chapter 3 of Part 3 of Division 101).
(L)The Safe Drinking Water State Revolving Fund (Chapter 4.5 (commencing with Section 116760) of Part 12 of Division 104).
(M)The Drinking Water Technical Programs (Chapter 4 (commencing with Section 16270) of Part 12 of Division 104; Chapter 4.5 (commencing with Section 116760) of Part 12 of Division 104; Article 3 (commencing with Section 106875) of Chapter 4 of Part 1 of Division 104; Chapter 5 (commencing with Section 116775) of Part 12 of Division 104; Chapter 5 (commencing with Section 115825) of Part 10 of Division 104; Chapter 7 (commencing with Section 13500) of Division 7 of the Water Code; Section 13411 of the Water Code).
(N)The Water Security, Clean Drinking Water, Coastal and Beach Protection Act of 2002 (Proposition 50) (Division 26.5 (commencing with Section 79500) of the Water Code).
(6)The Division of Environmental and Occupational Disease Control, including, but not limited to, all of the following:
(A)The California Birth Defect Monitoring Program (Chapter 1 (commencing with Section 103825) of Part 2 of Division 102).
(B)The Childhood Lead Poisoning Prevention Program (Chapter 5 (commencing with Section 105275) of Part 5 of Division 103; Article 7 (commencing with Section 124125) of Chapter 3 of Part 2 of Division 106).
(C)The Lead Related Construction Program (Chapter 4 (commencing with Section 105250) of Part 5 of Division 103).
(D)The Epidemiology Studies Laboratory (Sections 25416, former Section 100170, Section 100325, and Section 104324.25).
(E)The Center for Autism and Developmental Disabilities Research and Epidemiology (former Section 100170).
(F)The Cancer Cluster/Environmental Investigations (former Section 100170).
(G)The Toxic Mold Program (Chapter 18 (commencing with Section 26100) of Division 20).
(H)The Federal Agency for Toxic Substances and Disease Registry Health Assessments, Education and Investigations program (former Section 100170).
(I)The Fish Contamination Outreach and Education program (former Section 100170).
(J)The Air Pollution and Cardiovascular Disease in the California Teachers Study Cohort Project (former Section 100170).
(K)The Delta Watershed Fish Project (outreach, education, and training to reduce exposures to mercury in fish) (former Section 100170).
(L)The Environmental Health Laboratory (former Section 100170; Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101).
(M)The Indoor Air Quality program (Chapter 7 (commencing with Section 105400) of Part 5 of Division 103).
(N)The Outdoor Air Quality program (Section 60.9 of the Labor Code).
(O)The Laboratory Response Network for Chemical Terrorism program (former Section 100170; Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101).
(P)The Air Quality and Human Monitoring Support Program (former Section 100170).
(Q)The Hazard Evaluation System and Information Service Program (Article 1 (commencing with Section 105175) of Chapter 2 of Part 5 of Division 103; Section 147.2 of the Labor Code).
(R)The Occupational Health Surveillance and Evaluation Program (Article 1 (commencing with Section 105175) of Chapter 2 of Part 5 of Division 103).
(S)The Occupational Lead Poisoning Prevention Program (Article 2 (commencing with Section 105185) of Chapter 2 of Part 5 of Division 103).
(T)The Occupational Blood Lead Registry (Article 2 (commencing with Section 105185) of Chapter 2 of Part 5 of Division 103).
(7)The Division of Food, Drug and Radiation Safety, including, but not limited to, all of the following:
(A)The Drug Licensing Program (Article 6 (commencing with Section 111615) of Chapter 6 of Part 5 of Division 104).
(B)The Consumer Product Safety Program (Part 3 (commencing with Section 108100) of Division 104).
(C)The Export Program (Article 2 (commencing with Section 110190) of Chapter 2 of Part 5 of Division 104).
(D)The Food Safety Inspection Program (Part 5 (commencing with Section 109875) and Part 6 (commencing with Section 111940) of Division 104).
(E)The Foodborne Illness and Tampering Emergency Response Program (Part 5 (commencing with Section 109875) of Division 104).
(F)The Retail Food Safety Program (Part 7 (commencing with Section 113700) of Division 104).
(G)The Food Safety Industry Education and Training Program (pursuant to Section 110485).
(H)The Medical Device Licensing Program (Article 6 (commencing with Section 111615) of Chapter 6 of Part 5 of Division 104).
(I)The Medical Device Safety Program (Part 5 (commencing with Section 109875) of Division 104).
(J)The Stop Tobacco Access to Kids Enforcement Program (STAKE) (Division 8.5 (commencing with Section 22950) of the Business and Professions Code).
(K)The Food and Drug Laboratory (Chapter 2 (commencing with Section 100250) of Division 101).
(L)The Drug Safety Program (Part 4 (commencing with Section 109250) and Part 5 (commencing with Section 109875) of Division 104).
(M)The General Food Safety Program (Part 5 (commencing with Section 109875) and Part 6 (commencing with Section 111940) of Division 104).
(N)The Food Testing Program (Chapter 2 (commencing with Section 100250) of Division 101).
(O)The Forensic Alcohol Testing Program (Article 2 (commencing with Section 100700) of Chapter 4 of Part 1 of Division 101).
(P)The Methadone Laboratory Regulating Program (Article 2 (commencing with Section 11839.23) of Chapter 10 of Part 2 of Division 10.5).
(Q)The Radiologic Health Program (Part 9 (commencing with Section 114650) of Division 104).
(R)The Mammography Program (Chapter 6 (commencing with Section 114840) of Part 9 of Division 104).
(S)The Radioactive Materials Licensing and Inspection Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(T)The Radiological Technologist Certification Program (Article 5 (commencing with Section 106955) of Part 1, and Article 3 (commencing with Section 114855) of Chapter 6 of Part 9 of Division 104).
(U)The Radioactive Waste Tracking Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(V)The Radioactive Waste Minimization Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(W)The Low Level Radioactive Waste Management, Treatment and Disposal Program (Chapter 8 (commencing with Section 114960) of Part 9 of Division 104).
(X)The Statewide Environmental Radiation Monitoring Program (pursuant to Section 114755).
(Y)The Department of Energy Oversight Program (Part 9 (commencing with Section 114650) of Division 104).
(Z)The X-Ray Machine Inspection and Registration and Mammography Quality Standards Act Inspection Program (Article 5 (commencing with Section 106955) of Part 1, and Article 3 (commencing with Section 114855) of Chapter 6 of Part 9 of Division 104).
(8)The Deputy Director for Laboratory Science, including, but not limited to, all of the following:
(A)The Environmental Laboratory Accreditation Program (Article 3 (commencing with Section 100825) of Chapter 4 of Part 1 of Division 101).
(B)The Laboratory Central Services Program (Article 2 (commencing with Section 100250) of Chapter 2 of Part 1 of Division 101).
(C)The National Laboratory Training Network (Section 131085).
(D)The Laboratory Field Services program (Chapter 3 (commencing with Section 1200) of Division 2 of the Business and Professions Code).
(b)Under the jurisdiction of the Deputy Director for Licensing and Certification:
(1)The General Acute Care Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(2)The Acute Psychiatric Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(3)The Special Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(4)The Chemical Dependency Recovery Hospitals Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(5)The Skilled Nursing Facilities Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(6)The Intermediate Care Facilities Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(7)The Intermediate Care Facilities-Developmentally Disabled Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(8)The Intermediate Care Facilities-Developmentally Disabled-Habilitative Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(9)The Intermediate Care Facility-Developmentally Disabled-Nursing Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(10)The Home Health Agencies Licensing Program (Chapter 8 (commencing with Section 1725) of Division 2).
(11)The Referral Agencies Licensing Program (Chapter 2.3 (commencing with Section 1400) of Division 2).
(12)The Adult Day Health Centers Licensing Program (Chapter 3.3 (commencing with Section 1570) of Division 2).
(13)The Congregate Living Health Facilities (Chapter 2 (commencing with Section 1250) of Division 2).
(14)The Psychology Clinics Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(15)The Primary ClinicsCommunity and Free Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(16)The Specialty ClinicsRehab Clinics Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(17)The Dialysis Clinics Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(18)The Pediatric Day Health/Respite Care Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(19)The Alternative Birthing Centers Licensing Program (Chapter 1 (commencing with Section 1200) of Division 2).
(20)The Hospice Licensing Program (Chapter 2 (commencing with Section 1339.30) of Division 2).
(21)The Correctional Treatment Centers Licensing Program (Chapter 2 (commencing with Section 1250) of Division 2).
(22)The Medicare/Medi-Cal Certification Program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).
(23)The Nursing Home Administrator Professional Certification Program (Chapter 2.35 (commencing with Section 1416) of Division 2).
(24)The Certified Nursing Assistants Professional Certification Program (Chapter 2 (commencing with Section 1337) of Division 2).
(25)The Home Health Aides Professional Certification Program (Chapter 8 (commencing with Section 1725) of Division 2).
(26)The Hemodialysis Technicians Professional Certification Program (Chapter 3 (commencing with Section 1247) of Division 2 of the Business and Professions Code; Chapter 10 (commencing with Section 1794) of Division 2).
(27)The Criminal Background Clearance Program (Chapter 2 (commencing with Section 1337), Chapter 3 (commencing with Section 1520), Chapter 3.01 (commencing with Section 1569.15), Chapter 3.4 (commencing with Section 1496.80) of Division 2, and Chapter 4 (commencing with Section 11150) of Division 8).
(c)Under the jurisdiction of the Deputy Director for Health Information and Strategic Planning:
(1)The Refugee Health Program (Subpart G of Part 400 of Title 45 of the Code of Federal Regulations).
(2)The Office of County Health Services (Article 5 (commencing with Section 101300) of Chapter 3 of Part 3 of Division 101; Part 4.7 (commencing with Section 16900) of Division 9 of the Welfare and Institutions Code).
(3)The Medically Indigent Services Program (Article 5 (commencing with Section 101300) of Chapter 3 of Part 3 of Division 101).
(4)The Office of Vital Records (Part 1 (commencing with Section 102100) of Division 102).
(5)The Office of Health Information and Research (Article 1 (commencing with Section 102175) of Chapter 2 of Part 1 of Division 102; Section 128730).
(6)The Local Public Health Services Program (Article 5 (commencing with Section 101300) of Chapter 3 of Part 3 of Division 101).
(7)The Center for Health Statistics (Part 1 (commencing with Section 102100) of Division 102; Section 128730).
(8)The Medical Marijuana Program (Article 2.5 (commencing with Section 11362.7) of Chapter 6 of Division 10 of the Health and Safety Code).
(d)Under the jurisdiction of the Deputy Director for Primary Care and Family Health:
(1)The Maternal, Child and Adolescent Health program (Part 2 (commencing with Section 123225) of Division 106).
(2)The Adolescent Family Life Program (Article 1 (commencing with Section 124175) of Chapter 4 of Part 2 of Division 106).
(3)The Advanced Practice Nurse Training program (Part 2 (commencing with Section 123225) of Division 106).
(4)The Black Infant Health Program (Part 2 (commencing with Section 123225) of Division 106).
(5)The Breastfeeding Program (Article 3 (commencing with Section 123360) of Chapter 1 of Part 2 of Division 6).
(6)The California Diabetes and Pregnancy Program (Part 2 (commencing with Section 123225) of Division 106).
(7)The California Initiative to Improve Adolescent Health (Part 2 (commencing with Section 123225) of Division 106).
(8)The Childhood Injury Prevention Program (Article 4 (commencing with Section 100325) of Chapter 2 of Division 101).
(9)The Comprehensive Perinatal Services Program (Article 3 (commencing with Section 123475) of Chapter 2 of Part 2; Section 14134.5 of the Welfare and Institutions Code).(10)(9)The Fetal and Infant Mortality Review Program (Article 1 (commencing with Section 123650) of Chapter 3 of Part 2 of Division 106).
(11)(10)The Human Stem Cell Research Program (Chapter 3 (commencing with Section 125290.10) of Part 5 of Division 106; Chapter 1 (commencing with Section 125300) of Part 5.5 of Division 106).
(12)(11)The Local Health Department Maternal, Child and Adolescent Health Program (Section 123255).
(13)(12)The Maternal Mortality Review Program (Article 4 (commencing with Section 100325) of Chapter 2 of Division 101).
(14)(13)The Oral Health Program (Part 2 (commencing with Section 123225) of Division 106).
(15)(14)The Preconception Health and Health Care Initiative (Part 2 (commencing with Section 123225) of Division 106).
(16)(15)The Regional Perinatal Programs of California (Article 4 (commencing with Section 123550) of Chapter 2 of Part 2 of Division 106).
(17)(16)The Perinatal Dispatch Centers Outreach and Education Program (Article 4 (commencing with Section 123750) of Chapter 3 of Part 2 of Division 106).
(18)(17)The State Early Childhood Comprehensive Services program (Part 2 (commencing with Section 123225) of Division 106).
(19)(18)The Sudden Infant Death Syndrome Program (Article 3 (commencing with Section 123725) of Chapter 3 of Part 2 of Division 106).
(20)(19)The Youth Pilot Program (Chapter 12.85 (commencing with Section 18987) of Part 6 of Division 9 of the Welfare and Institutions Code).
(21)(20)The Office of Family Planning (Chapter 8.5 (commencing with Section 14500) of Part 3 of Division 9 of the Welfare and Institutions Code; Division 24 (commencing with Section 24000) of the Welfare and Institutions Code), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this office are hereby with the State Department of Health Care Services.
(22)(21)The Community Challenge Grant Program (Section 14504.1 of the Welfare and Institutions Code, and Chapter 14 (commencing with Section 18993) of Part 6 of Division 9 of the Welfare and Institutions Code).
(23)(22)The Information and Education Program (Section 14504.3 of the Welfare and Institutions Code).
(24)(23)The Family PACT Program (subdivision (aa) of Section 14132 and Section 24005 of the Welfare and Institutions Code), until June 30, 2012. Commencing July 1, 2012, the duties, powers, functions, jurisdiction, and responsibilities of the State Department of Public Health regarding this program are hereby with the State Department of Health Care Services.
(25)(24)The Male Involvement Program (Section 14504 of the Welfare and Institutions Code).
(26)(25)The TeenSMART Outreach Program (Section 14504.2 of the Welfare and Institutions Code).
(27)(26)The Battered Women Shelter Program (Chapter 6 (commencing with Section 124250) of Part 2 of Division 106).
(28)(27)The Women, Infants and Children Program (Article 1 (commencing with Section 123275) of Chapter 1 of Part 2 of Division 106).
(29)(28)The WIC Supplemental Nutrition Program (Article 1 (commencing with Section 123275) of Chapter 1 of Part 2 of Division 106).
(30)(29)The Farmers Market Nutrition Program (Section 123279).
(31)(30)Genetic Disease Program (Chapter 1 (commencing with Section 124975) of Part 5 of Division 106).
(32)(31)The Newborn Screening Program (Chapter 1 (commencing with Section 124975) of Part 5 of Division 106).
(33)(32)The Prenatal Screening Program (Chapter 1 (commencing with Section 124975) of Part 5 of Division 106).
SEC. 14.Section 14132 of the Welfare and Institutions Code is amended to read:14132.The following is the schedule of benefits under this chapter:
(a)Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center, respiratory care, optometric, chiropractic, psychology, podiatric, occupational therapy, physical therapy, speech therapy, audiology, acupuncture to the extent federal matching funds are provided for acupuncture, and services of persons rendering treatment by prayer or healing by spiritual means in the practice of any church or religious denomination insofar as these can be encompassed by federal participation under an approved plan, subject to utilization controls.
(b)(1)Inpatient hospital services, including, but not limited to, physician and podiatric services, physical therapy, and occupational therapy, are covered subject to utilization controls.
(2)For a Medi-Cal fee-for-service beneficiary, member, emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition. This paragraph does not change the obligation of Medi-Cal managed care plans to provide emergency services and care. For the purposes of this paragraph, emergency services and care and emergency medical condition have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.
(c)Nursing facility services, subacute care services, and services provided by any category of intermediate care facility for the developmentally disabled, including podiatry, physician, nurse practitioner services, and prescribed drugs, as described in subdivision (d), are covered subject to utilization controls. Respiratory care, physical therapy, occupational therapy, speech therapy, and audiology services for patients in nursing facilities and any category of intermediate care facility for persons with developmental disabilities are covered subject to utilization controls.
(d)(1)Purchase of prescribed drugs is covered subject to the Medi-Cal List of Contract Drugs and utilization controls.
(2)Purchase of drugs used to treat erectile dysfunction or any off-label uses of those drugs are covered only to the extent that federal financial participation is available.
(3)(A)To the extent required by federal law, the purchase of outpatient prescribed drugs, for which the prescription is executed by a prescriber in written, nonelectronic form on or after April 1, 2008, is covered only when executed on a tamper resistant prescription form. The implementation of this paragraph shall conform to the guidance issued by the federal Centers for Medicare and Medicaid Services, but shall not conflict with state statutes on the characteristics of tamper resistant prescriptions for controlled substances, including Section 11162.1 of the Health and Safety Code. The department shall provide providers and beneficiaries members with as much flexibility in implementing these rules as allowed by the federal government. The department shall notify and consult with appropriate stakeholders in implementing, interpreting, or making specific this paragraph.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instructions without taking regulatory action.
(4)(A)(i)For the purposes of this paragraph, nonlegend has the same meaning as defined in subdivision (a) of Section 14105.45.
(ii)Nonlegend acetaminophen-containing products, including childrens acetaminophen-containing products, selected by the department are covered benefits.
(iii)Nonlegend cough and cold products selected by the department are covered benefits.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instruction without taking regulatory action.
(e)Outpatient dialysis services and home hemodialysis services, including physician services, medical supplies, drugs, and equipment required for dialysis, are covered, subject to utilization controls.
(f)Anesthesiologist services when provided as part of an outpatient medical procedure, nurse anesthetist services when rendered in an inpatient or outpatient setting under conditions set forth by the director, outpatient laboratory services, and x-ray services are covered, subject to utilization controls. This subdivision does not require prior authorization for anesthesiologist services provided as part of an outpatient medical procedure or for portable x-ray services in a nursing facility or any category of intermediate care facility for the developmentally disabled.
(g)Blood and blood derivatives are covered.
(h)(1)Emergency and essential diagnostic and restorative dental services, except for orthodontic, fixed bridgework, and partial dentures that are not necessary for balance of a complete artificial denture, are covered, subject to utilization controls. The utilization controls shall allow emergency and essential diagnostic and restorative dental services and prostheses that are necessary to prevent a significant disability or to replace previously furnished prostheses that are lost or destroyed due to circumstances beyond the beneficiarys members control. Notwithstanding the foregoing, the director may by regulation provide for certain fixed artificial dentures necessary for obtaining employment or for medical conditions that preclude the use of removable dental prostheses, and for orthodontic services in cleft palate deformities administered by the departments California Childrens Services program.
(2)For persons 21 years of age or older, the services specified in paragraph (1) shall be provided subject to the following conditions:
(A)Periodontal treatment is not a benefit.
(B)Endodontic therapy is not a benefit except for vital pulpotomy.
(C)Laboratory processed crowns are not a benefit.
(D)Removable prosthetics shall be a benefit only for patients as a requirement for employment.
(E)The director may, by regulation, provide for the provision of fixed artificial dentures that are necessary for medical conditions that preclude the use of removable dental prostheses.
(F)Notwithstanding the conditions specified in subparagraphs (A) to (E), inclusive, the department may approve services for persons with special medical disorders subject to utilization review.
(3)Paragraph (2) shall become inoperative on July 1, 1995.
(i)Medical transportation is covered, subject to utilization controls.
(j)Home health care services are covered, subject to utilization controls.
(k)(1)Prosthetic and orthotic devices and eyeglasses are covered, subject to utilization controls. Utilization controls shall allow replacement of prosthetic and orthotic devices and eyeglasses necessary because of loss or destruction due to circumstances beyond the beneficiarys members control. Frame styles for eyeglasses replaced pursuant to this subdivision shall not change more than once every two years, unless the department so directs.
(2)Orthopedic and conventional shoes are covered when provided by a prosthetic and orthotic supplier on the prescription of a physician and when at least one of the shoes will be attached to a prosthesis or brace, subject to utilization controls. Modification of stock conventional or orthopedic shoes when medically indicated is covered, subject to utilization controls. If there is a clearly established medical need that cannot be satisfied by the modification of stock conventional or orthopedic shoes, custom-made orthopedic shoes are covered, subject to utilization controls.
(3)Therapeutic shoes and inserts are covered when provided to a beneficiary member with a diagnosis of diabetes, subject to utilization controls, to the extent that federal financial participation is available.
(l)Hearing aids are covered, subject to utilization controls. Utilization controls shall allow replacement of hearing aids necessary because of loss or destruction due to circumstances beyond the beneficiarys members control.
(m)Durable medical equipment and medical supplies are covered, subject to utilization controls. The utilization controls shall allow the replacement of durable medical equipment and medical supplies when necessary because of loss or destruction due to circumstances beyond the beneficiarys members control. The utilization controls shall allow authorization of durable medical equipment needed to assist a disabled beneficiary member in caring for a child for whom the disabled beneficiary member is a parent, stepparent, foster parent, or legal guardian, subject to the availability of federal financial participation. The department shall adopt emergency regulations to define and establish criteria for assistive durable medical equipment in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(n)Family planning services are covered, subject to utilization controls. However, for Medi-Cal managed care plans, utilization controls shall be subject to Section 1367.25 of the Health and Safety Code.
(o)Inpatient intensive rehabilitation hospital services, including respiratory rehabilitation services, in a general acute care hospital are covered, subject to utilization controls, when either of the following criteria are met:
(1)A patient with a permanent disability or severe impairment requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to develop function beyond the limited amount that would occur in the normal course of recovery.
(2)A patient with a chronic or progressive disease requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to maintain the patients present functional level as long as possible.
(p)(1)Adult day health care is covered in accordance with Chapter 8.7 (commencing with Section 14520).
(2)Commencing 30 days after the effective date of the act that added this paragraph, and notwithstanding the number of days previously approved through a treatment authorization request, adult day health care is covered for a maximum of three days per week.
(3)As provided in accordance with paragraph (4), adult day health care is covered for a maximum of five days per week.
(4)As of the date that the director makes the declaration described in subdivision (g) of Section 14525.1, paragraph (2) shall become inoperative and paragraph (3) shall become operative.
(q)(1)Application of fluoride, or other appropriate fluoride treatment as defined by the department, and other prophylaxis treatment for children 17 years of age and under are covered.
(2)All dental hygiene services provided by a registered dental hygienist, registered dental hygienist in extended functions, and registered dental hygienist in alternative practice licensed pursuant to Sections 1753, 1917, 1918, and 1922 of the Business and Professions Code may be covered as long as they are within the scope of Denti-Cal benefits and they are necessary services provided by a registered dental hygienist, registered dental hygienist in extended functions, or registered dental hygienist in alternative practice.
(r)(1)Paramedic services performed by a city, county, or special district, or pursuant to a contract with a city, county, or special district, and pursuant to a program established under former Article 3 (commencing with Section 1480) of Chapter 2.5 of Division 2 of the Health and Safety Code by a paramedic certified pursuant to that article, and consisting of defibrillation and those services specified in subdivision (3) of former Section 1482 of the article.
(2)A provider enrolled under this subdivision shall satisfy all applicable statutory and regulatory requirements for becoming a Medi-Cal provider.
(3)This subdivision shall be implemented only to the extent funding is available under Section 14106.6.
(s)(1)In-home medical care services are covered when medically appropriate and subject to utilization controls, for a beneficiary member who would otherwise require care for an extended period of time in an acute care hospital at a cost higher than in-home medical care services. The director shall have the authority under this section to contract with organizations qualified to provide in-home medical care services to those persons. These services may be provided to a patient placed in a shared or congregate living arrangement, if a home setting is not medically appropriate or available to the beneficiary. member.
(2)As used in this subdivision, in-home medical care service includes utility bills directly attributable to continuous, 24-hour operation of life-sustaining medical equipment, to the extent that federal financial participation is available.
(3)As used in this subdivision, in-home medical care services include, but are not limited to:
(A)Level-of-care and cost-of-care evaluations.
(B)Expenses, directly attributable to home care activities, for materials.
(C)Physician fees for home visits.
(D)Expenses directly attributable to home care activities for shelter and modification to shelter.
(E)Expenses directly attributable to additional costs of special diets, including tube feeding.
(F)Medically related personal services.
(G)Home nursing education.
(H)Emergency maintenance repair.
(I)Home health agency personnel benefits that permit coverage of care during periods when regular personnel are on vacation or using sick leave.
(J)All services needed to maintain antiseptic conditions at stoma or shunt sites on the body.
(K)Emergency and nonemergency medical transportation.
(L)Medical supplies.
(M)Medical equipment, including, but not limited to, scales, gurneys, and equipment racks suitable for paralyzed patients.
(N)Utility use directly attributable to the requirements of home care activities that are in addition to normal utility use.
(O)Special drugs and medications.
(P)Home health agency supervision of visiting staff that is medically necessary, but not included in the home health agency rate.
(Q)Therapy services.
(R)Household appliances and household utensil costs directly attributable to home care activities.
(S)Modification of medical equipment for home use.
(T)Training and orientation for use of life-support systems, including, but not limited to, support of respiratory functions.
(U)Respiratory care practitioner services as defined in Sections 3702 and 3703 of the Business and Professions Code, subject to prescription by a physician and surgeon.
(4)A beneficiary member receiving in-home medical care services is entitled to the full range of services within the Medi-Cal scope of benefits as defined by this section, subject to medical necessity and applicable utilization control. Services provided pursuant to this subdivision, which are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with a home- and community-based services waiver.
(t)Home- and community-based services approved by the United States Department of Health and Human Services are covered to the extent that federal financial participation is available for those services under the state plan or waivers granted in accordance with Section 1315 or 1396n of Title 42 of the United States Code. The director may seek waivers for any or all home- and community-based services approvable under Section 1315 or 1396n of Title 42 of the United States Code. Coverage for those services shall be limited by the terms, conditions, and duration of the federal waivers.
(u)Comprehensive perinatal services, as provided through an agreement with a health care provider designated in Section 14134.5 and services meeting the standards developed by the department pursuant to Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to implement the provisions of this subdivision. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented. Provisions for which waivers are obtained or for which waivers are not required shall be implemented notwithstanding any inability to obtain federal waivers for the other provisions. No provision of this subdivision shall be implemented unless matching funds from Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code are available.
(v)Early and periodic screening, diagnosis, and treatment for any individual under 21 years of age is covered, consistent with the requirements of Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code.
(w)(1)Hospice services are covered, in accordance with Medicare requirements, and are subject to utilization controls. Coverage shall be available only to the extent that no additional net program costs are incurred.
(2)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(3)Notwithstanding any other law, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions.
(x)When a claim for treatment provided to a beneficiary member includes both services that are authorized and reimbursable under this chapter and services that are not reimbursable under this chapter, that portion of the claim for the treatment and services authorized and reimbursable under this chapter shall be payable.
(y)Home- and community-based services approved by the United States Department of Health and Human Services for a beneficiary member with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex, who requires intermediate care or a higher level of care.
Services provided pursuant to a waiver obtained from the Secretary of the United States Department of Health and Human Services pursuant to this subdivision, and that are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with the waiver, and subject to the terms, conditions, and duration of the waiver. These services shall be provided to a beneficiary member in accordance with the clients needs as identified in the plan of care, and subject to medical necessity and applicable utilization control.
The director may, under this section, contract with organizations qualified to provide, directly or by subcontract, services provided for in this subdivision to an eligible beneficiary. member. Contracts or agreements entered into pursuant to this division shall not be subject to the Public Contract Code.
(z)Respiratory care when provided in organized health care systems as defined in Section 3701 of the Business and Professions Code, and as an in-home medical service as outlined in subdivision (s).
(aa)(1)There is hereby established in the department a program to provide comprehensive clinical family planning services to any person who has a family income at or below 200 percent of the federal poverty level, as revised annually, and who is eligible to receive these services pursuant to the waiver identified in paragraph (2). This program shall be known as the Family Planning, Access, Care, and Treatment (Family PACT) Program.
(2)The department shall seek a waiver in accordance with Section 1315 of Title 42 of the United States Code, or a state plan amendment adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code, which was added to Section 1396a of Title 42 of the United States Code by Section 2303(a)(2) of the federal Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148), for a program to provide comprehensive clinical family planning services as described in paragraph (8). Under the waiver, the program shall be operated only in accordance with the waiver and the statutes and regulations in paragraph (4) and subject to the terms, conditions, and duration of the waiver. Under the state plan amendment, which shall replace the waiver and shall be known as the Family PACT successor state plan amendment, the program shall be operated only in accordance with this subdivision and the statutes and regulations in paragraph (4). The state shall use the standards and processes imposed by the state on January 1, 2007, including the application of an eligibility discount factor to the extent required by the federal Centers for Medicare and Medicaid Services, for purposes of determining eligibility as permitted under Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the extent that federal financial participation is available, the program shall continue to conduct education, outreach, enrollment, service delivery, and evaluation services as specified under the waiver. The services shall be provided under the program only if the waiver and, when applicable, the successor state plan amendment are approved by the federal Centers for Medicare and Medicaid Services and only to the extent that federal financial participation is available for the services. This section does not prohibit the department from seeking the Family PACT successor state plan amendment during the operation of the waiver.
(3)Solely for the purposes of the waiver or Family PACT successor state plan amendment and notwithstanding any other law, the collection and use of an individuals social security number shall be necessary only to the extent required by federal law.
(4)Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and 24013, and any regulations adopted under these statutes shall apply to the program provided for under this subdivision. No other law under the Medi-Cal program or the State-Only Family Planning Program shall apply to the program provided for under this subdivision.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, without taking regulatory action, the provisions of the waiver after its approval by the federal Centers for Medicare and Medicaid Services and the provisions of this section by means of an all-county letter or similar instruction to providers. Thereafter, the department shall adopt regulations to implement this section and the approved waiver in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act adding this subdivision, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.
(6)If the Department of Finance determines that the program operated under the authority of the waiver described in paragraph (2) or the Family PACT successor state plan amendment is no longer cost effective, this subdivision shall become inoperative on the first day of the first month following the issuance of a 30-day notification of that determination in writing by the Department of Finance to the chairperson in each house that considers appropriations, the chairpersons of the committees, and the appropriate subcommittees in each house that considers the State Budget, and the Chairperson of the Joint Legislative Budget Committee.
(7)If this subdivision ceases to be operative, all persons who have received or are eligible to receive comprehensive clinical family planning services pursuant to the waiver described in paragraph (2) shall receive family planning services under the Medi-Cal program pursuant to subdivision (n) if they are otherwise eligible for Medi-Cal with no spend down of excess income, or shall receive comprehensive clinical family planning services under the program established in Division 24 (commencing with Section 24000) either if they are eligible for Medi-Cal with a spend down of excess income or if they are otherwise eligible under Section 24003.
(8)For purposes of this subdivision, comprehensive clinical family planning services means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, natural family planning, abstinence methods, and basic, limited fertility management. Comprehensive clinical family planning services include, but are not limited to, preconception counseling, maternal and fetal health counseling, general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, medical family planning treatment and procedures, including supplies and followup, and informational, counseling, and educational services. Comprehensive clinical family planning services shall not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care that is not incident to the diagnosis of pregnancy. Comprehensive clinical family planning services shall be subject to utilization control and include all of the following:
(A)Family planning related services and male and female sterilization. Family planning services for men and women shall include emergency services and services for complications directly related to the contraceptive method, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, and followup, consultation, and referral services, as indicated, which may require treatment authorization requests.
(B)All United States Department of Agriculture, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies that are in keeping with current standards of practice and from which the individual may choose.
(C)Culturally and linguistically appropriate health education and counseling services, including informed consent, that include all of the following:
(i)Psychosocial and medical aspects of contraception.
(ii)Sexuality.
(iii)Fertility.
(iv)Pregnancy.
(v)Parenthood.
(vi)Infertility.
(vii)Reproductive health care.
(viii)Preconception and nutrition counseling.
(ix)Prevention and treatment of sexually transmitted infection.
(x)Use of contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies.
(xi)Possible contraceptive consequences and followup.
(xii)Interpersonal communication and negotiation of relationships to assist individuals and couples in effective contraceptive method use and planning families.
(D)A comprehensive health history, updated at the next periodic visit (between 11 and 24 months after initial examination) that includes a complete obstetrical history, gynecological history, contraceptive history, personal medical history, health risk factors, and family health history, including genetic or hereditary conditions.
(E)A complete physical examination on initial and subsequent periodic visits.
(F)Services, drugs, devices, and supplies deemed by the federal Centers for Medicare and Medicaid Services to be appropriate for inclusion in the program.
(G)(i)Home test kits for sexually transmitted diseases, including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal or Family PACT clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(ii)For purposes of this subparagraph, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(iii)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Family PACT provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(9)In order to maximize the availability of federal financial participation under this subdivision, the director shall have the discretion to implement the Family PACT successor state plan amendment retroactively to July 1, 2010.
(ab)(1)Purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products and utilization controls.
(2)Purchase of enteral nutrition products is limited to those products to be administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube. A beneficiary member under the Early and Periodic Screening, Diagnostic, and Treatment Program shall be exempt from this paragraph.
(3)Notwithstanding paragraph (2), the department may deem an enteral nutrition product, not administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube, a benefit for patients with diagnoses, including, but not limited to, malabsorption and inborn errors of metabolism, if the product has been shown to be neither investigational nor experimental when used as part of a therapeutic regimen to prevent serious disability or death.
(4)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the amendments to this subdivision made by the act that added this paragraph by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.
(5)The amendments made to this subdivision by the act that added this paragraph shall be implemented June 1, 2011, or on the first day of the first calendar month following 60 days after the date the department secures all necessary federal approvals to implement this section, whichever is later.
(ac)Diabetic testing supplies are covered when provided by a pharmacy, subject to utilization controls.
(ad)(1)Nonmedical transportation is covered, subject to utilization controls and permissible time and distance standards, for a beneficiary member to obtain covered Medi-Cal services.
(2)(A)(i)Nonmedical transportation includes, at a minimum, round trip transportation for a beneficiary member to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance, and mileage reimbursement when conveyance is in a private vehicle arranged by the beneficiary member and not through a transportation broker, bus passes, taxi vouchers, or train tickets.
(ii)Nonmedical transportation does not include the transportation of a sick, injured, invalid, convalescent, infirm, or otherwise incapacitated beneficiary member by ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations.
(B)Nonmedical transportation shall be provided for a beneficiary member who can attest in a manner to be specified by the department that other currently available resources have been reasonably exhausted. For a beneficiary member enrolled in a managed care plan, nonmedical transportation shall be provided by the beneficiarys members managed care plan. For a Medi-Cal fee-for-service beneficiary, member, the department shall provide nonmedical transportation when those services are not available to the beneficiary member under Sections 14132.44 and 14132.47.
(3)Nonmedical transportation shall be provided in a form and manner that is accessible, in terms of physical and geographic accessibility, for the beneficiary member and consistent with applicable state and federal disability rights laws.
(4)It is the intent of the Legislature in enacting this subdivision to affirm the requirement under Section 431.53 of Title 42 of the Code of Federal Regulations, in which the department is required to provide necessary transportation, including nonmedical transportation, for recipients to and from covered services. This subdivision shall not be interpreted to add a new benefit to the Medi-Cal program.
(5)The department shall seek any federal approvals that may be required to implement this subdivision, including, but not limited to, approval of revisions to the existing state plan that the department determines are necessary to implement this subdivision.
(6)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained.
(7)Prior to the effective date of any necessary federal approvals, nonmedical transportation was not a Medi-Cal managed care benefit with the exception of when provided as an Early and Periodic Screening, Diagnostic, and Treatment service.
(8)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing January 1, 2018, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(9)This subdivision shall not be implemented until July 1, 2017.
(ae)(1)No sooner than January 1, 2022, Rapid Whole Genome Sequencing, including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal beneficiary member who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(af)(1)Home test kits for sexually transmitted diseases that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(2)For purposes of this subdivision, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(3)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Medi-Cal provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(4)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
(ag)(1)Violence prevention services are covered, subject to medical necessity and utilization controls.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(4)The department shall post on its internet website the date upon which violence prevention services may be provided and billed pursuant to this subdivision.
(5)Violence prevention services means evidence-based, trauma-informed, and culturally responsive preventive services provided to reduce the incidence of violent injury or reinjury, trauma, and related harms and promote trauma recovery, stabilization, and improved health outcomes.
SEC. 15.Section 14132.100 of the Welfare and Institutions Code, as added by Section 104 of Chapter 21 of the Statutes of 2025, is amended to read:14132.100.(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services that are eligible for federal financial participation shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)A change in costs is not, in and of itself, a scope-of-service change, unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, or a visiting nurse that is eligible for federal financial participation. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit that is eligible for federal financial participation.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist that is eligible for federal financial participation.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist or dental hygienist in alternative practice services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist that is eligible for federal financial participation.
(4)(A)(i)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(ii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed professional clinical counselor, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care and are eligible for federal financial participation. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iv)(I)An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction.
(II)Notwithstanding subclause (I), the department may provide for exceptions to the prohibition established by subclause (I), including, but not limited to, the exceptions described in sub-subclauses (ia) and (ib), which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(ia)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(ib)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(v)An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:
(I)The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
(II)The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
(III)The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.
(IV)An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(B)(i)Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary member choice.
(ii)The department may provide specific exceptions to the requirement specified in clause (i), based on an FQHCs or RHCs access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(iii)Effective on the date designated by the department pursuant to clause (i), an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:
(I)Offer those services via in-person, face-to-face contact.
(II)Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.
(iv)In addition to any existing law requiring beneficiary member consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by an FQHC or RHC to a Medi-Cal beneficiary, member, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: member: an explanation that beneficiaries members have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary member without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for nonmedical transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the FQHC or RHC.
(I)The FQHC or RHC shall document in the patient record the provision of this information and the patients verbal or written acknowledgment that the information was received.
(II)The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subparagraph.
(C)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.
(D)This paragraph shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subparagraph (C), whichever is later. This paragraph shall not be construed to limit coverage of, and reimbursement for, covered telehealth services provided before the operative date of this paragraph.
(E)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this paragraph by means of all-county letters, plan letters, provider manuals, information notices, provider bulletins, and similar instructions, without taking any further regulatory action.
(F)Telehealth modalities authorized pursuant to this paragraph shall be subject to the billing, reimbursement, and utilization management policies imposed by the department.
(G)Services delivered via telehealth modalities described in this paragraph shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid state plan, and any other applicable state and federal statutes and regulations.
(5)For purposes of this section, physician shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor.
(6)(A)Notwithstanding any other provision of this section, pursuant to an effective date designated by the department that is no sooner than January 1, 2027, a PPS billable visit shall not include an encounter with a comprehensive perinatal practitioner who is not otherwise a PPS billable health professional pursuant to paragraph (1).
(B)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(C)This paragraph shall be implemented only for dates of service on or after the department implements the alternative payment methodology or other appropriate financing mechanism described in paragraph (7).
(7)(A)Notwithstanding any other provision of this section, pursuant to an effective date designated by the department that is no sooner than January 1, 2027, the department may implement an alternative payment methodology or other appropriate financing mechanism that allows FQHCs and RHCs to obtain reimbursement for encounters with community health workers at no less than the applicable Medi-Cal fee-for-service rate when provided either on the same day or different day as a PPS-billable visit.
(B)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)Provided that the following entities are not operating as intermittent clinics, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, each entity shall have its reimbursement rate established in accordance with one of the methods outlined in paragraph (2) or (3), as selected by the FQHC or RHC:
(A)An entity that first qualifies as an FQHC or RHC in 2001 or later.
(B)A newly licensed facility at a new location added to an existing FQHC or RHC.
(C)An entity that is an existing FQHC or RHC that is relocated to a new site.
(2)(A)An FQHC or RHC that adds a new licensed location to its existing primary care license under paragraph (1) of subdivision (b) of Section 1212 of the Health and Safety Code may elect to have the reimbursement rate for the new location established in accordance with paragraph (3), or notwithstanding subdivision (e), an FQHC or RHC may choose to have one PPS rate for all locations that appear on its primary care license determined by submitting a change in scope of service request if both of the following requirements are met:
(i)The change in scope of service request includes the costs and visits for those locations for the first full fiscal year immediately following the date the new location is added to the FQHCs or RHCs existing licensee.
(ii)The FQHC or RHC submits the change in scope of service request within 90 days after the FQHCs or RHCs first full fiscal year.
(B)The FQHCs or RHCs single PPS rate for those locations shall be calculated based on the total costs and total visits of those locations and shall be determined based on the following:
(i)An audit in accordance with Section 14170.
(ii)Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successors.
(iii)Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(C)Except as specified in subdivision (j), this paragraph does not apply to a location that was added to an existing primary care clinic license by the State Department of Public Health, whether by a regional district office or the centralized application unit, prior to January 1, 2017.
(3)If an FQHC or RHC does not elect to have the PPS rate determined by a change in scope of service request, the FQHC or RHC shall have the reimbursement rate established for any of the entities identified in paragraph (1) or (2) in accordance with one of the following methods at the election of the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(4)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(5)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)(1)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, in a mobile unit as defined in subdivision (b) of Section 1765.105 of the Health and Safety Code, or at the election of the FQHC or RHC and subject to paragraph (2), a location added to an existing primary care clinic license by the State Department of Public Health prior to January 1, 2017, shall be billed by and reimbursed at the same rate as the FQHC or RHC that either established the intermittent clinic site or mobile unit, or that held the clinic license to which the location was added prior to January 1, 2017.
(2)If an FQHC or RHC with at least one additional location on its primary care clinic license that was added by the State Department of Public Health prior to January 1, 2017, applies for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (e), all locations on the FQHCs or RHCs primary care clinic license shall be subject to a scope-of-service adjustment in accordance with either paragraph (2) or (3) of subdivision (i), as selected by the FQHC or RHC.
(3)This subdivision does not preclude or otherwise limit the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2)(A)For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing Drug Medi-Cal services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B)An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A)In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B)In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6)For purposes of this subdivision, the following definitions apply:
(A)Drug Medi-Cal organized delivery system or DMC-ODS means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B)Special Terms and Conditions has the same meaning as set forth in subdivision (o) of Section 14184.10.
(m)Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal beneficiaries members as part of the mental health plans network.
(2)(A)For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B)An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department is retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but the effective date shall not be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(n)The department shall seek any necessary federal approvals and issue appropriate guidance to allow an FQHC or RHC to bill, under a supervising licensed behavioral health practitioner, for an encounter between an FQHC or RHC patient and a psychological associate, associate professional clinical counselor, associate clinical social worker, or associate marriage and family therapist when all of the following conditions are met:
(1)The psychological associate, associate professional clinical counselor, associate clinical social worker, or associate marriage and family therapist is supervised by the designated licensed behavioral health practitioner, as required by their applicable clinical licensing board.
(2)The behavioral health visit is billed under the supervising licensed practitioner of the FQHC or RHC, pursuant to paragraph (1).
(3)The FQHC or RHC is otherwise authorized to bill for services provided by the supervising licensed behavioral health practitioner as a separate visit.
(o)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(p)The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(q)The department shall implement this section only to the extent that federal financial participation is available.
(r)Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of this section, including all of the following:
(1)Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days prior to the meeting described in paragraph (2).
(2)Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.
(3)Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4)Providing at least 60 days advance notice of the effective date of the proposed action or change.
(s)This section shall become operative on July 1, 2026.
SEC. 16.Section 14134.5 of the Welfare and Institutions Code is repealed.14134.5.All of the following requirements apply to the provision of services pursuant to subdivision (u) of Section 14132:(a)Comprehensive perinatal provider means any general practice physician, family physician and surgeon, obstetrician-gynecologist, pediatrician, certified nurse-midwife, a group, any of whose members is one of the above-named providers, or any preferred provider organization or clinic enrolled in the Medi-Cal program and certified pursuant to the standards of this section.(b)Perinatal means the period from the establishment of pregnancy to one month following delivery.(c)Comprehensive perinatal services shall include, but not be limited to, the provision of the combination of services developed through the former Department of Health Services Obstetrical Access Pilot Program provided or coordinated by a comprehensive perinatal provider.(d)The comprehensive perinatal provider shall schedule visits with appropriate providers and track the patient to verify whether services have been received. As part of the reimbursement for coordinating these services, the comprehensive perinatal provider shall ensure the provision of the following services either through the providers own service or through subcontracts or referrals to other providers:(1)A psychosocial assessment and when appropriate referrals to counseling.(2)Nutrition assessments and when appropriate referral to counseling on food supplement programs, vitamins, and breastfeeding.(3)Health, childbirth, and parenting education.(e)(1)Except where existing law prohibits the employment of physicians, a health care provider may employ or contract with all of the following medical and other practitioners for the purpose of providing the comprehensive services delineated in this section:(A)Physicians, including a general practitioner, a family physician and surgeon, a pediatrician, or an obstetrician-gynecologist.(B)Certified nurse-midwives.(C)Licensed midwives.(D)Nurses.(E)Nurse practitioners.(F)Physician assistants.(G)Social workers.(H)Health and childbirth educators.(I)Registered dietitians.(2)The department shall adopt regulations that define the qualifications of any of these practitioners who are not currently included under the regulations adopted pursuant to this chapter. Providers shall, as feasible, utilize staffing patterns that reflect the linguistic and cultural features of the populations they serve.(f)The California Medical Assistance Program and the Maternal and Child Health Branch of the State Department of Public Health, in consultation with the California Conference of Local Health Officers, shall establish standards for health care providers and services rendered pursuant to this subdivision.(g)The department shall assist local health departments to establish a community perinatal program whose responsibilities may include certifying and monitoring providers of comprehensive perinatal services. The department shall provide the local health departments with technical assistance for the purpose of implementing the community perinatal program. The department shall utilize, to the extent feasible, and to the extent funding for administrative costs is available, local health departments in the administration of the perinatal program. If these funds are unavailable, the department shall use alternative means to implement the community perinatal program.(h)(1)It is the intent of the Legislature that the department shall establish a method for reimbursement of comprehensive perinatal providers that shall include a fee for coordinating services and shall be sufficient to cover reasonable costs for the provision of comprehensive perinatal services. The department may utilize fees for service, capitated fees, or global fees to reimburse providers. However, if capitated or global fees are established, the department shall set minimum standards for the provision of services including, but not limited to, the number of prenatal visits, and the amount and type of psychosocial, nutritional, and educational services that patients receive.(2)Notwithstanding the type of reimbursement system, the comprehensive perinatal provider shall not be financially at risk for the provision of inpatient services. The provision of inpatient services that are not related to perinatal care shall not be subject to the requirements of this section. Inpatient services related to services pursuant to this subdivision shall be reimbursed, in accordance with Section 14081, 14086, 14087, or 14087.2, whichever is applicable.(i)The department shall develop systems for the monitoring and oversight of the comprehensive perinatal services provided in this section. The monitoring shall include, but shall not be limited to, the collection of information using the perinatal data form.(j)Participation for services provided pursuant to this section shall be voluntary. The department shall adopt patient rights safeguards for recipients of the comprehensive perinatal services.(k)The amendments made to this section by the act that added this subdivision do not revise or expand the scope of practice of licensed midwives, as defined in Article 24 (commencing with Section 2505) of Chapter 5 of Division 2 of the Business and Professions Code.(l)Notwithstanding subdivision (a), on the effective date of the regulations adopted by the Medical Board of California pursuant to Section 2507 of the Business and Professions Code, a licensed midwife shall be eligible to serve as a comprehensive perinatal provider.(m)For purposes of this section, family physician means a primary care physician and surgeon who renders continued comprehensive and preventative health care services to individuals and families, and who has received specialized training in an approved family medicine residency for three years after graduation from an accredited medical school.SEC. 17.Section 14134.5 is added to the Welfare and Institutions Code, to read:14134.5.(a)A Medi-Cal provider providing pregnancy care shall inform each Medi-Cal member treated during the perinatal period regarding the availability of and access to comprehensive perinatal services, in accordance with this section.
(b)A Medi-Cal members participation in comprehensive perinatal services provided pursuant to subdivision (u) of Section 14132 and this section is voluntary.
(c)Comprehensive perinatal services shall, to the extent feasible, be provided in a manner that reflects the linguistic and cultural features of the populations served.
(d)The department shall do all of the following:
(1)Establish a method for reimbursement of comprehensive perinatal services that shall cover reasonable costs for the provision of comprehensive perinatal services, in accordance with subdivision (a) of Section 14105.05. The department may utilize fee schedules, capitated fees, or global fees to reimburse Medi-Cal providers providing comprehensive perinatal services.
(2)Develop systems for the monitoring and oversight of comprehensive perinatal services.
(3)Establish standards for comprehensive perinatal services rendered by a Medi-Cal provider pursuant to subdivision (u) of Section 14132 and this section.
(4)Adopt patient rights safeguards for recipients of the comprehensive perinatal services.
(5)Adopt regulations to implement this section, as determined to be necessary by the department.
(e)For purposes of this section and the provision of services pursuant to subdivision (u) of Section 14132:
(1)Comprehensive perinatal services includes the provision of the combination of Medi-Cal services and supports, as determined and defined by the department. Comprehensive perinatal services includes all of the following:
(A)A psychosocial assessment and, if appropriate, referral to counseling.
(B)Nutrition assessments and, if appropriate, referral to counseling on food supplement programs, vitamins, and breastfeeding.
(C)Health, childbirth, and parenting education.
(D)Assistance with scheduling visits with appropriate providers and followup to verify whether services have been received.
(2)Family physician means a primary care physician and surgeon who renders continued comprehensive and preventative health care services to individuals and families, and who has received specialized training in an approved family medicine residency for three years after graduation from an accredited medical school.
(3)Medi-Cal provider providing pregnancy care means an obstetrician-gynecologist, a family physician, a certified nurse-midwife, or a licensed midwife enrolled in Medi-Cal pursuant to subdivision (b) of Section 438.602 of Title 42 of the Code of Federal Regulations or Chapter 7 (commencing with Section 14000) that directly, indirectly, or through a group, association, corporation, institution, entity, or clinic, provide outpatient care related to pregnancy to a Medi-Cal member. For the purposes of this definition, Medi-Cal provider providing pregnancy care also includes the clinic, group, association, corporation, institution, entity, or clinic through which the aforementioned providers provide pregnancy care.
(4)Perinatal means the period from the establishment of pregnancy through 12 months following the end of pregnancy.
(f)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar instructions.
(g)This section does not revise or expand the scope of practice of licensed midwives, as defined in Article 24 (commencing with Section 2505) of Chapter 5 of Division 2 of the Business and Professions Code.
|
Date
|
Status
|
|---|---|
| May 14, 2026 | May 14 hearing: Held in committee and under submission. |
| May 8, 2026 | Set for hearing May 14. |
| May 4, 2026 | May 4 hearing: Placed on APPR. suspense file. |
| Apr 28, 2026 | Set for hearing May 4. |
| Apr 27, 2026 | Read second time and amended. Re-referred to Com. on APPR. |
| Apr 23, 2026 | From committee: Do pass as amended and re-refer to Com. on APPR. with recommendation: To consent calendar. (Ayes 11. Noes 0. Page 4010.) (April 22). |
| Apr 23, 2026 | From committee: Do pass as amended and re-refer to Com. on APPR. with recommendation: To consent calendar. (Ayes 11. Noes 0.) (April 22). |
| Apr 9, 2026 | Set for hearing April 22. |
| Apr 8, 2026 | April 15 set for first hearing canceled at the request of author. |
| Mar 27, 2026 | Set for hearing April 15. |
| Feb 11, 2026 | Referred to Com. on HEALTH. |
| Jan 27, 2026 | From printer. May be acted upon on or after February 26. |
| Jan 26, 2026 | Introduced. Read first time. To Com. on RLS. for assignment. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| May 4, 2026 | Placed on suspense file | Senate Standing Committee on Appropriations |
Passed |
|
| Apr 22, 2026 | Do pass as amended, but first amend, and re-refer to the Committee on [Appropriations] with the recommendation: To Consent Calendar | Senate Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| California Life Sciences | ** Support | |
| California Nurse Midwives Association | ** Support | |
| CALIFORNIA PRIMARY CARE ASSOCIATION ADVOCATES | ** Against | |
| Local Health Plans Of California | ** Against | |
| National Association of Pediatric Nurse Practitioners, California Chapters | ** Support |
SENATE COMMITTEE ON
Senator Sabrina Cervantes, Chair
2025 - 2026 Regular Session
SB 912 (Cervantes) - Comprehensive perinatal services
Version: | Policy Vote: |
Urgency: | Mandate: |
Hearing Date: | Consultant: |
Bill Summary:
SB 912 would revise and clarify the roles and responsibilities for the Department of Health Care Services (DHCS) and the California Department of Public Health (CDPH) in the administration of the Comprehensive Perinatal Services Program (CPSP).
Fiscal Impact:
- Unknown ongoing General Fund costs, potentially hundreds of thousands, for DHCS for state administration.
- Unknown potential General Fund costs, likely minor, for CDPH for state administration to collaborate with DHCS.
Background:
The CPSP, administered by CDPH, provides a model of enhanced perinatal services for Medi-Cal eligible pregnant and postpartum individuals. These enhanced services are delivered by qualified Medi-Cal providers. CPSP providers are reimbursed by fee-for-service Medi-Cal or according to their contract with a Medi-Cal managed care plan. CPSP clients receive a program orientation, initial nutrition, psychosocial and health education assessments, second and third trimester reassessments and postpartum assessments. DHCS is responsible for the administration of the Medi-Cal program, which provides health care services to low-income individuals.
In February 2024, the California State Auditor (CSA) released a report, “The Comprehensive Perinatal Services Program: The Lack of Usage Data Prevents the State From Knowing How Often Medi‑Cal Members Receive Perinatal Care.” Among the audit results, the CSA found that both CDPH and DHCS have provided limited oversight and have not exercised their respective authority to make program improvements. The CSA also found that both CDPH and DHCS have not sufficiently communicated the availability of the program to providers or members.
In March 2026, DHCS released an All-Plan Letter to describe coverage requirements for Medi-Cal plans pertaining to coverage and delivery of services for pregnant and postpartum Medi-Cal members. With regards to CPSP, the guidance states that Medi-Cal plans must ensure that their maternity network providers implement a comprehensive risk assessment tool for all pregnant and postpartum members that is comparable to the American College of Obstetricians and Gynecologists (ACOG) standard and the CPSP standards and that the results of this assessment are maintained in the recipient’s medical record. An individualized care plan must be developed that includes obstetric, nutrition, psychosocial and health education interventions and provide appropriate follow-ups and referrals as indicated by the identified risk factors. The risk assessment is to be done at an early prenatal visit, once each trimester, and at the postpartum visit. If the assessment is not administered at a visit, the Medi-Cal plan must ensure its care coordination team works directly with the recipient and their provider to complete the assessment. The Medi-Cal plan and network providers must follow up on all identified risks with interventions consistent with the ACOG and CPSP standards and document those interventions in the medical record. The guidance also specifies that Medi-Cal plans must cover and ensure all medically necessary services for pregnant and postpartum members utilizing the ACOG and CPSP standards as the minimum measure of quality for maternity services, in addition to other allowable standards. Medi-Cal plans cannot, however, require their network providers to enroll as certified CPSP providers in order to be in-network, so long as those providers meet the Medi-Cal provider enrollment requirements.
Proposed Law:
Specific provisions of the bill would:
- Repeal the provision that requires CDPH to develop and maintain a statewide CPSP, and instead require that DHCS must oversee a statewide CPSP and enroll health care providers to deliver these services to Medi-Cal members.
- Require DHCS to collaborate with CDPH to update the regulations related to comprehensive perinatal services to clarify the roles and responsibilities from each department and make adjustments to the current monitoring and oversights systems, including the monitoring of managed care plans and fee-for-service providers, by January 1, 2028.
- Require DHCS, with collaboration from the CDPH, to develop informational and educational materials on comprehensive perinatal services for providers and recipients; and require the DHCS to disseminate the materials, as specified.
- Require DHCS to establish a method for reimbursement of comprehensive perinatal services, as specified.
- Require DHCS to develop systems for the monitoring and oversight of comprehensive perinatal services.
- Require DHCS to establish standards for comprehensive perinatal services rendered by a Medi-Cal provider, as specified.
- Require DHCS to adopt patient rights safeguards for recipients of the comprehensive perinatal services.
- Require DHCS to adopt regulations for implementation, as determined to be necessary by the department.
- Require DHCS to require all Medi-Cal managed care plans to include information on comprehensive perinatal services in the plan member handbooks.
- Require DHCS to update an existing system or implement a new system to monitor and publicly report deidentified comprehensive perinatal services utilization data for eligible Medi-Cal members, consistent with state and federal privacy laws.
- Require DHCS to require Medi-Cal managed care plans to conduct site reviews on perinatal providers at least once every three years, starting in January 1, 2027, to ensure that eligible Medi-Cal managed care plan members receive comprehensive perinatal services.
- Require DHCS, no later than July 15, 2027, to provide a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services from January 1, 2022, to January 1, 2025, inclusive; and require, commencing July 15, 2028, and every three years thereafter, DHCS to provide a report that identifies the number of pregnant and postpartum individuals that received comprehensive perinatal services during the previous three calendar years.
- Require a Medi-Cal managed care plan to inform each Medi-Cal member treated during the perinatal period regarding the availability of and access to comprehensive perinatal services.
Related Legislation:
SB 228 (Cervantes, 2025) would have included requirements for DHCS and CDPH in the administration of the CPSP. The bill was held on the suspense file in the Assembly Appropriations Committee.
-- END --
SENATE COMMITTEE ON HEALTH
Senator Dr. Akilah Weber Pierson, Chair
BILL NO: SB 912
AUTHOR: | Cervantes | ||
VERSION: | January 26, 2026 | ||
HEARING DATE: | April 22, 2026 | ||
CONSULTANT: | Jen Flory | ||
SUBJECT: Comprehensive perinatal services
SUMMARY:
Transfers primary jurisdiction of the Medi-Cal comprehensive perinatal services program from the California Department of Public Health (CDPH) and Department of Health Care Services (DHCS) jointly to DHCS with collaboration from CDPH. Makes other revisions to Medi-Cal’s provision of comprehensive perinatal services, including payment requirements for clinics, and requires DHCS to develop a provider training on the services and prepare triennial reports to the Legislature on the number of Medi-Cal recipients receiving the services.
Existing law:
- Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
- Requires the Medi-Cal program to cover a pregnant individual who is eligible for and is receiving health care coverage under a Medi-Cal program for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individual’s pregnancy. [WIC §14005.185]
- Establishes Comprehensive Perinatal Services Program (CPSP) within CDPH as a community-based system of comprehensive perinatal care for low-income women. States that prenatal care, delivery service, postpartum care, and neonatal and infant care are necessary services that have been demonstrated to be effective in preventing or reducing maternal, perinatal, and infant mortality and morbidity, including prematurity and low birth weight. Includes initial and ongoing physical assessment, psychosocial, nutrition, and health education assessments, interventions, counseling and referral, food supplement programs, vitamins, and breast-feeding and other services as appropriate. Requires all contracted providers to make these services available directly or by subcontract, and to use an appropriate multidisciplinary team. [HSC §123475, et seq.]
- Establishes CPSP services as a Medi-Cal benefit. [WIC §14132]
- Defines CPSP providers to include any general practice physician, family practice physician, obstetrician-gynecologist, pediatrician, certified nurse midwife, a group, any of whose members is one of the above-named physicians, or any preferred provider organization or clinic enrolled in the Medi-Cal program and certified pursuant to the standards of this section. Allows providers to contract with medical and other practitioners, including social workers, health educators, and registered dietitians, for the purpose of delivering CPSP services. [WIC §14134.5]
- States that “perinatal” means the period from the establishment of pregnancy to one month following delivery. Requires the CPSP provider to schedule visits with appropriate providers and track the patient to make sure services have been received. Requires that the patient receive psychosocial assessment and referrals; nutrition assessment, appropriate referrals to counseling for food supplement programs, vitamins, and breastfeeding, health, childbirth, and parenting education. [WIC §14134.5]
- Requires DHCS to assist local health departments to establish a community perinatal program whose responsibilities may include certifying and monitoring providers of CPSP. Requires DHCS to use local health departments to the extent feasible and to the extent funding for administrative costs are available, in the administration of the program. Provides that if such funds are not available, requires DHCS to use alternative means to implement the program. [WIC §14134.5]
- Requires federally qualified health center (FQHC) and rural health clinic (RHC) services to be covered benefits under the Medi-Cal program and requires these services to be reimbursed on a per-visit basis, as defined. Includes a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner providing comprehensive perinatal services in the definition of “visit.” [WIC §14132.100]
This bill:
- Repeals language establishing CPSP within CDPH and instead requires DHCS to oversee CPSP and enroll health care providers to deliver these services to Medi-Cal recipients.
- Requires DHCS to collaborate with CDPH on updated regulations related to comprehensive perinatal services to clarify the roles and responsibilities of each department and adjust the current monitoring and oversights systems, including the monitoring of Medi-Cal managed care plans (Medi-Cal plans), by January 1, 2028.
- Requires DHCS, with collaboration from CDPH, to develop training on administering comprehensive perinatal services and to require all Medi-Cal perinatal providers to complete the training, including Medi-Cal plan and fee-for-service providers.
- Clarifies that CDPH participation in the administration of CPSP does not supplant, create concurrent, nor supersede DHCS’s authority as the single state agency designated for the administration of the federal Medicaid program as required by state and federal law. Makes other changes throughout the code specifying where CDPH still retains a role in the administration of CPSP.
- Requires DHCS, by July 15, 2027, to issue a report to the Senate and Assembly Health Committees and post it on its website identifying the number of pregnant and postpartum individuals receiving CPSP services from January 1, 2022 to January 1, 2025. Requires subsequent reports every three years starting January 1, 2028.
- Deletes the designated CPSP provider agreement requirement from the description of CPSP services in the Medi-Cal schedule of benefits.
- Deletes reference to CPSP providers and their authorization to contract with other providers, and instead uses “Medi-Cal provider providing pregnancy care,” defined as an obstetrician gynecologist, a family physician, a certified nurse midwife or a licensed midwife, and tasks these providers with the responsibility of informing Medi-Cal recipients of the availability of and access to comprehensive perinatal services.
- Authorizes DHCS to implement an alternative payment methodology or other appropriate financing mechanism that allows FQHCs and RHCs to obtain reimbursement for encounters with community health workers at no less than the applicable Medi-Cal fee-for-service rate when provided either on the same day or different day as a billable visit, no sooner than January 1, 2028 and subject to federal approval and federal financial participation.
- Excludes FQHC or RHC comprehensive perinatal practitioners who are not otherwise eligible to bill for an FQHC or RHC visit from billing whenever the payment methodology in 8) is implemented.
- Extends the definition of perinatal from one month following delivery to twelve months following the end of pregnancy.
- Gives DHCS discretion in determining whether regulations are needed and otherwise authorizes implementation via guidance.
- Deletes existing law related to the role of local health departments.
FISCAL EFFECT:
This bill has not been analyzed by a fiscal committee.
COMMENTS:
- Author’s statement. According to the author, in 1984, the Legislature established CPSP. CPSP is provided to eligible low income pregnant and postpartum people from conception to 60 days postpartum. In addition to standard obstetric services, patients receive enhanced services in other areas such as psychosocial, health education, nutrition and more. According to the California State Auditor, based on their report of 2023, CPSP has a lack of data available to track how often Medi-Cal members receive the services. This bill will help provide more transparency in the number of people who seek the services under this program by transferring the administration and oversight responsibilities of CPSP to DHCS. This bill will also require DHCS to submit a report to the Assembly and Senate Health Committee every three years and disclose which providers conducted the reviews of the perinatal services, which is already a requirement of this program. Finally, this bill requires a Medi-Cal provider providing pregnancy care to inform each Medi-Cal member treated during the perinatal period regarding the availability of and access to the CPSP. Modifying the administration and oversight of the CPSP program will help inform the usage of one of many important maternal programs in the State.
- CPSP. CPSP is administered by the CDPH’s Maternal, Child and Adolescent Health division, and provides a model of enhanced perinatal services for Medi-Cal eligible pregnant and postpartum individuals from entry to care through postpartum. These enhanced services are delivered by qualified Medi-Cal providers. CPSP services must be provided in conformance with current American College of Obstetrics and Gynecologists recommendations and California regulation. CPSP providers are reimbursed by fee-for-service Medi-Cal or according to their contract with a Medi-Cal managed care plan (Medi-Cal plan). CPSP clients receive a program orientation, initial nutrition, psychosocial and health education assessments, second and third trimester reassessments and postpartum assessments. The practitioner develops an individualized care plan to address needs identified in the assessments, conducts case coordination, and ensures that the client receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. The plan is developed for each CPSP client at the time of the initial assessment and updated at least every trimester and postpartum visit, and more often if needed. CPSP providers are also required to make referrals to programs and services such as the Women, Infant and Children nutrition program, genetic screening, dental care, and family planning, as well as provide case coordination to assure that health care members work together with the client to assure that the care plan is completed, and the client receives the necessary services.
- State Auditor report. The California State Auditor released a report on CPSP on February 15, 2024, finding that neither DHCS nor CDPH provide sufficient oversight of CPSP. The report found that although DHCS requires the Medi-Cal plans it contracts with to conduct reviews of each of their primary care providers at least every three years, in 2022 only 45 of the approximately 2,600 providers’ reviews included an assessment of CPSP services. CDPH delegated its oversight of CPSP to local health jurisdictions, but it did not require that those jurisdictions complete the quality assurance chart reviews that would have provided insight into service quality. The auditor’s survey of the 61 local health jurisdictions found that 22 did not complete the chart reviews. Finally, the auditor found that the State lacks data on CPSP’s utilization necessary for its improvement. The auditor was only able to assess the usage of CPSP for 14% of Medi-Cal recipients in 2022. As part of the report, the auditor found that because nearly all Medi-Cal recipients are now enrolled in a Medi-Cal plan, rather than using the fee-for-service network, the Legislature should assign the primary responsibility for CPSP to DHCS, despite their failure to monitor or oversee the program thus far, and consider additional data collection duties. The auditor also made a number of other recommendations, including updating the CPSP regulations, require training of perinatal providers in the fee-for-service and managed care networks, require Medi-Cal plans to conduct quality assurance reviews, and require information on CPSP in Medi-Cal plan member handbooks. In its responses to the audit, DHCS did not commit to making changes specific to CPSP, but instead committed more generally to improving access to pregnancy and pregnancy-related services and supports. For example, DHCS committed to requiring Medi-Cal plans to independently ensure that providers have training on the comprehensive suite of pregnancy and pregnancy-related benefits covered under Medi-Cal and that the training is documented. CDPH did agree to update CPSP regulations in collaboration with DHCS and improve provider training on the CPSP program.
- Birthing Care Pathway. In February 2025, DHCS released a Birthing Care Pathway report to summarize the current state of maternal health in Medi-Cal, outline DHCS’s vision for the Birthing Care Pathway, and identify a series of policy solutions to address the physical, behavioral, and health-related social needs of pregnant and postpartum Medi-Cal enrollees by improving access to providers, strengthening clinical care and care coordination, providing whole-person care, and modernizing how Medi-Cal pays for maternity care. With regards to CPSP, the report states that CPSP is provided inconsistently across delivery systems and counties, and many Medi-Cal recipients report being unaware of the services available. The report further states that CPSP should be modernized to ensure uniform, high-quality access to comprehensive perinatal services for all pregnant and postpartum Medi-Cal recipients. The report states that the separate CPSP provider enrollment process with CDPH is burdensome for providers, CPSP should be aligned with more recent clinical guidelines and best practices, and the delivery system and billing codes should be updated. The report also notes that some Workgroup members recommend extending CPSP coverage from 60 days to 12 months postpartum to align with Medi-Cal’s 12-month postpartum coverage.
- All Plan Letter (APL) 26-005. DHCS released APL 26-005 on March 25, 2026, “Maternity Services for Pregnant and Postpartum Medi-Cal Members,” to describe coverage requirements for Medi-Cal plans pertaining to coverage and delivery of services for pregnant and postpartum Medi-Cal members. The letter implements the Birthing Care Pathway as it pertains to Medi-Cal plans, pointing out that Medi-Cal plans currently cover over 85% of pregnant and postpartum Medi-Cal recipients. With regards to CPSP, the guidance states that Medi-Cal plans must ensure that their maternity network providers implement a comprehensive risk assessment tool for all pregnant and postpartum members that is comparable to the American College of Obstetricians and Gynecologists (ACOG) standard and the CPSP standards and that the results of this assessment are maintained in the recipient’s medical record. An individualized care plan must be developed that includes obstetric, nutrition, psychosocial and health education interventions and provide appropriate follow-ups and referrals as indicated by the identified risk factors. The risk assessment is to be done at an early prenatal visit, once each trimester, and at the postpartum visit. If the assessment is not administered at a visit, the Medi-Cal plan must ensure its care coordination team works directly with the recipient and their provider to complete the assessment. The Medi-Cal plan and network providers must follow up on all identified risks with interventions consistent with the ACOG and CPSP standards and document those interventions in the medical record. These assessments may also be completed through telehealth with the recipient’s consent.
The guidance also specifies that Medi-Cal plans must cover and ensure all medically necessary services for pregnant and postpartum members utilizing the ACOG and CPSP standards as the minimum measure of quality for maternity services, in addition to other allowable standards. Medi-Cal plans cannot, however, require their network providers to enroll as certified CPSP providers in order to be in-network, so long as those providers meet the Medi-Cal provider enrollment requirements. The guidance is silent with regards to the training of network providers on CPSP assessments or standards, though it does mention provider training with regards to some of the other topics of the guidance.
- Related legislation. AB 2160 (C. Rodriguez) requires DHCS to update guidance on Medi-Cal coverage for lactation services. AB 2160 is pending in the Assembly Appropriations Committee.
- Prior legislation. SB 228 (Cervantes of 2025) would have required CDPH, in collaboration with DHCS, to update regulations, create a provider training, and collect information on CPSP. SB 228 would have required DHCS to implement a program to monitor Medi-Cal plan’s provision of CPSP services and to prepare a report on the number of people offered and receiving CPSP services every three years. SB 228 was held on the Assembly Appropriations Committee suspense file.
AB 608 (Schiavo of 2023) would have required DHCS to extend the CPSP benefit for up to one year after the end of a Medi-Cal beneficiary’s pregnancy and required DHCS to allow an unlicensed perinatal provider to render preventive services recommended by a licensed provider and to provide those services in a beneficiary’s home or other community setting away from a medical site. AB 608 was vetoed by Governor Newsom who stated in his veto message: “I support the author's goal to improve maternal health outcomes and reduce disparities. However, Medi-Cal already provides full-scope coverage for one year after pregnancy, and DHCS is actively working on a "Birthing Care Pathway" proposal to improve services provided during the perinatal period, reduce maternal mortality, and address disparities in maternal health outcomes. Given the significant ongoing General Fund costs of over $20 million annually to implement this bill, it should be evaluated as part of the annual budget process.”
AB 1930 (Arambula of 2022) was substantially similar to AB 608. AB 1930 was vetoed by Governor Newsom who stated in his veto message: “I support the author's efforts to improve maternal health outcomes and ensure Medi-Cal offers appropriate care for beneficiaries during and after their pregnancy. DHCS already provides full-scope coverage for all individuals for one year after pregnancy, which offers a range of services above and beyond the services provided by CPSP. However, this bill attempts to expand the services offered by comprehensive perinatal workers and make these services a Medi-Cal benefit apart from CPSP. This bill would result in millions of dollars in ongoing General Fund costs that are not accounted for in the budget.”
- Support. The National Association of Pediatric Nurse Practitioners, California Chapters, write that DHCS is better equipped than CDPH to coordinate services and ensure that pregnant and postpartum Medi-Cal members have access to the care they need. They also write that the bill’s creation of an oversight system and mandated training program will improve service delivery and quality. The California Life Sciences write that by creating accountability and transparency in CPSP delivery, the bill creates the infrastructure that enables their member companies’ maternal health products, including diagnostics, monitoring tools, therapeutics, and care technologies targeting maternal and perinatal health, to reach the patients who need them. They also point to persistent disparities in maternal outcomes in California as a signal that the care infrastructure needs strengthening.
- Opposition unless amended. CPCA Advocates, representing community health centers and clinics throughout the state, write in opposition to the proposed payment changes to FQHCs and RHCs as that portion of the bill would eliminate reimbursement for certain CPSP providers from the per-visit payment system utilized by the clinics. They write that this piece threatens the financial viability of integrated perinatal care at clinics and health centers at a time when clinics are facing unprecedented challenges from H.R. 1, federal policy change proposals, state budget decisions and a ballot initiative. They urge striking section 15 from this bill.
- Amendments. The author and committee have agreed to the following amendments:
- Delete the section that changes the existing payment structure for FQHCs and RHCs;
- Change provider training requirements to requirements for DHCS and plans to send information to providers and recipients about comprehensive perinatal services;
- Technical change on how physician providers are referred to; and,
- Change a report due date to allow for sufficient time between the reporting period and the report due date.
SUPPORT AND OPPOSITION:
Support: California Life Sciences
California Nurse Midwives Association
National Association of Pediatric Nurse Practitioners California Chapters
Oppose: California Primary Care Association Advocates (unless amended)
Local Health Plans of California (unless amended)
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Bill Author
Bill Co-Author(s):