Section 14094.11 - Participation requirements A Medi-Cal managed care plan participating in the Whole Child Model program shall meet all of the following requirements:
(a) Ensure that each CCS-eligible child or youth receives case management, care coordination, provider referral, and service authorization services from an employee or contractor of the plan who has knowledge of, and receives adequate training on, the CCS program, and who has clinical experience with the CCS population, or clinical experience with pediatric patients with complex medical conditions. In addition, the plan shall ensure that a CCS-eligible child has a primary point of contact who shall be responsible for the child's care coordination.(b) Work with the state or county CCS program, as appropriate, to ensure that, at a minimum, and in addition to other statutory and contractual requirements, care coordination and care management activities do all of the following: (1) Reflect a CCS child or youth family-centered, outcome-based approach to care planning.(2) Ensure families have access to ongoing information, education, and support so that they understand the care plan for their child or youth and their role in the individual care process, the benefits of mental health services, what self-determination means, and what services might be available.(3) Adhere to the CCS child's or youth's or the CCS child's or youth's family's determination about the appropriate involvement of their medical providers and caregivers, according to the federal Health Insurance Portability and Accountability Act of 1996 ( Public Law 104-191 ).(4) Include individual care plans for CCS-eligible children and youth based on the results of the risk assessment process with a particular focus on CCS specialty care.(5) Consider behavioral health needs of CCS-eligible children and youth and coordinate those services as part of the CCS child's or youth's individual care plan, when appropriate, and facilitate a CCS child's or youth's ability to access appropriate community resources and other agencies, including referrals, as necessary and appropriate, for behavioral services, such as specialty mental health services and substance use disorder services.(6) Ensure that children and youth and their families have appropriate access to transportation and other support services necessary to receive treatment.(c) Incorporate all of the following into the CCS child's or youth's plan of care: (1) Access for families so that families know where to go for ongoing information, education, and support in order that they understand the goals, treatment plan, and course of care for their child or youth and their role in the process, what it means to have primary or specialty care for their child or youth, when it is time to call a specialist, primary, urgent care, or emergency room, what an interdisciplinary team is, and what the community resources are.(2) A primary or specialty care physician who is the primary clinician for the CCS-eligible child or youth and who provides core clinical management functions.(3) Care management and care coordination for the CCS-eligible child or youth across the health care system, including transitions among levels of care and interdisciplinary care teams.(4) Provision of information about qualified professionals, community resources, or other agencies for services or items outside the scope of responsibility of the managed care plan.(d) Use clinical data to identify CCS-eligible children or youth at the care site with chronic illness or other significant health issues.(e) Arrange for timely preventive, acute, and chronic illness treatment of CCS-eligible children or youth in the appropriate setting.Ca. Welf. and Inst. Code § 14094.11
Amended by Stats 2023 ch 42 (AB 118),s 130, eff. 7/10/2023.Added by Stats 2016 ch 625 (SB 586),s 7, eff. 1/1/2017.