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Medicaid/CHIP Data Requirements in California

California’s Medicaid program, known as Medi-Cal, is administered through a two plan program, where the first plan is a private plan awarded by competitive bidding and the second is a public plan organized or designated by the county government1

The law requires that all medical records of individuals receiving Medicaid be kept confidential and not be released without the written consent of the Medicaid recipient or his or her representative.  However, the medical record may be released for statistical or summary data purposes long as the record has been de-identified.  Information from the medical record may also be exchanged between entities that provide care, payers, or state or local agencies.2

California law also sets forth standards for fraud and abuse within Medi-Cal.  For example, a provider must reimburse Medicaid funds acquired using false or incomplete information to the Department.3

All pre-paid health plans must comply with the Medicaid program standards for participation, including having grievance procedures for consumers.  Health plans must provide the same rights to Medicaid patients that are provided to other enrollees.4

California requires specific records to be kept with respect to Medicaid patients.  Providers must maintain retrievable records that disclose the type of treatment given to the Medicaid recipient, records of medications given to the recipient, treatment authorization requests and records identifying the individual who performed the medical services.  Providers that work in hospitals or health centers are subject to additional requirements to keep receipts and disbursements of patients’ funds being held in trust, employment records outlining employee shifts, provider’s accounting records and individual ledger accounts for each recipient.5  All inpatient records must contain the patient’s Medicaid identification number.6  Licensed health facilities must provide the Office of Statewide Health Planning and Development, among other things, data required for Medicaid reimbursement.7

Each of the plans that make up the Medicaid program must submit annual reports, quarterly reports and other reports that include utilization and statistical data to the State Department of Health Services.8  Additionally, Medicaid plans are required to maintain all records necessary to verify information and reports that are required by federal, state, or local authorities for five years. Each plan must have these records available for examination by the Department of Health Services, Department of Justice, or the Comptroller General.9

In addition to reporting requirements,  plans must monitor and evaluate the quality of care provided to the Medicaid recipients and undertake any improvements.  Each plan must implement a quality improvement plan along with a system of accountability.10 The law also requires the Department of Health Services to implement a system to monitor and evaluate the quality of care given to Medicaid recipients, including access to services, through a Management Information System.11

In an effort to eliminate any cultural or linguistic disparities among the state’s Medicaid recipients, the law requires both plans to implement cultural and linguistic services requirements, which include interpreters, translated signs, translated written materials, and culturally and linguistically appropriate community service programs.12

 

Footnotes

  • 1. 22 CA ADC §53861
  • 2. 22 CA ADC §51009
  • 3. Welfare & Inst. Code §14043.3
  • 4. Welfare & Inst. Code §14450
  • 5. 22 CA ADC §51476
  • 6. 22 CA ADC §70749
  • 7. 22 CA ADC §97040
  • 8. 22 CA ADC §53862
  • 9. 22 CA ADC §53861
  • 10. 22 CA ADC §53860
  • 11. Welfare & Inst. Code §14459.7
  • 12. 22 CA ADC §53876

 

Medicaid/CHIP Data Requirements in California

Subtopic Statute/Regulation Description
EHR incentive payments, including meaningful use (Cross reference with Health Information Technology) Administration of Medi-Cal Electronic Health Records Incentive Program and Requirements of State Medicaid Health Information Technology Plan – Cal. Welf. & Inst. Code § 14046.1 “Administration of Medi-Cal Electronic Health Records Incentive Program; requirements of State Medicaid Health Information Technology Plan...
Management Information System/Decision Support System and Access to Information – Cal. Welf. & Inst. Code § 14459.7 "Management information system/decision support system; progress and status reports; expenditures and staffing; access to information"   The...
Access to Medicaid data (by patients, providers, and government agencies) California Medicaid Plan Records Requirements – Cal. Code Regs. tit. 22 § 53861 California’s Medicaid plan is administered through a two plan mode, where one plan is a prepaid plan awarded by competitive bidding and the...
Medi-Cal Provider Maintenance and Availability of Records Requirements – Cal. Code Regs. tit. 22 § 51476 Each provider must maintain retrievable records to disclose the type of treatment given to a Medi-Cal (California’s Medicaid program)...
Medicaid medical records maintenance by providers (including retention period, storage, and other recordkeeping requirements) California Medicaid Plan Records Requirements – Cal. Code Regs. tit. 22 § 53861 California’s Medicaid plan is administered through a two plan mode, where one plan is a prepaid plan awarded by competitive bidding and the...
Medi-Cal Provider Maintenance and Availability of Records Requirements – Cal. Code Regs. tit. 22 § 51476 Each provider must maintain retrievable records to disclose the type of treatment given to a Medi-Cal (California’s Medicaid program)...
Mandatory reporting by Medicaid providers (cost/utilization information) California Medicaid Plan Reporting Requirements – Cal. Code Regs. tit. 22 § 53862 California’s Medicaid plan is administered through a two plan mode, where one plan is a prepaid plan awarded by competitive bidding and the...
California Medicaid Quality of Care Monitoring, Evaluation, and Improvement Plan Requirements – Cal. Code Regs. tit. 22 § 53860 Quality of Care California’s Medicaid plan is administered through a two plan mode, where one plan is a prepaid plan awarded by competitive...
Quality reporting by Medicaid providers (cross post to care coordination/care management (chronic disease management; sharing information across providers; enrollee participation) California Medicaid Quality of Care Monitoring, Evaluation, and Improvement Plan Requirements – Cal. Code Regs. tit. 22 § 53860 Quality of Care California’s Medicaid plan is administered through a two plan mode, where one plan is a prepaid plan awarded by competitive...
Confidentiality of Medicaid data (including penalties for violating confidentiality) Confidential Nature of Medical Records For Those Receiving Medical Assistance – Cal. Code Regs. tit. 22 § 51009 All medical records of individuals receiving medical assistance, such as Medicare or Medicaid, must remain confidential and cannot be released...
Medicaid/CHIP Data Requirements Health Care Waiver or Demonstration Project in California Medicaid – Cal. Welf & Inst. Code §14180 “Health care waiver or demonstration project; application; proposals; amendments”   The State Department of Health Services must...
Medi-Cal Beneficiary Privacy and Fraud Reduction-Cal. Welf. & Inst. Code § 14045 Medi-Cal beneficiary social security numbers cannot be transferred by providers if the beneficiary has a personalized Medi-Cal identification card...