10950. (Amended by Stats. 2017, Ch. 738, Sec. 2.)

(b) (1) The requirements of Sections 100506.2 and 100506.4 of the Government Code apply to state hearings regarding eligibility for or enrollment in an insurance affordability program administered by the State Department of Health Care Services to the extent that those sections conflict with the state hearing requirements under this chapter.

(2) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. The department shall adopt regulations by July 1, 2017, in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Notwithstanding Section 10231.5 of the Government Code, beginning July 1, 2015, the department shall provide a semiannual status report to the Legislature, in compliance with Section 9795 of the Government Code, until regulations have been adopted.

(3) This subdivision shall be implemented only to the extent it does not conflict with federal law.

(c) Priority in setting and deciding cases shall be given in those cases in which aid is not being provided pending the outcome of the hearing. This priority shall not be construed to permit or excuse the failure to render decisions within the time allowed under federal and state law.

(d) Notwithstanding any other provision of this code, there is no right to a state hearing when either (1) state or federal law requires automatic grant adjustments for classes of recipients unless the reason for an individual request is incorrect grant computation, or (2) the sole issue is a federal or state law requiring an automatic change in services or medical assistance which adversely affects some or all recipients.

(e) For the purposes of administering health care services and medical assistance, the Director of Health Care Services shall have those powers and duties conferred on the Director of Social Services by this chapter to conduct state hearings in order to secure approval of a state plan under applicable federal law.

(f) The Director of Health Care Services may contract with the State Department of Social Services for the provisions of state hearings in accordance with this chapter.

(g) For purposes of this chapter, the following terms have the following meanings:

(1) “Adverse benefit determination” means, in the case of a Medi-Cal managed care plan, any of the following:

(A) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.

(B) The reduction, suspension, or termination of a previously authorized service.

(C) The denial, in whole or in part, of payment for a service.

(D) The failure to provide services in a timely manner, as described in Section 14197.

(E) The failure of a Medi-Cal managed care plan to act within the timeframes provided in Section 438.408(b)(1) and Section 438.408(b)(2) of Title 42 of the Code of Federal Regulations regarding the standard resolution of grievances and appeals.

(F) For a resident of a rural area with only one Medi-Cal managed care plan, excluding a Medi-Cal managed care plan defined in subparagraphs (H) and (I) of paragraph (2), the denial of an enrollee’s request to exercise his or her right under Section 438.52(b)(2)(ii) of Title 42 of the Code of Federal Regulations to obtain services outside the network.

(G) The denial of an enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.

(2) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a contract with the department to provide services to enrolled Medi-Cal beneficiaries pursuant to any of the following:

(A) Article 2.7 (commencing with Section 14087.3) of Chapter 7 of Part 3, including dental managed care programs developed pursuant to Section 14087.46.

(B) Article 2.8 (commencing with Section 14087.5) of Chapter 7 of Part 3.

(C) Article 2.81 (commencing with Section 14087.96) of Chapter 7 of Part 3.

(D) Article 2.82 (commencing with Section 14087.98) of Chapter 7 of Part 3.

(E) Article 2.9 (commencing with Section 14088) of Chapter 7 of Part 3.

(F) Article 2.91 (commencing with Section 14089) of Chapter 7 of Part 3.

(G) Chapter 8 (commencing with Section 14200) of Part 3, including dental managed care plans.

(H) Chapter 8.9 (commencing with Section 14700) of Part 3.

(I) A county Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions. For purposes of this subdivision, “Special Terms and Conditions” shall have the same meaning as set forth in subdivision (o) of Section 14184.10.

(3) “Recipient” means an applicant for or recipient of public social services except aid exclusively financed by county funds or aid under Article 1 (commencing with Section 12000) to Article 6 (commencing with Section 12250), inclusive, of Chapter 3 of Part 3, and under Article 8 (commencing with Section 12350) of Chapter 3 of Part 3, or those activities conducted under Chapter 6 (commencing with Section 18350) of Part 6, and shall include any individual who is an approved adoptive parent, as described in paragraph (3) of subdivision (a) of Section 8708 of the Family Code, and who alleges that he or she has been denied or has experienced delay in the placement of a child for adoption solely because he or she lives outside the jurisdiction of the department.