14197.8.
(a) In the case of a Medi-Cal enrollee of a Medi-Cal managed care plan who also has other health care coverage and for whom the Medi-Cal program is a secondary payer, the department shall ensure that a provider billing the Medi-Cal managed care plan for payer of last resort,
the department shall ensure that a provider that is not contracted with the Medi-Cal managed care plan and that is billing the Medi-Cal managed care plan for Medi-Cal allowable costs not paid by the other health care coverage does not face administrative requirements significantly in excess of the administrative requirements for billing those same costs to the Medi-Cal fee-for-service delivery system.(b) (1) In the case of a Medi-Cal enrollee of a Medi-Cal managed care plan who also has other health
care coverage, excluding Medicare, and for whom the Medi-Cal program is a secondary payer, payer of last resort, a provider participating in the Medi-Cal fee-for-service delivery system shall not be required to contract with the Medi-Cal managed care plan in order to provide services to that Medi-Cal enrollee and to bill the Medi-Cal managed care plan. as an in-network provider with the Medi-Cal managed care plan in order to bill the Medi-Cal managed care plan for Medi-Cal allowable costs for covered health care services.
(c)A Medi-Cal managed care plan shall provide assistance to Medi-Cal providers and beneficiaries, upon request, on options for maintaining health care relationships between beneficiaries and existing providers that are contracted with, or have agreements with, a beneficiary’s primary form of health care coverage, if the beneficiary transitions from receiving services under the Medi-Cal fee-for-service delivery system to being an enrollee of the Medi-Cal managed care plan.
(2) A Medi-Cal managed care plan may require a letter of agreement, or a similar agreement, under either of the following circumstances:
(A) If a covered service requires prior authorization, or if a service is not covered by the other health care coverage but is a covered service under the Medi-Cal managed care plan, the Medi-Cal managed care plan may require a letter of agreement, or a similar agreement, with a provider that is not contracted with the Medi-Cal managed care plan for the provision of that service. Without a letter of agreement, or a similar agreement, the provider may be responsible for billed amounts for any services that exceed the allowable Medi-Cal fee-for-service rate or any applicable limitations on the number or duration of services provided. Pursuant to Section 14019.4, the provider shall not bill a Medi-Cal enrollee of a Medi-Cal managed care plan for any
excess amounts not paid by the Medi-Cal managed care plan.
(B) If a Medi-Cal enrollee of a Medi-Cal managed care plan requires a covered service and meets the requirements for continuity of care or the completion of covered services through a Medi-Cal managed care plan pursuant to Section 1373.96 of the Health and Safety Code, the Medi-Cal managed care plan may require a provider to enter into an agreement for the provision of the applicable services.
(d)
(c) (1) The department shall solicit input from stakeholders, including consumer advocates, Medi-Cal managed care plans, other commercial plans, and
and, to the extent that information is available to the department, providers that serve regional center clients, regarding the coordination of other commercial health coverage with Medi-Cal managed care, payment for services between Medi-Cal enrollees’ other commercial health care coverage and their Medi-Cal managed care plans, with a specific emphasis on Medi-Cal recipients who receive regional center services. The department shall also include an item on the agenda of the first meeting of the Medi-Cal Managed Care Advisory Committee of 2025 to discuss this topic. After receiving stakeholder input, the department shall, within 12
six months of the meeting, take the actions it deems necessary to ensure that Medi-Cal managed care enrollees who have other health coverage, including those receiving regional center services, are able to coordinate their care as seamlessly as possible.
that it deems necessary to provide clarification regarding the conditions for billing Medi-Cal managed care plans to providers that render services to Medi-Cal managed care enrollees who also have other health care coverage. The department’s actions may include updating regulations, providing revised guidance to plans and providers, increasing reporting requirements, taking enforcement action, and providing education and outreach to Medi-Cal enrollees, especially to those enrollees who receive regional center services and have other commercial health coverage. and taking enforcement action as it deems necessary.
(e)At least annually, from
(2) It is the intent of the Legislature that the department offer educational resources to an enrollee of a Medi-Cal managed care plan who needs assistance with understanding continuity of care and coordinating Medi-Cal and their other health care coverage when requested by the enrollee.
(d) On an annual basis, from 2025 through 2028, the department shall report to update the Assembly Committee on Health and the Senate Committee on Health, in accordance with Section 9795 of the Government Code,
Health on the effectiveness of implementing this section.
(f)
(e) For purposes of this section “Medi-Cal managed care plan” has the same meaning as that term is defined in subdivision (j) of Section 14184.101.
(g)
(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 by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions.
section, in whole or in part, by means of all-county letters, plan letters, plan or provider bulletins, information notices, or similar instructions, without taking any further regulatory action.
(h)
(g) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized.