124900-124945

HEALTH AND SAFETY CODE
SECTION 124900-124945




124900.  (a) (1) The State Department of Health Care Services shall
select primary care clinics that are licensed under subparagraph (A)
or (B) of paragraph (1) of subdivision (a) of Section 1204, or are
exempt from licensure under subdivision (c) of Section 1206, to be
reimbursed for delivering medical services, including preventive
health care, and smoking prevention and cessation health education,
to program beneficiaries.
   (2) In order to be eligible to receive funds under this article a
clinic shall meet all of the following conditions, at a minimum:
   (A) Provide medical diagnosis and treatment.
   (B) Provide medical support services of patients in all stages of
illness.
   (C) Provide communication of information about diagnosis,
treatment, prevention, and prognosis.
   (D) Provide maintenance of patients with chronic illness.
   (E) Provide prevention of disability and disease through
detection, education, persuasion, and preventive treatment.
   (F) Meet one or both of the following conditions:
   (i) Be located in an area or a facility federally designated as a
health professional shortage area, medically underserved area, or
medically underserved population.
   (ii) Be a clinic that is able to demonstrate that at least 50
percent of the patients served are persons with incomes at or below
200 percent of the federal poverty level.
   (3) Notwithstanding the requirements of paragraph (2), all clinics
that received funds under this article in the 1997-98 fiscal year
shall continue to be eligible to receive funds under this article.
   (b) As a part of the award process for funding pursuant to this
article, the department shall take into account the availability of
primary care services in the various geographic areas of the state.
The department shall determine which areas within the state have
populations that have clear and compelling difficulty in obtaining
access to primary care. The department shall consider proposals from
new and existing eligible providers to extend clinic services to
these populations.
   (c) A primary care clinic applying for funds pursuant to this
article shall demonstrate that the funds shall be used to expand
medical services, including preventive health care, and smoking
prevention and cessation health education, for program beneficiaries
above the level of services provided in the 1988 calendar year, or in
the year prior to the first year a clinic receives funds under this
article if the clinic did not receive funds in the 1989 calendar
year.
   (d) (1) The department, in consultation with clinics funded under
this article, shall develop a formula for allocation of funds
available. It is the intent of the Legislature that the funds
allocated pursuant to this article promote stability for those
clinics participating in programs under this article as part of the
state's health care safety net and at the same time be distributed in
a manner that best promotes access to health care to uninsured
populations.
   (2) The formula shall be based on both of the following:
   (A) A hold harmless for clinics funded in the 1997-98 fiscal year
to continue to reimburse them for some portion of their uncompensated
care.
   (B) Demonstrated unmet need by both new and existing clinics, as
reflected in their levels of uncompensated care reported to the
department. For purposes of this article, "uncompensated care" means
clinic patient visits for persons with incomes at or below 200
percent of the federal poverty level for which there is no
encounter-based third-party reimbursement which includes, but is not
limited to, unpaid expanded access to primary care claims.
   (3) The department shall allocate available funds, for a
three-year period, as follows:
   (A) Clinics that received funding in the prior fiscal year shall
receive 90 percent of their prior fiscal year allocation, subject to
available funds, provided that the funding award is substantiated by
the clinics' reported levels of uncompensated care.
   (B) The remaining funds beyond 90 percent shall be awarded to new
and existing applicants based on the clinics' reported levels of
uncompensated care as verified by the department according to
subparagraph (A) of paragraph (4). The department shall seek input
from stakeholders to discuss adjustments to award levels that the
department deems reasonable, such as including base amounts for new
applicant clinics.
   (C) New applicants shall be awarded funds pursuant to this
subdivision if they meet the minimum requirements for funding under
this article based on the clinics' reported levels of uncompensated
care as verified by the department according to subparagraph (A) of
paragraph (4). New applicants include applicants for new site
expansions by existing applicants.
   (4) In assessing reported levels of uncompensated care, the
department shall utilize the data available from the Office of
Statewide Health Planning and Development's (OSHPD's) completed
analysis of the "Annual Report of Primary Care Clinics" for the prior
fiscal year, or if more recent data is available, then the most
recent data. If this data is unavailable for an existing applicant to
assess reported levels of uncompensated care, the existing applicant
shall receive an allocation pursuant to subparagraph (A) of
paragraph (3).
   (A) The department shall utilize the most recent data available
from OSHPD's completed analysis of the "Annual Report of Primary Care
Clinics" for the prior fiscal year, or if more recent data is
available, then the most recent data.
   (B) If the funds allocated to the program are less than the prior
year, the department shall allocate available funds to existing
program providers only.
   (5) The department shall establish a base funding level, subject
to available funds, of no less than thirty-five thousand dollars
($35,000) for frontier clinics and Native American reservation-based
clinics. For purposes of this article, "frontier clinics" means
clinics located in a medical services study area with a population of
fewer than 11 persons per square mile.
   (6) The department shall develop, in consultation with clinics
funded pursuant to this article, a formula for reallocation of unused
funds to other participating clinics to reimburse for uncompensated
care. The department shall allocate the unused funds remaining on
October 30, for the prior fiscal year to other participating clinics
to reimburse for uncompensated care.
   (e) In applying for funds, eligible clinics shall submit a single
application per clinic corporation. Applicants with multiple sites
shall apply for all eligible clinics, and shall report to the
department the allocation of funds among their corporate sites in the
prior year. A corporation may claim reimbursement only for services
provided at a program-eligible clinic site identified in the
corporate entity's application for funds, and approved for funding by
the department. A corporation may increase or decrease the number of
its program-eligible clinic sites on an annual basis, at the time of
the annual application update for the subsequent fiscal years of any
multiple-year application period.
   (f) Grant allocations pursuant to this article shall be based on
the formula developed by the department, notwithstanding a merger of
one of more licensed primary care clinics participating in the
program.
   (g) A clinic that is eligible for the program in every other
respect, but that provides dental services only, rather than the full
range of primary care medical services, shall only be eligible to
receive funds under this article on an exception basis. A dental-only
provider's application shall include a memorandum of understanding
(MOU) with a primary care clinic funded under this article. The MOU
shall include medical protocols for making referrals by the primary
care clinic to the dental clinic and from the dental clinic to the
primary care clinic, and ensure that case management services are
provided and that the patient is being provided comprehensive primary
care as described in subdivision (a).
   (h) (1) For purposes of this article, an outpatient visit shall
include diagnosis and medical treatment services, including the
associated pharmacy, X-ray, and laboratory services, and prevention
health and case management services that are needed as a result of
the outpatient visit. For a new patient, an outpatient visit shall
also include a health assessment encompassing an assessment of
smoking behavior and the patient's need for appropriate health
education specific to related tobacco use and exposure.
   (2) "Case management" includes, for this purpose, the management
of all physician services, both primary and specialty, and
arrangements for hospitalization, postdischarge care, and followup
care.
   (i) (1) Payment shall be on a per-visit basis at a rate that is
determined by the department to be appropriate for an outpatient
visit as defined in this section, and shall be not less than
seventy-one dollars and fifty cents ($71.50).
   (2) In developing a statewide uniform rate for an outpatient visit
as defined in this article, the department shall consider existing
rates of payments for comparable outpatient visits. The department
shall review the outpatient visit rate on an annual basis.
   (j) Not later than June 1 of each year, the department shall adopt
and provide each licensed primary care clinic with a schedule for
programs under this article, including the date for notification of
availability of funds, the deadline for the submission of a completed
application, and an anticipated contract award date for successful
applicants.
   (k) In administering the program created pursuant to this article,
the department shall utilize the Medi-Cal program statutes and
regulations pertaining to program participation standards, medical
and administrative recordkeeping, the ability of the department to
monitor and audit clinic records pertaining to program services
rendered to program beneficiaries and take recoupments or recovery
actions consistent with monitoring and audit findings, and the
provider's appeal rights. A primary care clinic applying for program
participation shall certify that it will abide by these statutes and
regulations and other program requirements set forth in this article.




124905.  For purposes of this article, a "program beneficiary" is
any person whose income level is at or below 200 percent of the
federal poverty level as adjusted annually. Program beneficiaries
shall not be required to provide any copayment for services that are
funded pursuant to this article, except that clinics may charge
beneficiaries on a sliding fee scale for services, but no beneficiary
shall be denied services because of an inability to pay. The
department shall annually adjust this income standard to reflect any
changes in the federal poverty level. Payment pursuant to this
article shall be made only for services for which payment will not be
made through any private or public third-party reimbursement.




124910.  (a) (1) Each licensed primary care clinic, as specified in
subdivision (a) of Section 124900, applying for funds under this
article, shall demonstrate in its application that it meets all of
the following conditions, at a minimum:
   (A) Provides medical diagnosis and treatment.
   (B) Provides medical support services of patients in all stages of
illness.
   (C) Provides communication of information about diagnosis,
treatment, prevention, and prognosis.
   (D) Provides maintenance of patients with chronic illness.
   (E) Provides prevention of disability and disease through
detection, education, persuasion, and preventive treatment.
   (F) Meets one or both of the following conditions:
   (i) Is located in an area or a facility federally designated as a
health professional shortage area, medically underserved area, or
medically underserved population.
   (ii) Is a clinic in which at least 50 percent of the patients
served are persons with incomes at or below 200 percent of the
federal poverty level.
   (2) Any applicant who has applied for and received a federal or
state designation for serving a health professional shortage area,
medically underserved area, or population shall be deemed to meet the
requirements of subdivision (a) of Section 124900.
   (b) Each applicant shall also demonstrate to the satisfaction of
the department that the proposed services supplement, and do not
supplant, those primary care services to program beneficiaries that
are funded by any county, state, or federal program.
   (c) Each applicant shall demonstrate that it is an active Medi-Cal
provider by being enrolled in Medi-Cal and diligently billing the
Medi-Cal program for services rendered to Medi-Cal eligible patients
during the past three months prior to the application due date. This
subdivision shall not apply to clinics that are not currently
Medi-Cal providers, and were funded participants pursuant to this
article during the 1993-94 fiscal year.
   (d) Each application shall be evaluated by the state department
prior to funding to determine all of the following:
   (1) The applicant shall provide its most recently audited
financial statement to verify budget information.
   (2) The applicant's ability to deliver basic primary care to
program beneficiaries.
   (3) A description of the applicant's operational quality assurance
program.
   (4) The applicant's use of protocols for the most common diseases
in the population served under this article.




124911.  (a) Commencing in the 1998-99 fiscal year, the department
shall release a request for allocation of funds for a period of three
succeeding fiscal years. The request for allocation shall include
specifications for the clinics to submit uniform data on
uncompensated patient visits.
   (b) Annual funding awards for a clinic provider in the second and
third fiscal years of a three-year funding period shall be contingent
upon the clinic's satisfactory performance under the program, and
upon the availability of sufficient funds appropriated by the annual
Budget Act.



124915.  Services funded pursuant to this article shall be limited
to the extent that funds are appropriated for this purpose.



124920.  (a) The department shall utilize existing contractual
claims processing services in order to promote efficiency and to
maximize use of funds.
   (b) The department shall certify which primary care clinics are
selected to participate in the program for each specific fiscal year,
and how much in program funds each selected primary care clinic will
be allocated each fiscal year.
   (c) The department shall pay claims from selected primary care
clinics up to each clinic's annual allocation. Once a clinic has
exhausted its annual allocation, the state shall stop paying its
program claims.
   (d) The department may adjust any selected primary care clinic's
allocation to take into account:
   (1) An increase in program funds appropriated for the fiscal year.
   (2) A decrease in program funds appropriated for the fiscal year.
   (3) A clinic's projected inability to fully spend its allocation
within the fiscal year.
   (4) Surplus funds reallocated from other selected primary care
clinics.
   (e) The department shall notify all affected primary care clinics
in writing prior to adjusting selected primary care clinics'
allocations.
   (f) Cessation of program payments under subdivision (e) or
adjustment of selected primary care clinic's allocations under
subdivision (d) shall not be subject to the Medi-Cal appeals process
referenced in subdivision (g) of Section 124900.
   (g) A clinic's allocation under this article shall not be reduced
solely because the clinic has engaged in supplemental fundraising
drives and activities, the proceeds of which have been used to defray
the costs of services to the uninsured.



124925.  The department shall submit a report on its activities
under this article to the Legislature no later than January 1, 1991,
and annually thereafter.


124930.  (a) For any condition detected as part of a child health
and disability prevention screen for any child eligible for services
under Section 104395, if the child was screened by the clinic or upon
referral by a child health and disability prevention program
provider, unless the child is eligible to receive care with no share
of cost under the Medi-Cal program, is covered under another publicly
funded program, or the services are payable under private coverage,
a clinic shall, as a condition of receiving funds under this article,
do all of the following:
   (1) Insofar as the clinic directly provides these services for
other patients, provide medically necessary followup treatment,
including prescription drugs.
   (2) Insofar as the clinic does not provide treatment for the
condition, arrange for the treatment to be provided.
   (b) (1) If any child requires treatment the clinic does not
provide, the clinic shall arrange for the treatment to be provided,
and the name of that provider shall be noted in the patient's medical
record.
   (2) The clinic shall contact the provider or the patient or his or
her guardian, or both, within 30 days after the arrangement for the
provision of treatment is made, and shall determine if the provider
has provided appropriate care, and shall note the results in the
patient's medical record.
   (3) If the clinic is not able to determine, within 30 days after
the arrangement for the provision of treatment is made, whether the
needed treatment was provided, the clinic shall provide written
notice to the county child health and disability prevention program
director, and shall also provide a copy to the state director of the
program.



124940.  The use of funds granted pursuant to this article for use
by school-based clinics shall be limited to those school-based
clinics that were licensed and in operation before January 1, 1990.



124945.  Any entity or provider that receives funds pursuant to this
article shall expend those funds in accordance with the requirements
of Article 2 (commencing with Section 30121) of Chapter 2 of Part 13
of Division 2 of the Revenue and Taxation Code.