Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) For each benefit year, the Board will
designate as the community provider plan in each county the participating health
plan with a service area that includes zip codes in which at least eighty-five
percent (85%) of the residents of the county reside and that has the highest
percentage of traditional and safety net providers pursuant to the calculation in
subsection (g) below.
(b) In November of
the benefit year immediately preceding the benefit year described in subsection (a),
the Board shall compile and make available a list for each county of all Child
Health and Disability Prevention Program (CHDP), clinic and hospital traditional and
safety net providers.
(c) The lists
shall be compiled as follows:
(1) The CHDP list
shall include all CHDP providers, except for clinical laboratories, that were on the
Department of Health Care Services (DHCS) CHDP Master File as of October 1st of the
benefit year immediately preceding the benefit year described in subsection (a) and
that provided a State-only funded CHDP service as identified on the CHDP Paid Claims
Tape to at least one (1) child aged one (1) through eighteen (18) in the state
fiscal year that ended immediately prior to the most recently ended state fiscal
year. For each listed provider, the list shall indicate the percentage of county
children that received State-only funded CHDP services from the listed provider. The
percentage shall be calculated by dividing the number of county children receiving
State-only funded services from the listed provider by the total number of county
children receiving State-only funded services from all listed providers in the
county.
(2) The clinic list shall
include all Community Outpatient Hospital Based Clinics, Rural Health Clinics,
Federally Qualified Health Centers, Free Clinics, Community Clinics, Clinics Exempt
from Licensure, County Clinics Not With Hospital and County Hospital Outpatient
Clinics, in the county, that were so identified by the Medi-Cal program as of
October 1st of the benefit year immediately preceding the benefit year described in
subsection (a) and were identified on the Medi-Cal Paid Claims Tape as having
provided at least (1) service to a child aged one (1) through eighteen (18) in the
state fiscal year that ended immediately prior to the most recently ended state
fiscal year. The list shall indicate a percentage for each clinic which shall be
equal to one (1) divided by the number of listed clinics in the county.
(3) The hospital list shall be compiled as
follows:
(A) For a county that has, located in the
county, at least one hospital which, as of October 1st of the benefit year
immediately preceding the benefit year described in subsection (a), was a hospital
eligible for the inpatient disproportionate share hospital payment program as
reported by the Department of Health Care Services (DHCS), a University teaching
hospital, a Children's Hospital (as defined in Section
10727
of the Welfare and Institutions Code), or a county owned and operated general acute
care hospital, the list shall include all hospitals of one of these types whether or
not they are located in the county and which reported to the Office of Statewide
Health Planning and Development (OSHPD) discharging at least one resident of the
county who was a Medi-Cal, county indigent, or charity care patient aged one (1)
through eighteen (18) in the year for which OSHPD most recently released its annual
compilation of Discharge Data. The list shall indicate, for each hospital, the
percentage of the Medi-Cal, county indigent, and charity care discharges of county
residents aged one (1) through eighteen (18) from the listed hospital. The hospital
list shall not include acute psychiatric hospitals (as defined in Section
1250(b)
of the Health and Safety Code), psychiatric health facilities (as defined in Section
1250.2(a)
of the Health and Safety Code), or chemical dependency recovery hospitals (as
defined in Section
1250.3(a)
of the Health and Safety Code).
(B) For
all other counties, the list shall include all hospitals located in the county and
all hospitals located outside the county, which, as of October 1st of the benefit
year immediately preceding the benefit year described in subsection (a), discharged
at least one resident of the county who was a Medi-Cal, county indigent, or charity
care patient aged one (1) through eighteen (18) in the year for which OSHPD most
recently released its annual compilation of Discharge Data and which were hospitals
eligible for the inpatient disproportionate share hospital payment program as
reported by the DHCS, a university teaching hospital, a children's hospital (as
defined in Section
10727
of the Welfare and Institutions Code), or a county owned and operated general acute
care hospital. The list shall indicate, for each hospital, the percentage of the
Medi-Cal, county indigent, and charity care discharges of county residents aged one
(1) through eighteen (18) from the listed hospital. The hospital list shall not
include acute psychiatric hospitals (as defined in Section
1250(b)
of the Health and Safety Code, psychiatric health facilities (as defined in Section
1250.2(a)
of the Health and Safety Code), or chemical dependency recovery hospitals (as
defined in Section
1250.3(a)
of the Health and Safety Code).
(d) The lists of CHDP providers, clinics and
hospitals described in subsection (c) shall be revised only under the following
circumstances:
(1) Any CHDP provider not included
on a county list pursuant to subsection (c)(1) or any participating health plan that
asserts the CHDP provider met the specified criteria to be on that list and was
excluded in error may, within thirty (30) calendar days after the list described in
subsection (b) is released by the Board, provide written documentation to the Board
demonstrating that the CHDP provider met the criteria described in subsection
(c)(1). If the Executive Director of the Board finds that the CHDP provider met the
specified criteria then the CHDP provider shall be added to the county
list.
(2) Any clinic not included on a
county list pursuant to subsection (c)(2) or any participating health plan that
asserts the clinic met the specified criteria to be on that list and was excluded in
error may, within thirty (30) calendar days after the list described in subsection
(b) is released by the Board, provide written documentation to the Board
demonstrating that the clinic met the criteria as described in subsection (c)(2). If
the Executive Director of the Board finds that the clinic met the specified criteria
then the clinic shall be added to the county list.
(3) Any hospital not included on a county list
pursuant to subsection (c)(3) or any participating health plan that asserts the
hospital met the specified criteria to be on that list and was excluded in error
may, within thirty (30) calendar days after the list described in subsection (b) is
released by the Board, provide written documentation to the Board demonstrating that
the hospital met the criteria described in subsection (c)(3). If the Executive
Director of the Board finds that the hospital met the specified criteria then the
hospital shall be added to the county list.
(e) The Board shall compile and make available a
final list for each county of CHDP, clinic, and hospital traditional and safety net
providers after the revision period described in subsection (d) has expired. For the
benefit year described in section (a) that commences July 1, 2009 only, the final
list shall be the list made available January 22, 2009.
(f) By January 15th of the benefit year
immediately preceding the benefit year described in subsection (a), each
participating health plan shall submit the following to the Board for each county:
(1) A list of the CHDP providers identified by the
Board pursuant to subsection (e) that have a contractual relationship with the
participating health plan for the provision of services to program
subscribers.
(2) A list of the clinics
identified by the Board pursuant to subsection (e) that have a contractual
relationship with the participating health plan for the provision of services to
program subscribers.
(3) A list of the
hospitals identified by the Board pursuant to subsection (e) that have a contractual
relationship with the participating health plan for the provision of services to
program subscribers.
(4) For the benefit
year described in section (a) that commences July 1, 2009 only, the lists described
in subsections (f)(1), (2) and (3) shall be those lists submitted by the health
plans prior to the effective date of this subsection.
(g) The percentage of traditional and safety net
providers in the provider network of each participating health plan will be
calculated by summing the CHDP percentage, the clinic percentage, and the hospital
percentage.
(1) The CHDP percentage is calculated
by summing the percentages assigned to the CHDP providers pursuant to Section (c)(1)
that were identified by the plan pursuant to (f)(1), and multiplying that number by
0.35.
(2) The clinic percentage is
calculated by summing the percentages assigned to each listed clinic in the county
pursuant to subsection (c)(2) that was identified by the plan pursuant to subsection
(f)(2) and multiplying that number by 0.45.
(3) The hospital percentage is calculated by
summing the percentages assigned to each hospital pursuant to subsection (c)(3)
identified by the plan pursuant to (f)(3), and multiplying that number by
0.2.
(h) The Board shall
designate a community provider plan for each county for the benefit year described
in subsection (a). Notwithstanding subsection (h) of section 2600.6500, the
designation shall take effect on the day the open enrollment transfers described in
section 2699.6621 take effect, and the previous
designation shall remain in effect until that time. Prior to designation, each
plan's relationships with traditional and safety net providers may be verified by
the Board.
1. New section
filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate
of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be
repealed by operation of law on the following day.
2. Certificate of
Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register
98, No. 29).
3. Amendment of subsections (c)(2) and (c)(3)(A)-(B) filed
12-14-98 as an emergency; operative 12-14-98 (Register 98, No. 51). A Certificate of
Compliance must be transmitted to OAL by 4-13-99 or emergency language will be
repealed by operation of law on the following day.
4. Certificate of
Compliance as to 12-14-98 order transmitted to OAL 3-25-99 and filed 5-6-99
(Register 99, No. 19).
5. Amendment filed 6-20-2000 as an emergency;
operative 6-20-2000 (Register 2000, No. 25). A Certificate of Compliance must be
transmitted to OAL by 10-18-2000 or emergency language will be repealed by operation
of law on the following day.
6. Certificate of Compliance as to 6-20-2000
order transmitted to OAL 10-12-2000; disapproval and reinstatement of text as it
existed prior to emergency amendment pursuant to Government Code section
11349.6(d)
filed 11-27-2000 (Register 2000, No. 48).
7. Amendment filed 11-28-2000
as an emergency; operative 11-28-2000 (Register 2000, No. 48). A Certificate of
Compliance must be transmitted to OAL by 3-28-2001 or emergency language will be
repealed by operation of law on the following day.
8. Certificate of
Compliance as to 11-28-2000 order transmitted to OAL 1-31-2001 and filed 2-20-2001
(Register 2001, No. 8).
9. Amendment of subsections (c)(1), (c)(3)(A)-(B)
and (f) filed 3-27-2008 as an emergency; operative 3-27-2008 (Register 2008, No.
13). A Certificate of Compliance must be transmitted to OAL by 9-23-2008 or
emergency language will be repealed by operation of law on the following
day.
10. Certificate of Compliance as to 3-27-2008 order, including
further amendment of section, transmitted to OAL 8-15-2008 and filed 9-22-2008
(Register 2008, No. 39).
11. Amendment of subsections (b), (c)(2) and
(e), new subsection (e)(4), amendment of subsections (g)(1)-(2), repealer of
subsections (g)(2)(A)-(B) and amendment of subsection (g)(3) filed 2-26-2009 as an
emergency; operative 2-26-2009 (Register 2009, No. 9). A Certificate of Compliance
must be transmitted to OAL by 8-25-2009 or emergency language will be repealed by
operation of law on the following day.
12. Certificate of Compliance as
to 2-26-2009 order transmitted to OAL 8-24-2009 and filed 9-17-2009 (Register 2009,
No. 38).
Note: Authority cited: Section
12693.21,
Insurance Code. Reference: Sections
12693.21 and
12693.37,
Insurance Code.
