(c) Each Medi-Cal managed care plan in the population health management program shall, at a minimum, do all of the following:

1. (1) Prioritize preventive and wellness services.
2. (2) Identify and assess beneficiary member risks and needs on an ongoing basis.
3. (3) Manage beneficiary member safety and outcomes during care transitions, across all applicable delivery systems and settings, through effective care coordination.
4. (4) Identify and mitigate social determinants of health and reduce health disparities or inequities.

(f) The Population Health Management Program shall include, but is not limited to, all of the following:

1. (1) Appropriate use of preventive services for children and adults, and other interventions, including chronic disease management, referrals for behavioral and oral health care services, housing, nutrition, and other health-related social needs.
2. (2) Risk assessment is comparable and consistent between Medi-Cal managed care plans.
3. (3) Any algorithm used to conduct member risk assessment is comparable, standardized, and mitigated for racial and other biases through consideration of disease burden relative to utilization and other patient risk factors beyond cost and historical utilization. The department shall report the underlying measures it uses in its algorithm.
4. (4) Any screening tool used to assess beneficiaries is age appropriate and comparable across Medi-Cal managed care plans.
5. (5) Each Medi-Cal managed care plan incorporates the findings of its Population Needs Assessment in its population health management program.
6. (6) Each Medi-Cal managed care plan describes how it will incorporate preventive and wellness services in partnership with Medi-Cal behavioral health delivery systems, county public health and social services, providers, community-based organizations, and consumer advocates.