Section 51303 - General Provisions(a) Health care services set forth in this article and in Chapter 5, Article 4 (commencing with Section 54301 of this title), which are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury are covered by the Medi-Cal program, subject to utilization controls, to the extent specified in this Chapter, Chapter 5, and Chapter 11. Such utilization controls shall take into account those diseases, illnesses, or injuries which require preventive health services or treatment to prevent serious deterioration of health. Nothing in this section shall preclude payment for family planning services, or for early, periodic screening, diagnosis and treatment services (EPSDT), provided under the Child Health and Disability Prevention (CHDP) Program. Authorization may only be granted when fully documented medical justification is provided that the services are medically necessary. Services not requiring prior authorization are subject to other utilization controls, as specified in this chapter.(b) Limitations specified in this article do not apply to Medicare/Medi-Cal program covered services (crossover services).(c) Except as set forth in (b) above, if the Medi-Cal Program is to pay any portion of a charge for services for which other coverage is available, the limitations and controls specified in this article apply.(d) Inpatient services in hospitals are covered only when provided on the signed order of the physician, dentist or podiatrist responsible for the care of the patient.(e) Inpatient services in skilled nursing facilities and intermediate care facilities are covered only when provided on the signed order of the physician responsible for the care of the patient.(f) Outpatient services are covered subject to the limitations and controls set forth in this chapter.(g) Experimental services are not covered.(h) Investigational services are not covered except when it is clearly documented that all of the following apply:(1) Conventional therapy will not adequately treat the intended patient's condition;(2) Conventional therapy will not prevent progressive disability or premature death;(3) The provider of the proposed service has a record of safety and success with it equivalent or superior to that of other providers of the investigational service;(4) The investigational service is the lowest cost item or service that meets the patient's medical needs and is less costly than all conventional alternatives;(5) The service is not being performed as a part of a research study protocol;(6) There is a reasonable expectation that the investigational service will significantly prolong the intended patient's life or will maintain or restore a range of physical and social function suited to activities of daily living. All investigational services require prior authorization. Payment will not be authorized for investigational services that do not meet the above criteria, or for associated inpatient care when a beneficiary needs to be in the hospital primarily because she/he is receiving such nonapproved investigational services.
(i) Services and supplies not primarily medical in purpose or which are common household items are not covered.(j) Services set forth in this article must be provided by providers who meet, where applicable, the standards set forth in Article 3 of this chapter.(k) Services prescribed or ordered by a provider suspended from participation in the Medi-Cal program shall not be covered by the program while the suspension is in effect, providing that at least 15 days written notice is given to all affected providers.Cal. Code Regs. Tit. 22, § 51303
1. Amendment filed 6-28-78 as an emergency; designated effective 7-1-78 (Register 78, No. 26). For prior history, see Register 76, No. 37.
2. Amendment filed 8-16-78 as an emergency; designated effective 8-16-78 (Register 78, No. 32).
3. Certificate of Compliance filed 12-12-78 (Register 78, No. 50). For prior history, see Register 78, No. 32.
4. Amendment of subsection (a) filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37).
5. Certificate of Compliance as to 9-1-82 order transmitted to OAL 12-28-82 and filed 1-21-83 (Register 83, No. 4).
6. Amendment of subsection (a) filed 7-7-86 as an emergency; effective upon filing (Register 86, No. 28). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-4-86.
7. Certificate of Compliance transmitted to OAL 10-30-86 and filed 11-25-86 (Register 86, No. 48).
8. Amendment of subsections (g)-(k) filed 12-18-87 as an emergency; operative 12-18-87 (Register 88, No. 1). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 4-18-88.
9. Certificate of Compliance including amendment of subsection (h) (3) transmitted to OAL 4-14-88 and filed 5-16-88 (Register 88, No. 21).
10. Amendment of subsection (b) filed 5-25-89; operative 6-24-89 (Register 89, No. 21).
11. Change without regulatory effect amending NOTE filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51). Note: Authority cited: Section 20, Health and Safety Code; Chapter 1066, Statutes of 1977; Section 57(c), Chapter 328, Statutes of 1982; and Sections 14059.5, 14105, 14105.44 and 14124.5, Welfare and Institutions Code. Reference: Sections 14021, 14053, 14059.5, 14105.44, 14124.5, 14124.24, 14131, 14132 and 14133.3, Welfare and Institutions Code.
1. Amendment filed 6-28-78 as an emergency; designated effective 7-1-78 (Register 78, No. 26). For prior history, see Register 76, No. 37.
2. Amendment filed 8-16-78 as an emergency; designated effective 8-16-78 (Register 78, No. 32).
3. Certificate of Compliance filed 12-12-78 (Register 78, No. 50). For prior history, see Register 78, No. 32.
4. Amendment of subsection (a) filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37).
5. Certificate of Compliance as to 9-1-82 order transmitted to OAL 12-28-82 and filed 1-21-83 (Register 83, No. 4).
6. Amendment of subsection (a) filed 7-7-86 as an emergency; effective upon filing (Register 86, No. 28). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-4-86.
7. Certificate of Compliance transmitted to OAL 10-30-86 and filed 11-25-86 (Register 86, No. 48).
8. Amendment of subsections (g)-(k) filed 12-18-87 as an emergency; operative 12-18-87 (Register 88, No. 1). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 4-18-88.
9. Certificate of Compliance including amendment of subsection (h) (3) transmitted to OAL 4-14-88 and filed 5-16-88 (Register 88, No. 21).
10. Amendment of subsection (b) filed 5-25-89; operative 6-24-89 (Register 89, No. 21).
11. Change without regulatory effect amending Note filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).