Section 53923.5 - Alternative to GMC Plan EnrollmentAn eligible beneficiary specified in Section 53906(a) who meets the requirements of (a) or (b) may request from the GMC enrollment contractor an alternative to GMC plan enrollment.
(a) An eligible beneficiary who is an Indian, is a member of an Indian household, or has written acceptance from an Indian Health Service program facility to receive health care services through that facility, may, as an alternative to GMC plan enrollment and upon request, choose to receive health care services through an Indian Health Service program facility. Any request for this alternative shall be made to the GMC enrollment contractor at the GMC options presentation or through the problem resolution process specified in Section 53926.(b) On or before March 31, 1995, an eligible beneficiary who is receiving treatment or services for a complex medical situation from a physician who is participating in the Medi-Cal program, but is not a contracted provider of any GMC plan, may request through the problem resolution process specified in Section 53926, continued fee-for-service Medi-Cal for the purposes of continuity of care. The department shall review on a case-by-case basis and make a determination on each request presenting a complex medical situation. The department may approve continued treatment under the fee-for-service Medi-Cal program for any eligible beneficiary whose diagnosis or treatment needs are verified in writing by the beneficiary's Medi-Cal provider and meet one of the criteria below in 1 through 3 for continued fee-for-service Medi-Cal.(1) The eligible beneficiary is under the care of a physician specialist: (A) For treatment of a condition that is within the specialist's scope of practice, pursuant to the Business and Professions Code;(B) That specialty is not practiced by any physician within the available providers of any GMC plan; and(C) That specialist is a participating Medi-Cal provider, but is not a contracted provider of any GMC plan.(2) The eligible beneficiary is in a complex, high risk medical treatment plan:(A) Under the supervision of a physician who is a participating Medi-Cal provider, but is not a contracted provider of any GMC plan; and(B) May experience deleterious medical effects if that treatment were to be disrupted by leaving the care of that physician to begin receiving care from a GMC plan physician.(3) The eligible beneficiary is a woman who is pregnant and under the care of a physician who is a participating Medi-Cal provider, but is not a contracted provider of any GMC plan.(c) Any eligible beneficiary granted continued fee-for-service Medi-Cal under (b)(1) or (2) may remain with that fee-for-service physician only until the medical condition has stabilized to a level that would enable the eligible beneficiary to change physicians and begin receiving care from a GMC plan physician without deleterious medical effects. An eligible beneficiary granted continued fee-for-service Medi-Cal under (b)(3) may remain with that physician through delivery and the end of the month in which ninety days post-partum occurs.(d) The department may verify the medical conditions and treatment plans presented by an eligible beneficiary, pursuant to (b), to confirm their complexity, validity, and status.Cal. Code Regs. Tit. 22, § 53923.5
1. New section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only pursuant to section 147, SB 485 (Chapter 722, Statutes of 1992) (Register 94, No. 15). Note: Authority cited: Sections 10725, 14089.7, 14105, 14124.5, 14203 and 14312, Welfare and Institutions Code. Reference: Section 14089, Welfare and Institutions Code.
1. New section filed 3-11-94; operative 3-11-94; Submitted to OAL for printing only pursuant to section 147, SB 485 (Chapter 722, Statutes of 1992) (Register 94, No. 15).