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