Page 35

29 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Populations 1, 3 and 4 has services delivered through a managed care delivery model.

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR, 457.490(b))

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b))

CA REPSONSE: DHCS utilizes Medi-Cal managed care plans that comply with the Medicaid utilization controls. Virtually all of the plans are regulated by California’s Department of Managed Health Care (DMHC) under the Knox-Keene Act - established specifically for managed care plans licensing. The Knox-Keene Act prescribes rules for the organization of HMOs and other managed care entities. It specifies plan standards, marketing rules, and consumer disclosure requirements. It also establishes fiscal solvency requirements and quality assurance standards. The Knox-Keene Act can be found at http://wpso.dmhc.ca.gov/regulations/docs/2017kkaregs.pdf, with Sections 1370-1370.4 outlining utilization review.

Health Plan Regulatory Oversight. POPULATION 1/CCHIP POPULATION 2/UNBORN OPTION POPULATION 3/MCAP POPULATION 4/MCAIP

These plans are regulated by DMHC, under the Knox- Keene Act. The Knox-Keene Act,