Cal. Code Regs. tit. 22 § 50185.5

Current through Register 2024 Notice Reg. No. 17, April 26, 2024

Section 50185.5 - Medi-Cal Managed Care Plan Assigned Enrollment Prior to Two-Plan Model Implementation or for Geographic Areas Not Designated for Two-Plan Model Implementation

(a) This section applies to geographic areas specified by the director, which may include geographic areas designated for implementation of the two-plan model as defined in section 53810(n) prior to implementation of the two-plan model, and geographic areas not designated for two-plan model implementation. This section applies to aid categories specified by the director, pursuant to Welfare and Institutions Code Section 14016.5 and 14087.305.

(b) The following definitions apply to this section:

(1) Affiliate means an existing Medi-Cal managed care plan that has a written agreement to become a subcontractor to the local initiative or the commercial plan when the local initiative or commercial plan commences operation, or an entity that has been awarded the local initiative or commercial plan contract under the Two-Plan Model and is an existing Medi-Cal prepaid health plan contractor that is authorized under its Medi-Cal prepaid health plan contract to operate in the service area to which the plan has been awarded the commercial plan or local initiative contract under the Two-Plan Model.

(2) Assignment means the action taken by the health care options contractor to enroll an eligible beneficiary or an eligible family group into a Medi-Cal managed care plan when the beneficiary fails to select a managed care plan and does not provide a written certification of an established patient-provider relationship.

(3) Authorized affiliate means any existing Medi-Cal prepaid health plan that has been awarded the local initiative or commercial plan contract under the Two-Plan Model, or is an affiliate that has been authorized by the department to receive assignments after a local initiative or commercial plan has submitted a written request to the department that assignments be made to that affiliate.

(4) Commercial plan means a prepaid health plan in a designated geographic area awarded a contract by the department pursuant to sections 53800(b)(1).

(5) Commercial plan enrollment maximum means the enrollment level established by the department pursuant to section 53820(b).

(6) Confirmed conditional start date means the date established by the department on which a local initiative or commercial plan is authorized to begin operation under the Two Plan Model, subject to the local initiative or commercial plan fulfilling the conditions specified by the department at the time the confirmed conditional start date is given by the department.

(7) CP/LI ratio means the total enrollment of the commercial plan, or if the commercial plan is not operational, the combined total enrollment of the commercial plan affiliates, DIVIDED by the combined total enrollment of the local initiative affiliates. The source of the enrollment totals is the department's monthly Medi-Cal managed care capitation report.

(8) Fee-for-service managed care program means a program operated in a designated geographic area by an entity contracting with the Department under which services continue to be provided on a fee-for-service basis, but each Medi-Cal beneficiary is provided with a primary care provider who coordinates the beneficiary's Medi-Cal health care.

(9) Health care options contractor means the entity contracting with the department to provide applicants and beneficiaries with information on the available options to receive Medi-Cal benefits and to process applicant and beneficiary enrollment choices or assignments in designated geographic areas.

(10) Health care options presentation means a presentation in-person or by mail to Medi-Cal applicants and beneficiaries which provides information on the Medi-Cal managed care plans and fee-for-service options available within the designated geographic area in which the applicant or beneficiary resides.

(11) Local initiative means a prepaid health plan awarded a contract by the department pursuant to sections 53800(b)(2) and 53810(h).

(12) Local initiative enrollment minimum means the total number of Medi-Cal beneficiaries in the mandatory aid categories in the designated geographic area less the maximum enrollment level established pursuant to section 53820 of the commercial plan.

(13) Operational means a managed care plan is providing covered services to enrolled Medi-Cal beneficiaries and is entitled to receive capitation payments from the department.

(c) Applicants and beneficiaries shall be informed by the county welfare department of the availability of health care options presentations which explain the options for receiving Medi-Cal benefits and the obligation of the applicants and beneficiaries to attend a presentation. For beneficiaries who do not attend a health care options presentation, the department shall mail information explaining the beneficiary's health care options.

(1) The county welfare department shall inform applicants and beneficiaries of the availability of health care options presentations at the time of their initial eligibility and annual redetermination in the following geographic areas:

(A) Areas designated for the two-plan model, when:

1. only the commercial plan is operational; or

2. only the local initiative is operational; or

3. the department intends to award two commercial plan contracts and no local initiative contract, and only one commercial plan is operational.

(B) Areas not designated for the two-plan model.

(2) If, within the same geographical area, the local initiative is scheduled to become operational prior to the date the commercial plan is expected to become operational, the local initiative may submit a written request to the department that the department include all existing beneficiaries in the mandatory aid categories in the health care options notification process.

(d) At the health care options presentation or by mail, the department shall provide to the applicant or beneficiary information on Medi-Cal managed care plans operating within the geographic area in which the applicant or beneficiary resides.

(e) Each applicant or beneficiary shall submit in writing to the health care options contractor a choice to enroll in a Medi-Cal managed care plan or shall certify in writing that he or she has an established patient-provider relationship either:

(1) within 30 days of the applicant's or beneficiary's attendance at a health care options presentation; or,

(2) if the applicant or beneficiary does not attend a health care options presentation prior to the postmark date on which the health care options materials were mailed to the applicant or beneficiary, within 30 days of the postmark date of the mailed health care options materials.

(f) The health care options contractor shall assign beneficiaries failing to comply with the requirements of subsection (e) to an available Medi-Cal managed care plan that has capacity to accept new beneficiaries and that has a primary care service site serving the postal ZIP code area in which the beneficiary resides. To the extent possible, a beneficiary shall not be assigned to a different Medi-Cal managed care plan than other members of the same family group.

(g) In geographic areas designated for health care to be provided under the two-plan model, if more than one Medi-Cal managed care plan meets the conditions in (f), assignments shall be made as follows:

(1) If the local initiative is operational, all assignments will be directed to the local initiative until it reaches the local initiative enrollment minimum.

(2) If the local initiative is operational and has attained its enrollment minimum and the commercial plan is not operational but has authorized affiliates, one of every two assignments will be directed to the local initiative and one will be directed to an authorized affiliate of the commercial plan. Assignments to the commercial plan's affiliates will be evenly distributed among all authorized affiliates of the commercial plan. Assignments to the authorized commercial plan affiliates will continue until their combined enrollment total reaches the commercial plan enrollment maximum, at which time assignments to authorized commercial plan affiliates will be discontinued. Enrollment in the local initiative and commercial plan affiliates will be reviewed on a monthly basis. If the local initiative's enrollment falls below the local initiative's enrollment minimum, all assignments will be directed to the local initiative as needed to restore it to its enrollment minimum. After the local initiative has been restored to its enrollment minimum, assignments to the authorized commercial plan affiliates will be resumed as provided above until the commercial plan affiliates' combined enrollment total reaches the commercial plan enrollment maximum, at which time assignments to authorized commercial plan affiliates will be discontinued. If the commercial plan does not have any authorized affiliates, all assignments will be directed to the local initiative.

(3) If the commercial plan is operational and the local initiative is not operational but has authorized affiliates, and the combined total enrollment of the local initiative affiliates is less than the total enrollment of the commercial plan, assignments will be made as follows:

(A) If the CP/LI ratio is 1.0 or less, one of every two assignments will be directed to an authorized affiliate of the local initiative and one assignment will be directed to the commercial plan.

(B) If the CP/LI ratio is greater than 1.0 but less than or equal to 2.0, two of every three assignments will be directed to the authorized affiliates of the local initiative and one assignment will be directed to the commercial plan.

(C) It the CP/LI ratio is greater than 2.0 but less than or equal to 3.0, three of every four assignments will be directed to the authorized affiliates of the local initiative and one assignment will be directed to the commercial plan.

(D) If the CP/LI ratio is greater than 3.0, four of every five assignments will be directed to the authorized affiliates of the local initiative and one assignment will be directed to the commercial plan.

(E) For (g)(3)(A), (B), (C) and (D), assignments to the authorized local initiative affiliates will be evenly distributed among all authorized affiliates of the local initiative.

(F) Once (g)(3)(B), (C), or (D) have been applied, and the CP/LI ratio reaches 1.0 or less, until 90 days prior to the Local Initiative's confirmed conditional start date, one of every two assignments will be directed to an authorized affiliate of the local initiative and one assignment will be directed to the commercial plan. No further use of the CP/LI ratio will be made to determine assignments. When the commercial plan reaches its enrollment maximum, further assignments to the commercial plan will be discontinued. Enrollment totals in the commercial plan and the combined enrollment total for the local initiative affiliates will be reviewed on a monthly basis. If enrollment falls below the commercial plan enrollment maximum, assignments to the commercial plan will be resumed with the commercial plan receiving one of every two assignments until the commercial plan reaches the commercial plan enrollment maximum.

(G) Beginning 90 days prior to a local initiative's confirmed conditional start date, all assignments will be made to the authorized affiliates of the local initiative. These assignments will be evenly distributed among all authorized affiliates of the local initiative. When enrollment in the affiliates of the local initiative reaches the local initiative's minimum enrollment, one of every two assignments will be directed to an authorized affiliate of the local initiative and one assignment will be directed to the commercial plan. Assignments to the authorized affiliates of the local initiative will be evenly distributed among all authorized affiliates of the local initiative. Assignments to the commercial plan will continue until the enrollment total of the commercial plan equals the commercial plan enrollment maximum, at which time assignments to the commercial plan will be discontinued. The enrollment total of the commercial plan and the combined enrollment total for the affiliates of the local initiative will be reviewed on a monthly basis. If the combined enrollment of the affiliates of the local initiative falls below the local initiative's enrollment minimum, all assignments will be directed to the authorized affiliates of the local initiative as needed to restore the combined enrollment in affiliates of the local initiative to the local initiative enrollment minimum. After enrollment in the affiliates of the local initiative has been restored to its enrollment minimum, assignments to the commercial plan will be resumed as provided above until the commercial plan's enrollment reaches the commercial plan enrollment maximum, at which time assignments to the commercial plan will be discontinued.

(4) If the commercial plan is operational, and the local initiative is not operational but has authorized affiliates, and the combined enrollment of the local initiative affiliates is equal to or greater than the enrollment in the commercial plan, one of every two assignments will be directed to an authorized affiliate of the local initiative and one assignment will be directed to the commercial plan. When the commercial plan reaches its enrollment maximum, further assignments to the commercial plan will be discontinued. Enrollment totals in the commercial plan and the combined enrollment total for the local initiative affiliates will be reviewed on a monthly basis. If enrollment falls below the commercial plan enrollment maximum, assignments to the commercial plan will be resumed with the commercial plan receiving one of every two assignments until the commercial plan reaches the commercial plan enrollment maximum.

(5) If the commercial plan is operational, and the local initiative is not operational and the local initiative does not have any authorized affiliates, all assignments will be directed to the commercial plan. When the commercial plan reaches its enrollment maximum, further assignment to the commercial plan will be discontinued. Enrollment in the commercial plan will be reviewed on a monthly basis. If enrollment falls below the commercial plan enrollment maximum, assignments to the commercial plan will be resumed with the commercial plan receiving all assignments until the commercial plan reaches its enrollment maximum.

(6) If neither the local initiative nor commercial plan is operational, but either one or both has authorized affiliates, assignment shall be as follows:

(A) If the local initiative does not have any authorized affiliates and the commercial plan has authorized affiliates, all assignments will be directed to the commercial plan's authorized affiliates. When the combined total enrollment of the commercial plan's affiliates reaches the commercial plan maximum, further assignments to the commercial plan's authorized affiliates will be discontinued. Enrollment in the commercial plan's affiliates will be reviewed on a monthly basis. If the combined total enrollment of the commercial plan's affiliates falls below the commercial plan maximum, assignments will be resumed until the combined enrollment in the commercial plan's affiliates reaches the commercial plan maximum.

(B) If the local initiative has authorized affiliates and the commercial plan does not have authorized affiliates, all assignments will be directed to the authorized affiliates of the local initiative.

(C) If the local initiative has not been given a confirmed conditional start date by the department, and the combined total enrollment of the local initiative affiliates is less than the combined total enrollment of the commercial plan affiliates, until the combined total enrollment of the local initiative affiliates is equal to or greater than the combined total enrollment of the commercial plan affiliates, assignments will be made as follows:

1. If the CP/LI ratio is 1.0 or less, one of every two assignments will be directed to the authorized affiliates of the local initiative and one assignment will be directed to an authorized affiliate of the commercial plan.

2. If the CP/LI ratio is greater than 1.0 but less than or equal to 2.0, two of every three assignments will be directed to the authorized affiliates of the local initiative and one assignment will be directed to an authorized affiliate of the commercial plan.

3. If the CP/LI ratio is greater than 2.0 but less than or equal to 3.0, three of every four assignments will be directed to the authorized affiliates of the local initiative and one assignment will be directed to an authorized affiliate of the commercial plan.

4. If the CP/LI ratio is greater than 3.0, four of every five assignments will be directed to the authorized affiliates of the local initiative and one assignment will be directed to an authorized affiliate of the commercial plan.

5. For (g)(6)(C)(1), (2), (3) and (4), assignments to the authorized affiliates of the local initiative will be evenly distributed among all authorized affiliates of the local initiative and assignments to authorized affiliates of the commercial plan will be evenly distributed among all authorized affiliates of the commercial plan.

6. Once (g)(6)(C), (2), (3) or (4) have been applied, and the CP/LI ratio reaches 1.0 or less, until 90 days prior to the local initiative's confirmed conditional start date, one of every two assignments will be directed to an authorized affiliate of the local initiative and one assignment will be directed to an authorized affiliate of the commercial plan. No further use of the CP/LI ratio will be made to determine assignments. Assignments to the authorized affiliates of the local initiative will be evenly distributed among all authorized affiliates of the local initiative and assignments to the authorized affiliates of the commercial plan will be evenly distributed among all authorized affiliates of the commercial plan. Assignments to the authorized affiliates of the commercial plan will continue until the combined enrollment total of the affiliates of the commercial plan equals the commercial plan enrollment maximum, at which time assignments to authorized affiliates of the commercial plan will be discontinued. In the case of an affiliate that has affiliated with both the local initiative and the commercial plan, the total enrollment of that affiliate will be included in the combined commercial plan enrollment totals to determine if the commercial plan enrollment maximum has been reached. The combined enrollment total for the affiliates of the commercial plan and combined total for the affiliates of the local initiative will be reviewed on a monthly basis. If the local initiative's enrollment falls below the local initiative's enrollment minimum, all assignments will be directed to the local initiative as needed to restore it to its enrollment minimum. After the local initiative has been restored to its enrollment minimum, assignments to the authorized affiliates of the commercial plan will be resumed as provided above until the combined enrollment of the authorized affiliates of the commercial plan reaches the commercial plan enrollment maximum, at which time assignments to the authorized affiliates of the commercial plan will be discontinued.

(D) If the combined enrollment of the affiliates of the local initiative is equal to or greater than the combined enrollment of the affiliates of the commercial plan, one of every two assignments will be directed to an authorized affiliate of the local initiative and one assignment will be directed to an authorized affiliate of the commercial plan. Assignments to the authorized affiliates of the local initiative will be evenly distributed among all authorized affiliates of the local initiative, and assignments to the authorized affiliates of the commercial plan will be evenly distributed among all authorized affiliates of the commercial plan. Assignments to the authorized affiliates of the commercial plan will continue until the combined enrollment total of affiliates of the commercial plan equals the commercial plan enrollment maximum, at which time assignments to the authorized affiliates of the commercial plan will be discontinued. In the case of an affiliate that has affiliated with both the local initiative and the commercial plan, the total enrollment of that affiliate will be included in the combined commercial plan enrollment totals to determine if the commercial plan enrollment maximum has been reached. The combined enrollment total for the affiliates of the commercial plan and combined total for the affiliates of the local initiative will be reviewed on a monthly basis. If enrollment falls below the commercial plan enrollment maximum, assignments to the authorized affiliates of the commercial plan will be resumed with the commercial plan receiving one of every two assignments until the combined enrollment of the affiliates of the commercial plan reaches the commercial plan enrollment maximum.

(E) Beginning 90 days prior to a local initiative's confirmed conditional start date, all assignments will be made to the authorized affiliates of the local initiative. These assignments will be evenly distributed among all authorized affiliates of the local initiative. When enrollment in the affiliates of the local initiative reaches the local initiative's minimum enrollment, one of every two assignments will be directed to an authorized affiliate of the local initiative and one assignment will be directed to an authorized affiliate of the commercial plan. Assignments to the authorized affiliates of the local initiative will be evenly distributed among all authorized affiliates of the local initiative and assignments to the authorized affiliates of the commercial plan will be evenly distributed among all authorized affiliates of the commercial plan. Assignments to the authorized affiliates of the commercial plan will continue until the combined enrollment total of the affiliates of the commercial plan equals the commercial plan enrollment maximum, at which time assignments to authorized affiliates of the commercial plan will be discontinued. In the case of an affiliate that has affiliated with both the local initiative and the commercial plan, the total enrollment of that affiliate will be included in the commercial plan's enrollment totals to determine if the commercial plan enrollment maximum has been reached. The combined enrollment total of the affiliates of the commercial plan and combined enrollment total for the affiliates of the local initiative will be reviewed on a monthly basis. If enrollment falls below the commercial plan enrollment maximum, assignments to the authorized affiliates of the commercial plan will be resumed with one of every two assignments directed to the authorized affiliates of the commercial plan until the combined enrollment of the affiliates of the commercial plan reaches its enrollment maximum. If the commercial plan does not have any authorized affiliates, all assignments will be directed to the authorized affiliates of the local initiative.

(7) Where the department awards two commercial plan contracts and no local initiative contract, assignment shall be as follows:

(A) If neither commercial plan is operational, assignments will be evenly distributed among authorized affiliates of the two commercial plans. When the combined total enrollment of a commercial plan's affiliates totals one-half of the mandatory enrollment population, assignments will cease for the authorized affiliates of that plan. In the case of an affiliate that has affiliated with both commercial plans, the total enrollment of this affiliate will be equally divided for purposes of computation of the enrollment total to determine when assignments will cease.

(B) If a single commercial plan is operational, assignments will be evenly distributed among the operational commercial plan and the authorized affiliates of the nonoperational commercial plan. Assignments to the authorized affiliates of the nonoperational commercial plan will be evenly distributed. When the total enrollment of the single operational commercial plan or the combined total enrollment of the authorized affiliates of the nonoperational commercial plan equals one-half of the mandatory enrollment in the designated geographic area, assignments will cease for that plan. In the case of an affiliate that has affiliated with both the operational and nonoperational commercial plan, the total enrollment of that affiliate will be equally divided for purposes of computation of the enrollment total to determine when assignments will cease.

(8) If both the local initiative and the commercial plan become operational in a geographic area prior to the implementation of mandatory enrollment of beneficiaries in the two plan model, assignments will be directed to the local initiative until it reaches its enrollment minimum, then assignments will be evenly distributed between the local initiative and the commercial plan. No assignments will be made to other Medi-Cal managed care plans. When the commercial plan reaches its enrollment maximum, further assignment to the commercial plan will be discontinued. Enrollment in the local initiative and commercial plan will be reviewed on a monthly basis. If the local initiative's enrollment falls below the local initiative's enrollment minimum, all assignments will be directed to the local initiative as needed to restore it to its enrollment minimum. After the local initiative has been restored to its enrollment minimum, assignments to the commercial plan will be resumed as provided above until the commercial plan's enrollment reaches the commercial plan enrollment maximum, at which time assignments to the commercial plan will be discontinued.

(9) This is a graphic presentation that illustrates the requirements set forth in sections (g)(1), (g)(2), (g)(3), (g)(4), (g)(5), (g)(6) and (g)(8):

LI is not Operational and has NO Authorized Affiliates	LI is not Operational but has Authorized Affiliates & LI does NOT have a Confirmed Conditional Start Date	LI with Authorized Affiliates, & Beginning 90 days prior to Confirmed Cond'l Start Date	LI is Operational: LI Enrollment < LI Minimum	LI is Operational: LI Enrollment >= LI Minimum
CP is not Operational and has NO Authorized Affiliates	No assignments.	(g)(6)(B). All assignments to the authorized affiliates of the LI.	(g)(6)(B) & (g)(6)(E). All assignments to the auth. affiliates of the LI.	(g)(1). All assignments to the LI.	(g)(2). All assignments to the LI.
CP is not	(g)(6)(A).	(g)(6)(C).	(g)(6)(E). All	(g)(1). All	(g)(2). 1 of 2
Operational but has Authorized Affiliates	All assignments to authorized	1. If CP/LI ratio [LESS THAN EQUAL TO] 1,* 1 of 2 assignments to the authorized affiliates of the LI.	assignments to auth. affiliates of the LI until it	assignments to the LI until it reaches the LI Min. After	assignments to the LI.
affiliates of CP.	2. If CP/LI ratio > 1 and [LESS THAN EQUAL TO] 2, 2 of 3 assignments to the authorized affiliates of the LI.	reaches the LI Min. After LI Min. is reached then 1	the LI Min is reached then 1 of 2 assignments to LI.
3. If the CP/LI ratio > 2 but [LESS THAN EQUAL TO] 3, 3 of 4 assignments to the authorized affiliates of the LI.	of 2 assignments to the authorized affiliates of the
4. If the CP/LI ratio > 3, 4 of 5 assignments to the authorized affiliates of the LI.	LI.
6. If the combined enrollment of LI affiliates = combined CP affiliate enrollment, then 1 of 2 assignments to the authorized affiliates of the LI.
CP is Operational:	(g)(5).	(g)(3).	(g)(3)(G). All	(g)(1). All	(g)(8). 1 of 2
Enrollment is < CP Max.	All assignments to CP.	(A) If CP/LI ratio [LESS THAN EQUAL TO] 1,* 1 of 2 assignments to the authorized affiliates of the LI.	assignments to the auth. affiliates of the LI until it	assignments to the LI until it reaches the LI Min. After	assignments to the LI.
(B) If CP/LI ratio > 1 and [LESS THAN EQUAL TO] 2, 2 of 3 assignments to the authorized affiliates of the LI.	reaches the LI Min. After LI Min. is reached then 1	the LI Min is reached then 1 of 2 assignments to LI.
(C) If the CP/LI ratio > 2 but [LESS THAN EQUAL TO] 3, 3 of 4 assignments to the authorized affiliates of the LI.	of 2 assignments to the authorized affiliates of the
(D) If the CP/LI ratio > 3, 4 of 5 assignments to the authorized affiliates of the LI.	LI.
(F) If the combined enrollment of the LI affiliates = CP enrollment, then 1 of 2 assignments to the authorized affiliates of the LI.
CP Operational: Enrollment is >= CP Max.	(g)(5): No assignments.	(g)(3)(F) & (g)(4). All assignments to the authorized affiliates of the LI.	(g)(3)(G). All assignments to auth. affiliates of the LI.	(g)(8). All assignments to LI.	(g)(8). All assignments to LI.

* CP/LI ratio means the total enrollment of the commercial plan, or if the commercial plan is not operational the combined total enrollment of the commercial plan affiliates, DIVIDED by the combined total enrollment of the local initiative affiliates.

(h) In geographic areas not designated for two-plan model implementation, if the department contracts for a fee-for-service managed care program, assignments will be directed to the fee-for-service managed care contractor as long as the contractor has an available capacity. In other geographic areas, assignments will be evenly distributed among Medi-Cal managed care plans which have been approved by the department to participate in the assignment process and have available enrollment capacity consistent with the growth limits pursuant to section 53830.

(i) The health care options contractor shall notify the beneficiary in writing of the beneficiary's assignment to a Medi-Cal managed care plan at least ten working days prior to the submission of the assignment documents to the department for processing. The notice shall contain the name of the Medi-Cal managed care plan to which the beneficiary is assigned; the conditions defined in subdivisions (j)(1), (2) and (3); and the time frame for advising the health care options contractor if the assignment is not appropriate or if the beneficiary wishes to enroll in a different Medi-Cal managed care plan or certify to a patient-provider relationship.

(j) An assignment is not appropriate when:

(1) The time and distance a beneficiary is required to travel to obtain primary care services from his or her residence exceeds the normal practice for the community or 30 minutes or 10 miles, whichever is greater.

(2) Public transportation is not available to the primary care site, unless the managed care plan to which the beneficiary is assigned provides transportation for outpatient services. This criteria will not apply to the designated fee-for-service managed care program geographic areas where public transportation to Medi-Cal services has not historically been available to the beneficiary.

(3) Culturally and linguistically appropriate services are not available to the beneficiary.

(k) The beneficiary may notify the health care options contractor that the assignment meets one or more of the conditions in subdivisions (j)(1), (2), or (3) or the beneficiary requests enrollment in another Medi-Cal managed care plan. The beneficiary may also certify to a patient-provider relationship. The notice from the beneficiary shall be in writing and state, if applicable, the specific condition(s) making the assignment inappropriate and the desired action by the health care options contractor.

(1) For such notices from beneficiaries received within ten working days of the postmark date of the notice of assignment from the health care options contractor, the health care options contractor shall respond by accepting the patient-provider certification, if provided, or by enrolling the beneficiary in another Medi-Cal managed care plan of his or her choice.

(2) For such notices from beneficiaries received after the tenth working day from the postmark date of the notice of assignment from the health care options contractor, the health care options contractor shall assist the beneficiary to disenroll from the assigned Medi-Cal managed care plan and then either accept the patient-provider certification or enroll the beneficiary in another Medi-Cal managed care plan of his or her choice.

(3) If the beneficiary notifies the health care options contractor that the assignment is inappropriate because one or more of the conditions described in subdivisions (j)(1), (2), and (3) exist, and if another Medi-Cal managed care plan within the geographic area cannot provide for an appropriate assignment in relation to the conditions in (j)(1), (2) and (3), or if another Medi-Cal managed care plan within the geographic area can provide for appropriate assignment in relation to the conditions in (j)(1), (2) and (3), but does not have available capacity, the beneficiary may elect to obtain benefits by receiving a fee-for-service card whether or not the beneficiary has certified to a patient-provider relationship.

Cal. Code Regs. Tit. 22, § 50185.5

1. New section filed 7-10-95; operative 7-10-95. Submitted to OAL for printing only pursuant to section 147, SB 485 (Ch. 722/92) (Register 95, No. 28).
2. Amendment of section filed 6-26-96; operative 6-26-96. Submitted to OAL for printing only pursuant to Section 147 SB 485 (Ch. 722/92) (Register 96, No. 27).
3. Amendment filed 8-30-96; operative 8-30-96. Submitted to OAL for printing only (Register 96, No. 36).

Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 14016.5, 14016.6 and 14087.305, Welfare and Institutions Code.