(a) The department may establish modified primary care case management contracts pursuant to this article. This authority shall be subject to the department seeking and obtaining all necessary federal waivers to implement this section.
(b) In establishing modified primary care case management contracts pursuant to this article, the department may enter into contracts with providers whose application to develop a full primary care case management contract has been accepted by the department and who are working with the department to document, develop, and install the required systems, policies, and procedures. These contracts may provide for the following:
(1) The modified primary care case management contract would have effect only until the contractor’s full primary care case management contract is executed.
(2) The scope of services covered and the case management and utilization control responsibilities of the contractor may be more limited than under a full primary care case management.
(3) Formal enrollment of Medi-Cal beneficiaries with the contractor would occur but the contractor could be reimbursed on a fee-for-service basis for the services the contractor provides to them. Beneficiaries enrolling under the modified primary care case management contract would remain enrolled under the full primary care case management contract entered into by the contractor.
(4) Contractor quality of care requirements could be modified to reflect the contractor’s fee-for-service managed care mode of health care delivery.
(5) Evaluation by the department of the contractor’s efficiency, case management effectiveness and the calculation of any savings and savings sharing would reflect the temporary fee-for-service approach under which the contractor is operating.
(c) Contracts shall not be entered into by the department unless the waivers or revision to any existing waiver are granted by the federal government. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented, but provisions for which waivers are either obtained or found to be unnecessary shall be unaffected by the inability to obtain federal waivers for other provisions.
(Amended by Stats. 1992, Ch. 722, Sec. 81. Effective September 15, 1992.)
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