ARTICLE 4. The Medi-Cal Benefits Program

Heading of Article 4 renumbered from Article 4.2 by Stats. 1977, Ch. 1252.

§§ 14131–14138 · 150 sections

§ 14131 The Medi-Cal Benefits Program comprises a department-administered uniform schedule of health care benefits. Notwithstanding any other provision of this…
§ 14131.05 (a) Notwithstanding any other provision of this chapter or Chapter 8 (commencing with Section 14200), optional hearing aid benefits are subject to per…
§ 14131.10 (a) Notwithstanding this chapter, Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591), in order to implement changes in…
§ 14131.11 (a) Notwithstanding any other provision of this chapter or Chapter 8 (commencing with Section 14200), any increase in the amount charged to the Medi-Cal…
§ 14131.15 (a) In geographic areas in which Medi-Cal managed care plans contracting under this chapter or Chapter 8 (commencing with Section 14200) are operating with…
§ 14132 The following is the schedule of benefits under this chapter: (a) Outpatient services are covered as follows: Physician, hospital or clinic outpatient,…
§ 14132.01 (a) Notwithstanding any other provision of law, a community clinic or free clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety…
§ 14132.02 (a) The department shall seek approval from the United States Secretary of Health and Human Services to provide individuals made eligible pursuant to Section…
§ 14132.025 (a) Notwithstanding any other law, emergency services and care necessary for the treatment of an emergency medical condition, as defined in subdivision (b) of…
§ 14132.03 (a) The following shall be covered Medi-Cal benefits effective January 1, 2014: (1) Mental health services included in the essential health benefits package…
§ 14132.05 The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of their submittal to the federal Health Care…
§ 14132.06 (a) Services specified in this section that are provided by a local educational agency are covered Medi-Cal benefits, to the extent federal financial…
§ 14132.07 (a) A Medi-Cal managed care plan shall not restrict the choice of the qualified provider from whom a beneficiary enrolled in the managed care plan may receive…
§ 14132.09 (a) By July 1, 2024, biomarker testing, as specified in this section, is a covered benefit, subject to utilization controls and medical necessity requirements,…
§ 14132.1 As used in this chapter “surgical center” means a surgical clinic that is licensed under Section 1203 of the Health and Safety Code. Pursuant to Section 14105,…
§ 14132.10 (a) (1) Pediatric day health care provided by a health facility licensed under paragraph (11) of subdivision (a) of Section 1250.1 of the Health and Safety…
§ 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…
§ 14132.101 (a) Notwithstanding paragraphs (4) and (5) of subdivision (e) of Section 14132.100, a scope-of-service change request, whether mandatory or permissive, shall…
§ 14132.102 (a) With the exception of clinics and hospital outpatient departments that are subject to Section 14105.24, federally qualified health centers (FQHCs) that are…
§ 14132.107 Claims for reimbursement under subdivision (e) of Section 14132.100 shall be finalized by the department within 150 days of receipt of the claims for…
§ 14132.108 Notwithstanding any other provision of law, requests for rate adjustments for scope-of-service rate changes under paragraph (4) of subdivision (e) of Section…
§ 14132.11 (a) Commencing on July 1, 2024, pharmacogenomic testing shall be a covered benefit under the Medi-Cal program, subject to utilization controls and…
§ 14132.13 (a) Services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program are covered benefits…
§ 14132.14 (a) Federal Food and Drug Administration-approved treatments for menopausal symptoms are covered benefits under the Medi-Cal program, subject to medical…
§ 14132.15 For purposes of subdivision (p) of Section 14132, “rehabilitation services” means services intended to assist physically or cognitively impaired persons to…
§ 14132.16 Mammography for screening or diagnostic purposes upon the referral of a patient’s physician shall be covered under this chapter on or after January 1, 1988, to…
§ 14132.17 Annual cervical cancer tests for screening or diagnostic purposes, upon the referral of a patient’s physician, is a covered benefit under this chapter, on or…
§ 14132.171 (a) (1) An annual cognitive health assessment for Medi-Cal beneficiaries who are 65 years of age or older is a covered benefit if they are otherwise ineligible…
§ 14132.18 (a) Community supported living arrangement services approved by the United States Department of Health and Human Services in accordance with Section 1396v of…
§ 14132.19 (a) (1) The department, in consultation with the State Department of Social Services, county mental health experts, managed care plan experts, behavioral…
§ 14132.195 (a) Consistent with federal law, screening services provided as an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit pursuant to…
§ 14132.20 (a) The department shall establish a program to provide continuous skilled nursing care to persons with developmental disabilities as a benefit of the Medi-Cal…
§ 14132.21 The department shall assess the feasibility of applying to the federal Health Care Financing Administration for a Medicaid State Plan amendment to provide…
§ 14132.22 (a) For purposes of this section, dental restorative materials are limited to composite resin, glass ionomer cement, resin ionomer cement, and amalgam, as…
§ 14132.23 (a) (1) Except as set forth in paragraph (2), and notwithstanding any other provision of law or regulation, the active and retentive phases of orthodontic…
§ 14132.25 (a) On or before July 1, 1983, the State Department of Health Care Services shall establish a subacute care program in health facilities in order to more…
§ 14132.26 (a) The department shall develop a program that requires a waiver of federal law to test the efficacy of providing an assisted living benefit to beneficiaries…
§ 14132.27 (a) (1) The department shall apply for a waiver of federal law pursuant to Section 1396n of Title 42 of the United States Code to test the efficacy of…
§ 14132.28 (a) If the department decides to terminate or not renew a health facility’s subacute care services provider contract, the department shall notify the health…
§ 14132.29 (a) A health facility that has a subacute services provider contract with the department under this chapter shall comply with the patient transfer and…
§ 14132.3 In addition to any other criteria as provided in subdivision (p) of Section 14132, no reimbursement shall be made pursuant to this chapter for any service in a…
§ 14132.34 (a) Human milk and human milk derivatives supplied by a mothers’ milk bank for human consumption are a covered service under this chapter. (b) For purposes of…
§ 14132.35 (a) Outpatient rehabilitation services are covered under this chapter, subject to utilization controls. (b) The department and the Medi-Cal field offices shall…
§ 14132.36 (a) Community health worker services are a covered Medi-Cal benefit. (b) For purposes of this section, the following definitions apply: (1) “Community health…
§ 14132.39 Midwifery services provided by a licensed midwife shall be covered under this chapter, to the extent that federal financial participation is available, and,…
§ 14132.4 Nurse-midwifery services provided by a certified nurse-midwife shall be covered under the provisions of this chapter, to the extent required by federal law,…
§ 14132.41 (a) Services provided by a certified nurse practitioner shall be covered under this chapter to the extent authorized by federal law, and subject to utilization…
§ 14132.42 Benefits under this chapter shall not be restricted for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and…
§ 14132.44 (a) Targeted case management (TCM), pursuant to Section 1915(g) of the Social Security Act as amended by Public Law 99-272 (42 U.S.C. Sec. 1396n(g)), shall be…
§ 14132.45 Regulations implementing, interpreting, or making specific the provisions of subdivision (z) of Section 14132 shall not be subject to Chapter 3.5 (commencing…
§ 14132.46 Pursuant to Sections 14024 and 14124.90, the Director of Health Services may recover for the cost of targeted case management services rendered under Section…
§ 14132.47 (a) It is the intent of the Legislature to provide local governmental agencies the choice of participating in either or both of the Targeted Case Management…
§ 14132.48 Targeted case management services to which Sections 14132.44 and 14132.47 does not apply, and as specified in Section 1915(g) of the federal Social Security…
§ 14132.49 (a) Upon federal approval of the state plan amendments made pursuant to Section 14021.7 for federal financial assistance, targeted case management, pursuant to…
§ 14132.55 For the purposes of reimbursement under the Medi-Cal program, a speech pathologist or audiologist shall be licensed by the Speech-Language Pathology and…
§ 14132.56 (a) (1) Only to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment…
§ 14132.57 (a) (1) The department shall seek all necessary federal approvals to exercise the option described in Section 1396w-6 of Title 42 of the United States Code, to…
§ 14132.58 (a) The department shall file all necessary state plan amendments, as set forth in Section 457.40 of Title 42 of the Code of Federal Regulations, to exercise…
§ 14132.6 External prostheses constructed of silicon or other comparable materials, prosthetic implants, and reconstructive surgery incident to mastectomy shall be…
§ 14132.62 (a) Reconstructive surgery shall be covered under this chapter, as defined in subdivision (c), when necessary to achieve the purposes specified in paragraphs…
§ 14132.63 (a) An orthotist or prosthetist providing services under this chapter shall be required to be certified in orthotics or prosthetics by either the Board for…
§ 14132.69 (a) Notwithstanding any other provision of law, donor and recipient organ transplant surgeries are covered under the Medi-Cal program when an organ transplant…
§ 14132.70 (a) A Medi-Cal beneficiary shall remain eligible to receive Medi-Cal coverage for antirejection medication for up to two years following an organ transplant,…
§ 14132.71 (a) For purposes of donor and recipient organ transplant surgeries, the department shall establish standards as to both the circumstances and the criteria that…
§ 14132.72 (a) For purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply. (b) It is the intent…
§ 14132.723 (a) (1) Notwithstanding any other law, neither face-to-face contact nor a patient’s physical presence on the premises shall be required for services provided…
§ 14132.724 (a) On or before July 1, 2020, the department shall issue, and shall publish on its internet website, guidance for enrolled community clinics and other…
§ 14132.725 (a) For purposes of this section, the following definitions apply: (1) “Border community” means border areas adjacent to the State of California where it is…
§ 14132.726 (a) (1) Commencing in 2028 and every two years thereafter, the department shall use Medi-Cal data and other data sources available to the department to produce…
§ 14132.73 The State Department of Health Care Services shall allow psychiatrists to receive fee-for-service Medi-Cal reimbursement for services provided through…
§ 14132.731 (a) A county that enters into a Drug Medi-Cal Treatment Program contract with the department in accordance with Section 14124.20, or the department if entering…
§ 14132.74 (a) The department, in consultation with interested stakeholders, shall develop, as a pilot project, a pediatric palliative care benefit to evaluate whether,…
§ 14132.75 (a) In enacting this section, it is the intent of the Legislature that palliative care include, but not be limited to, all of the following: (1) Specialized…
§ 14132.755 (a) Commencing no sooner than July 1, 2022, dyadic behavioral health visits shall be a covered benefit under the Medi-Cal program, subject to utilization…
§ 14132.76 (a) An individual who is determined to be eligible to receive hospice services prior to 21 years of age may continue to receive hospice services after 21 years…
§ 14132.765 (a) No treatment authorization request shall be required for the provision of prosthetic devices or for the replacement or repair of prosthetic devices, if the…
§ 14132.77 (a) (1) Any rural hospital may request to participate in a two-year pilot project to perform delegated acute inpatient hospital treatment authorization review…
§ 14132.8 Services covered under this chapter shall include rehabilitative services for the physically or cognitively impaired stroke patient, or a patient who has brain…
§ 14132.81 (a) The purchase of identification bracelets for eligible recipients under the Medi-Cal program who have Alzheimer’s Disease or some other cognitive defect, or…
§ 14132.85 (a) For purposes of this section, the following definitions apply: (1) “Complex needs patient” means an individual with a diagnosis or medical condition that…
§ 14132.86 (a) Notwithstanding subdivision (ab) of Section 14132, effective May 1, 2014, purchase of prescribed enteral nutrition products is covered, subject to the…
§ 14132.88 (a) Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made available in the annual Budget Act for this purpose, the following are…
§ 14132.89 (a) Notwithstanding subdivision (h) of Section 14132, effective May 1, 2014, or the effective date of any necessary federal approvals as required by…
§ 14132.9 Notwithstanding subdivision (h) of Section 14132, any utilization controls imposed under such subdivision shall not include mandatory examination by any person…
§ 14132.905 (a) Day care habilitative services, pursuant to subdivision (c) of Section 14021, shall be provided only to alcohol- and drug-exposed pregnant women and women…
§ 14132.91 (a) Subject to the availability of funding, the department shall conduct a dental outreach and education program for Medi-Cal beneficiaries. The program shall…
§ 14132.915 (a) (1) The department shall establish a list of performance measures to ensure the dental fee-for-service program meets quality and access criteria required…
§ 14132.92 (a) Notwithstanding subdivision (a) of Section 4512, or any other provision of this chapter or Chapter 8 (commencing with Section 14200), services provided on…
§ 14132.925 (a) (1) Notwithstanding any other provision of law or regulation to the contrary, to the extent federal financial participation is available, in furtherance of…
§ 14132.93 It is the intent of the Legislature that if services meeting the conditions of subdivision (a) of Section 14132.92 have been provided to a Medi-Cal beneficiary…
§ 14132.94 (a) Subject to approval by the Centers for Medicare and Medicaid Services of a medicaid state plan amendment electing the Programs of All-Inclusive Care for…
§ 14132.95 (a) Personal care services, when provided to a categorically needy person as defined in Section 14050.1 is a covered benefit to the extent federal financial…
§ 14132.951 (a) It is the intent of the Legislature that the State Department of Health Services seek approval of a Medicaid waiver under the federal Social Security Act…
§ 14132.952 (a) The department shall seek approval of an amendment to the Medicaid state plan pursuant to Section 1396n(j) of Title 42 of the United States Code to provide…
§ 14132.955 Personal care services that are provided pursuant to Section 14132.95 shall include services in the recipient’s place of employment if both of the following…
§ 14132.956 (a) The department shall assess and determine whether it would be cost efficient for the state to exercise the option made available under Section 1915(k) of…
§ 14132.96 Medi-Cal personal care services provider rates established as provided in the state plan under Subchapter 19 (commencing with Section 1396) of Chapter 7 of…
§ 14132.966 (a) Services provided by a physician assistant are a covered benefit under this chapter to the extent authorized by federal law and subject to utilization…
§ 14132.968 (a) (1) Pharmacist services are a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services. (2) The…
§ 14132.969 (a) Subject to an annual appropriation for this express purpose, the department shall implement a medication therapy management (MTM) reimbursement methodology…
§ 14132.97 (a) (1) For purposes of this section, “waiver personal care services” means personal care services authorized by the department for persons who are eligible…
§ 14132.971 (a) The county, or the public authority or nonprofit consortium established pursuant to Section 12301.6, shall be deemed to be the employer to meet and confer…
§ 14132.98 (a) For a beneficiary diagnosed with cancer and accepted into a phase I, phase II, phase III, or phase IV clinical trial for cancer or for any other qualifying…
§ 14132.985 For services provided pursuant to Chapter 7 (commencing with Section 14000) of Part 3 of Division 9, Section 14499.5, or Chapter 1 (commencing with Section…
§ 14132.99 (a) For the purposes of this section, “facility residents” means individuals who are currently residing in a nursing facility and whose care is paid for by…
§ 14132.991 (a) When renewing the Nursing Facility/Acute Hospital Transition and Diversion Waiver, as authorized by subdivision (t) of Section 14132, the director may take…
§ 14132.993 (a) This section applies to the Home- and Community-Based Alternatives Waiver (HCBA), the Assisted Living Waiver (ALW), and, to the extent that the dependent…
§ 14132.994 A Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, shall cover COVID-19 screening, testing, immunizations, and therapeutics in…
§ 14132.995 (a) Notwithstanding any other law, vaccines and immunizations are covered in accordance with a recommendation from the Advisory Committee on Immunization…
§ 14132aa (a) Services provided by facilities licensed as congregate living health facilities to individuals diagnosed as having acquired immune deficiency syndrome…
§ 14133 Utilization controls that may be applied to the services set forth in Section 14132 which are subject to utilization controls shall be limited to: (a) Prior…
§ 14133.01 (a) Notwithstanding any other law, the director or his or her designee may apply prior authorization by designing a sampling methodology that will result in a…
§ 14133.05 (a) Notwithstanding any other provision of law, a request for a treatment authorization received by the department shall be reviewed for medical necessity…
§ 14133.07 (a) A doctor of podiatric medicine shall not be required to submit prior authorization for podiatric services rendered in either an outpatient or inpatient…
§ 14133.1 (a) The director shall determine which of the utilization controls in Section 14133 shall be applied to any specific service or group of services which are…
§ 14133.10 (a) Where it is expected to be cost-effective, the director may, in conducting Medi-Cal acute care inpatient hospital utilization control, establish a program…
§ 14133.12 (a) The director shall apply utilization controls to continuous skilled nursing care services provided pursuant to the pilot program established under Section…
§ 14133.14 The criteria that the department shall use to identify providers to be placed on prior authorization for noninvasive testing procedures shall include, but not…
§ 14133.15 (a) The provision of services to beneficiaries eligible for medical assistance benefits may be subject to utilization controls, as provided for in Section…
§ 14133.16 (a) Notwithstanding subdivision (l) of Section 14132, hearing aids are covered when supplied by a hearing aid dispenser on prescription of an otolaryngologist,…
§ 14133.2 (a) The director shall include in the Medi-Cal list of contract drugs any drug approved for the treatment of cancer by the federal Food and Drug…
§ 14133.225 Notwithstanding any other law, the department shall not provide or pay for any prescription drug or other therapy to treat erectile dysfunction for any person…
§ 14133.23 (a) To the extent that federal financial participation is not available, the provision of drug benefits under this chapter to full-benefit dual eligible…
§ 14133.25 (a) The director shall identify those surgical and medical procedures capable of outpatient performance and establish conditions for assuring performance in an…
§ 14133.3 (a) The director shall require fully documented medical justification from providers that the requested services are medically necessary or a medical…
§ 14133.37 For drugs covered under this chapter requiring prior authorization, the department shall ensure the timely and efficient processing of authorization requests…
§ 14133.4 Notwithstanding any other provision of law, utilization controls adopted by the State Department of Health Services shall not include prior authorization for…
§ 14133.45 (a) Utilization controls adopted by the department shall not include prior authorization for renal dialysis treatment provided to eligible recipients for the…
§ 14133.6 In acting upon prior authorization requests for nonemergency medical transportation services, the department shall consider all relevant information in its…
§ 14133.65 Prior authorization for the use of nonemergency medical transportation services by patients to and from dialysis treatment shall be approved for a period of up…
§ 14133.7 The department shall not require emergency certification statements for hospital inpatient claims which have been reviewed and approved by the department for…
§ 14133.8 (a) A bone marrow transplant for the treatment of cancer for beneficiaries who are eligible for full-scope benefits under this chapter, shall be reimbursable…
§ 14133.85 (a) (1) Except as otherwise provided in this subdivision, prior authorization shall not be required for hospice services. (2) Paragraph (1) shall not apply to… see note
§ 14133.9 The implementation of prior authorization permitted by subdivision (a) of Section 14133 shall be subject to all of the following provisions: (a) The department…
§ 14134.2 The reimbursement rate for any three or more laboratory services for the same patient on the same day, which are commonly performed in an automated manner, as…
§ 14134.25 (a) Tobacco cessation services are covered benefits under the Medi-Cal program, subject to utilization controls. Tobacco cessation services shall include all…
§ 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…
§ 14134.55 The department shall streamline and simplify existing Medi-Cal program procedures in order to improve access to lactation supports and breast pumps among…
§ 14134.6 Long-term health care facilities may charge a resident only the actual price paid by the facility for goods and services actually supplied to the resident and…
§ 14135 To assure maximum federal financial participation under this chapter, the director shall establish an enrollment fee, premium or similar charge to the extent…
§ 14136 (a) No city or county shall establish equipment and personnel standards for the furnishing of nonemergency medical transportation services for eligible…
§ 14136.1 It is the intent of the Legislature that, in order for payment to be made to a medical transportation service provider, a patient who requires continuous…
§ 14136.3 No prior authorization shall be necessary for the provision of nonemergency medical transportation services to Medi-Cal beneficiaries when the beneficiary is…
§ 14136.4 A written treatment authorization request for nonemergency medical transportation services for which a department employed medical consultant had provided…
§ 14136.5 No entity which has received funds under paragraph (2) of subsection (b) of Section 1601 of the federal Urban Mass Transportation Act shall receive…
§ 14136.8 No reimbursement shall be made for medical transportation services provided pursuant to subdivision (i) of Section 14132 when the services are prescribed or…
§ 14137 The State Department of Health Services, following review and approval from the State Health and Welfare Agency, shall seek all necessary waivers from the…
§ 14137.6 (a) Notwithstanding any other provision of law, and subject to federal financial participation, covered services under this chapter shall include, subject to…
§ 14137.8 Approval of a request for acute inpatient care shall be solely dependent upon the medical necessity for this care, as documented in the proposed treatment…
§ 14138 (a) To the extent permitted by federal law, the department shall purchase vaccines and biological products in bulk from the Centers for Disease Control or any…