Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides for a schedule of benefits covered by the Medi-Cal program, including the purchase of prescribed drugs subject to the Medi-Cal list of contract drugs and utilization controls. Existing law requires a pharmacy provider under the Medi-Cal program to submit his or her usual and customary charge, as defined, when billing the Medi-Cal program for prescribed drugs. The Pharmacy Law specifies the functions a pharmacist is authorized to perform, including furnishing nicotine replacement products and administering immunizations, as specified.

This bill would add to the schedule of benefits pharmacist services, as specified, subject to department protocols and utilization controls. The bill would require the rate of reimbursement for pharmacist services to be at 85% of the fee schedule for physician services under the Medi-Cal program and would require the department to establish a fee schedule. The bill would authorize the department to implement these provisions by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until regulations are adopted, and would require the department to adopt those regulations by July 1, 2021. Commencing July 1, 2017, the bill would require the department to provide a status report to the Legislature on a semiannual basis until regulations have been adopted. The bill would require these provisions to be implemented only to the extent that federal financial participation is available and the necessary federal approvals are obtained.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides for a schedule of benefits covered by the Medi-Cal program, including the purchase of prescribed drugs subject to the Medi-Cal list of contract drugs and utilization controls. Existing law requires a pharmacy provider under the Medi-Cal program to submit his or her usual and customary charge, as defined, when billing the Medi-Cal program for prescribed drugs. The Pharmacy Law specifies the functions a pharmacist is authorized to perform, including furnishing nicotine replacement products and administering immunizations, as specified.

This bill would add to the schedule of benefits pharmacist services, as specified, subject to department protocols and utilization controls. The bill would require the rate of reimbursement for pharmacist services to be at 85% of the fee schedule for physician services under the Medi-Cal program and would require the department to establish a fee schedule. The bill would authorize the department to implement these provisions by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until regulations are adopted, and would require the department to adopt those regulations by July 1, 2021. Commencing July 1, 2017, the bill would require the department to provide a status report to the Legislature on a semiannual basis until regulations have been adopted. The bill would require these provisions to be implemented only to the extent that federal financial participation is available and the necessary federal approvals are obtained.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides for a schedule of benefits covered by the Medi-Cal program, including the purchase of prescribed drugs subject to the Medi-Cal list of contract drugs and utilization controls. Existing law requires a pharmacy provider under the Medi-Cal program to submit his or her usual and customary charge, as defined, when billing the Medi-Cal program for prescribed drugs. The Pharmacy Law specifies the functions a pharmacist is authorized to perform, including furnishing nicotine replacement products and administering immunizations, as specified.

This bill would add to the schedule of benefits pharmacist services, as specified, subject to department protocols and utilization controls. The bill would require pharmacist services to include only those services provided by a pharmacist consistent with the laws governing his or her scope of practice and would require the department to develop a list of pharmacist services. The bill would require the rate of reimbursement for pharmacist services to be at 85% of the fee schedule for physician services under the Medi-Cal program and would require the department to establish a fee schedule. The bill would authorize the department to implement these provisions by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until regulations are adopted, and would require the department to adopt those regulations by July 1, 2021. Commencing July 1, 2017, the bill would require the department to provide a status report to the Legislature on a semiannual basis until regulations have been adopted. The bill would require these provisions to be implemented only to the extent that federal financial participation is available and the necessary federal approvals are obtained.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law establishes various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the States Childrens Health Insurance Program. Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act (PPACA), and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans, and facilitating the purchase of qualified health plans through the Exchange. Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, operative as provided, requires the California Health and Human Services Agency, in consultation with specified entities, to establish standardized single, accessible, application forms and related renewal procedures for state health subsidy programs, as defined, in accordance with specified requirements relating to the forms and notices developed for these purposes.

This bill would define the terms forms and notices for these purposes as application, renewal, and other forms and letters application and renewal forms and notices of action needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, and all notices affecting the legal rights of applicants, beneficiaries, and enrollees. program.

Existing law establishes for various programs to provide health care coverage to persons with limited financial resources, including the Medi-Cal program and the States Childrens Health Insurance Program. Existing law establishes the California Health Benefit Exchange (Exchange), pursuant to the federal Patient Protection and Affordable Care Act (PPACA), and specifies the duties and powers of the board governing the Exchange relative to determining eligibility for enrollment in the Exchange and arranging for coverage under qualified health plans, and facilitating the purchase of qualified health plans through the Exchange. Existing law, the Health Care Reform Eligibility, Enrollment, and Retention Planning Act, operative as provided, requires the California Health and Human Services Agency, in consultation with specified entities, to establish standardized single, accessible, application forms and related renewal procedures for state health subsidy programs, as defined, in accordance with specified requirements relating to the forms and notices developed for these purposes.

This bill would revise these provisions to include letters, as well as forms and notices developed for purposes of creating the standardized application and renewal process, and would also specifically define the nature of these forms, letters, and notices. define the terms forms and notices for these purposes as application, renewal, and other forms and letters needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, and all notices affecting the legal rights of applicants, beneficiaries, and enrollees.

Existing law provides that school districts offering kindergarten may maintain kindergarten classes at different schoolsites for different lengths of time. Existing law requires the Superintendent of Public Instruction to provide the Legislature with an evaluation of kindergarten program implementation in the state, including part-day and full-day kindergarten programs, as specified. Existing law requires this provision to become inoperative on July 1, 2017.

This bill would change the inoperative date to July 15, 2017, and would make nonsubstantive changes to these provisions.

Date of Hearing: August 30, 2016

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1114 (

Author:Eggman) – As Amended Ver:August 24, 2016

SUBJECT: Medi-Cal: pharmacist services

Requires specified pharmacy services to be covered under Medi-Cal, and specifies the rate of reimbursement for these services at 85% of the fee schedule for physician services under Medi-Cal. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect after enactment. Specifically, this bill:

1. Specifies the following pharmacy services as a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services:
   1. Furnishing travel medications;
   2. Furnishing naloxone hydrochloride;
   3. Furnishing self-administered hormonal contraception;
   4. Initiating and administering immunizations; and,
   5. Providing tobacco cessation counseling and furnishing nicotine replacement therapy.
2. Requires the Department of Health Care Services (DHCS) to do the following: a) establish a fee schedule for the list of pharmacist services; and, b) specify the rate of reimbursement to be at 85% of the fee schedule for physician services under Medi-Cal.
3. Requires a pharmacist to be enrolled as an ordering, referring, and prescribing provider under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement under this bill.
4. Requires the Director of DHCS to seek any necessary federal approvals for purposes of this bill, prohibits implementation until such approvals are obtained, and implemented only if federal financial participation is available.
5. Specifies that this bill does not restrict nor prohibit any services currently provided by pharmacists as authorized by law, as specified.
6. Authorizes DHCS to implement, interpret, or make specific this bill, without taking any regulatory action, as specified. Requires DHCS to adopt regulations by July 1, 2021 and provide a status report to the Legislature, as specified.

The Senate amendments require specified pharmacist services to be covered under Medi-Cal.

AS PASSED BY THE ASSEMBLY, this bill clarified existing law regarding the documents necessary to retain eligibility, benefits, or services from Medi-Cal and subsidized programs under Covered California, as defined; in doing so, required these documents to be translated into the same threshold languages required for Medi-Cal managed care plans.

EXISTING LAW:

1. Establishes the Medi-Cal Program, which is administered by DHCS, under which qualified low-income individuals receive health care services, including certain prescription drugs.
2. Establishes a schedule of benefits under the Medi-Cal program, which includes outpatient prescription drugs, subject to utilization controls and the Medi-Cal list of contract drugs. Requires reimbursement to Medi-Cal pharmacy providers for drugs, as prescribed, and authorizes the department to establish a new reimbursement methodology based on average acquisition cost, as defined.
3. Establishes the Pharmacy Act to regulate the practice of pharmacy under the California Board of Pharmacy (BOP).

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. One-time costs of $400,000 to $600,000 to make changes to the system for processing Medi-Cal payments to allow pharmacist services to be reimbursed at the rate level specified in this bill (25% General Fund and 75% federal funds).
2. Unknown cost savings due to a shift from services being provided by physicians to those services being provided by pharmacists (General Fund and federal funds). Under this bill, Medi-Cal beneficiaries would be able to access certain services from a pharmacist without the need to see a physician to get a prescription. This bill requires pharmacists to be reimbursed at 85% of the rate paid to physicians. The extent of the cost savings from shifting from physician services to pharmacist services is unknown.
3. Likely overall cost savings to the Medi-Cal program due to increased utilization of certain drugs prescribed and dispensed by pharmacists (General Fund and federal funds). Under this bill, it is likely that there will be increased utilization of certain drugs, because it will be easier for some Medi-Cal beneficiaries to access those drugs directly from a pharmacist without the need for a physician visit. Under current law, the drugs that can be provided by a pharmacist in this manner include smoking cessation drugs, contraceptives, naloxone (a drug that prevents opioid overdoses), and immunizations. These types of drugs have been shown to result in overall health care cost savings, so it is likely that any overall increase in their utilization by Medi-Cal beneficiaries is likely to reduce long-term Medi-Cal spending.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, regulations were recently finalized (2016) to allow California pharmacists to provide hormonal contraceptives, the opioid overdose drug naloxone, and nicotine replacing products for smoking cessation directly to patients. This bill will improve access to these vital health services by authorizing the DHCS to establish a system for pharmacists to provide services in the Medi-Cal program. This bill was not introduced earlier this year because the last regulations to implement new pharmacist authorities were not finalized until after the bill introduction deadline. Discussions have since progressed with DHCS on the best structure for this bill. The author concluded this bill is necessary to pass this bill this year so that Medi-Cal patients can gain access to these health care services right away.
2. BACKGROUND. As passed by the Assembly, this bill clarified existing law regarding the documents necessary to retain eligibility, benefits or services from Medi-Cal and subsidized programs under Covered California, as defined. The August 15, 2016 amendments deleted the previous content and inserted the above-described language.

The Pharmacy Act authorizes pharmacists to furnish compounded drug products, transmit a valid prescription to another pharmacist, and administer drugs and biologicals pursuant to a prescriber's order. SB 493 (Hernandez), Chapter 469, Statutes of 2013, expanded the scope of pharmacists to authorize them to furnish self-administered hormonal contraceptives, vaccines, nicotine replacement products, and travel medications. Additionally, SB 493 authorized the BOP to recognize Advance Practice Pharmacists (APP) who can perform patient assessments, order and interpret drug therapy-related tests, refer patients to other health care providers, participate in the evaluation and management of diseases and health conditions in collaboration with other health care providers, and initiate, adjust, or discontinue drug therapy. AB 1535 (Bloom), Chapter 326, Statutes of 2014, additionally authorized pharmacists to furnish naloxone hydrochloride. Regulations were adopted by the BOP on the furnishing of naloxone and nicotine replacement products on January 2016 and the furnishing of self-administered hormonal contraceptives were adopted in April 2016. The regulations for the furnishing of travel medications, and administration of vaccinations are currently pending.

Medi-Cal reimbursement to pharmacies currently consists of two components: a) a professional dispensing fee; and, b) payment for the drug dispensed or referred to as "drug ingredient costs." The current dispensing fee is $7.25 per prescription and $8 per prescription for drugs dispensed to beneficiaries in skilled nursing and intermediate care facilities. This bill establishes a separate reimbursement structure for pharmacist services.

DHCS provided technical language on this bill, and points out that this bill only applies to fee-for-service. For an item to be added as a pharmacist-reimbursable service, the service must already be a Medi-Cal benefit, and the service must be within the pharmacist's scope of practice. Under this bill, medical evaluation, consultation, and prescription, as appropriate, would be reimbursed for hormonal contraception, smoking cessation, and naloxone hydrochloride. A list of pharmacist services will be determined by DHCS in a provider bulletin and all-plan letter (if applicable) then followed up with updated regulations.

DHCS indicates if a pharmacist counsels the patient under their expanded scope of practice and prescribes a medication under their current scope of practice, and then dispenses the prescribed drug, these would be two billable services. Under this bill, the pharmacy would be reimbursed for a medical service provided by a pharmacist. This service is separate and distinct from the dispensing of the drug, for which they also would be reimbursed for the drug, plus the $7.25 dispensing fee.

On the federal level, H.R. 592 is currently pending and establishes the Pharmacy and Medically Underserved Areas Enhancement Act which includes pharmacist in the list of healthcare providers under Medicare, and provides for reimbursement for pharmacist services either at an 80% of the lesser of the actual charge or 85% of the fee schedule amount, if such service had been furnished by a physician.

1. RELATED LEGISLATION. AB 2084 (Wood) of the current legislative session would have provided Medi-Cal coverage for comprehensive medication management, would have defined the process of care that ensured each beneficiary's medications were appropriate, safe, and effective, and are being used as intended. It would have also defined beneficiaries, goals, and related requirements, and required DHCS to study the effectiveness and costs. AB 2084 was held on the Assembly Appropriations Committee suspense file.
   
2. SUPPORT. The California Pharmacists Association (CPhA) states that this bill will expand access to a number of important preventative health care services for Medi-Cal beneficiaries. CPhA argues regulations finalized this year provide pharmacists with new authority, including furnishing hormonal contraceptives, certain tobacco cessation drugs, recommended travel medicines, and the opioid overdose drug naloxone directly to patients, allowing pharmacists to provide patients with direct access to important health care services. This bill ensures that Medi-Cal patients can benefit from the direct access to these health care services envisioned by the Legislature. Under existing law, pharmacists are not eligible "providers" in Medi-Cal and their services cannot be reimbursed. Pharmacies are reimbursed for drugs and a limited dispensing fee to cover the cost of dispensing. Federal rules do not allow a dispensing fee to cover the costs associated with these new pharmacist services.

This bill allows pharmacies to bill for services provided by pharmacists to Medi-Cal patients. Pharmacies would be reimbursed at 85% of the physician reimbursement rate, offering increased access to patients and savings to the state. As the state looks to manage the cost, quality of care, and access challenges posed by the over 12 million Californians enrolled in the Medi-Cal program, CPhA concludes the state needs to concentrate its efforts on smart solutions such as this.

CPhA notes that this bill was substantially amended in the Senate, in which the subject matter was not heard in an Assembly policy committee this legislative session.

Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097

CONCURRENCE IN SENATE AMENDMENTS

CSA2 Bill Id:AB 1114

Author:(Eggman)

As Amended Ver:August 24, 2016

2/3 vote. Urgency

(Health)

Original Committee Reference: HEALTH

SUMMARY: Requires specified pharmacy services to be covered under Medi-Cal, and specifies the rate of reimbursement for these services at 85% of the fee schedule for physician services under Medi-Cal. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect after enactment. Specifically, this bill:

1. Specifies the following pharmacy services as a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services:
   1. Furnishing travel medications;
   2. Furnishing naloxone hydrochloride;
   3. Furnishing self-administered hormonal contraception;
   4. Initiating and administering immunizations; and,
   5. Providing tobacco cessation counseling and furnishing nicotine replacement therapy.
2. Requires the Department of Health Care Services (DHCS) to do the following: a) establish a fee schedule for the list of pharmacist services; and, b) specify the rate of reimbursement to be at 85% of the fee schedule for physician services under Medi-Cal.
3. Requires a pharmacist to be enrolled as an ordering, referring, and prescribing provider under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement under this bill.
4. Requires the Director of DHCS to seek any necessary federal approvals for purposes of this bill, prohibits implementation until such approvals are obtained, and implemented only if federal financial participation is available.
5. Specifies that this bill does not restrict nor prohibit any services currently provided by pharmacists as authorized by law, as specified.
6. Authorizes DHCS to implement, interpret, or make specific this bill, without taking any regulatory action, as specified. Requires DHCS to adopt regulations by July 1, 2021 and provide a status report to the Legislature, as specified.

The Senate amendments require specified pharmacist services to be covered under Medi-Cal.

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. One-time costs of $400,000 to $600,000 to make changes to the system for processing Medi-Cal payments to allow pharmacist services to be reimbursed at the rate level specified in this bill (25% General Fund and 75% federal funds).
2. Unknown cost savings due to a shift from services being provided by physicians to those services being provided by pharmacists (General Fund and federal funds). Under this bill, Medi-Cal beneficiaries would be able to access certain services from a pharmacist without the need to see a physician to get a prescription. This bill requires pharmacists to be reimbursed at 85% of the rate paid to physicians. The extent of the cost savings from shifting from physician services to pharmacist services is unknown.
3. Likely overall cost savings to the Medi-Cal program due to increased utilization of certain drugs prescribed and dispensed by pharmacists (General Fund and federal funds). Under this bill, it is likely that there will be increased utilization of certain drugs, because it will be easier for some Medi-Cal beneficiaries to access those drugs directly from a pharmacist without the need for a physician visit. Under current law, the drugs that can be provided by a pharmacist in this manner include smoking cessation drugs, contraceptives, naloxone (a drug that prevents opioid overdoses), and immunizations. These types of drugs have been shown to result in overall health care cost savings, so it is likely that any overall increase in their utilization by Medi-Cal beneficiaries is likely to reduce long-term Medi-Cal spending.

COMMENTS: According to the author, regulations were recently finalized (2016) to allow California pharmacists to provide hormonal contraceptives, the opioid overdose drug naloxone, and nicotine replacing products for smoking cessation directly to patients. This bill will improve access to these vital health services by authorizing the DHCS to establish a system for pharmacists to provide services in the Medi-Cal program. This bill was not introduced earlier this year because the last regulations to implement new pharmacist authorities were not finalized until after the bill introduction deadline. Discussions have since progressed with DHCS on the best structure for this bill. The author concluded this bill is necessary to pass this bill this year so that Medi-Cal patients can gain access to these health care services right away.

The Pharmacy Act authorizes pharmacists to furnish compounded drug products, transmit a valid prescription to another pharmacist, and administer drugs and biologicals pursuant to a prescriber's order. SB 493 (Hernandez), Chapter 469, Statutes of 2013, expanded the scope of pharmacists to authorize them to furnish self-administered hormonal contraceptives, vaccines, nicotine replacement products, and travel medications. Additionally, SB 493 authorized the Board of Pharmacy (BOP) to recognize Advance Practice Pharmacists who can perform patient assessments, order and interpret drug therapy-related tests, refer patients to other health care providers, participate in the evaluation and management of diseases and health conditions in collaboration with other health care providers, and initiate, adjust, or discontinue drug therapy. AB 1535 (Bloom), Chapter 326, Statutes of 2014, additionally authorized pharmacists to furnish naloxone hydrochloride. Regulations were adopted by the BOP on the furnishing of naloxone and nicotine replacement products on January 2016 and the furnishing of self-administered hormonal contraceptives were adopted in April 2016. The regulations for the furnishing of travel medications, and administration of vaccinations are currently pending.

Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0005002

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1114

Author:(Eggman)

As Amended Ver:August 24, 2016

2/3 vote. Urgency

Original Committee Reference: HEALTH

SUMMARY: Requires specified pharmacy services to be covered under Medi-Cal, and specifies the rate of reimbursement for these services at 85% of the fee schedule for physician services under Medi-Cal. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect after enactment. Specifically, this bill:

1. Specifies the following pharmacy services as a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services:
   1. Furnishing travel medications;
   2. Furnishing naloxone hydrochloride;
   3. Furnishing self-administered hormonal contraception;
   4. Initiating and administering immunizations; and,
   5. Providing tobacco cessation counseling and furnishing nicotine replacement therapy.
2. Requires the Department of Health Care Services (DHCS) to do the following: a) establish a fee schedule for the list of pharmacist services; and, b) specify the rate of reimbursement to be at 85% of the fee schedule for physician services under Medi-Cal.
3. Requires a pharmacist to be enrolled as an ordering, referring, and prescribing provider under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement under this bill.
4. Requires the Director of DHCS to seek any necessary federal approvals for purposes of this bill, prohibits implementation until such approvals are obtained, and implemented only if federal financial participation is available.
5. Specifies that this bill does not restrict nor prohibit any services currently provided by pharmacists as authorized by law, as specified.
6. Authorizes DHCS to implement, interpret, or make specific this bill, without taking any regulatory action, as specified. Requires DHCS to adopt regulations by July 1, 2021 and provide a status report to the Legislature, as specified.

The Senate amendments require specified pharmacist services to be covered under Medi-Cal.

AS PASSED BY THE ASSEMBLY, this bill clarified existing law regarding the documents necessary to retain eligibility, benefits, or services from Medi-Cal and subsidized programs under Covered California, as defined; in doing so, required these documents to be translated into the same threshold languages required for Medi-Cal managed care plans.

EXISTING LAW:

1. Establishes the Medi-Cal Program, which is administered by DHCS, under which qualified low-income individuals receive health care services, including certain prescription drugs.
2. Establishes a schedule of benefits under the Medi-Cal program, which includes outpatient prescription drugs, subject to utilization controls and the Medi-Cal list of contract drugs. Requires reimbursement to Medi-Cal pharmacy providers for drugs, as prescribed, and authorizes the department to establish a new reimbursement methodology based on average acquisition cost, as defined.
3. Establishes the Pharmacy Act to regulate the practice of pharmacy under the California Board of Pharmacy (BOP).

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. One-time costs of $400,000 to $600,000 to make changes to the system for processing Medi-Cal payments to allow pharmacist services to be reimbursed at the rate level specified in this bill (25% General Fund and 75% federal funds).
2. Unknown cost savings due to a shift from services being provided by physicians to those services being provided by pharmacists (General Fund and federal funds). Under this bill, Medi-Cal beneficiaries would be able to access certain services from a pharmacist without the need to see a physician to get a prescription. This bill requires pharmacists to be reimbursed at 85% of the rate paid to physicians. The extent of the cost savings from shifting from physician services to pharmacist services is unknown.
3. Likely overall cost savings to the Medi-Cal program due to increased utilization of certain drugs prescribed and dispensed by pharmacists (General Fund and federal funds). Under this bill, it is likely that there will be increased utilization of certain drugs, because it will be easier for some Medi-Cal beneficiaries to access those drugs directly from a pharmacist without the need for a physician visit. Under current law, the drugs that can be provided by a pharmacist in this manner include smoking cessation drugs, contraceptives, naloxone (a drug that prevents opioid overdoses), and immunizations. These types of drugs have been shown to result in overall health care cost savings, so it is likely that any overall increase in their utilization by Medi-Cal beneficiaries is likely to reduce long-term Medi-Cal spending.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, regulations were recently finalized (2016) to allow California pharmacists to provide hormonal contraceptives, the opioid overdose drug naloxone, and nicotine replacing products for smoking cessation directly to patients. This bill will improve access to these vital health services by authorizing the DHCS to establish a system for pharmacists to provide services in the Medi-Cal program. This bill was not introduced earlier this year because the last regulations to implement new pharmacist authorities were not finalized until after the bill introduction deadline. Discussions have since progressed with DHCS on the best structure for this bill. The author concluded this bill is necessary to pass this bill this year so that Medi-Cal patients can gain access to these health care services right away.
2. BACKGROUND. As passed by the Assembly, this bill clarified existing law regarding the documents necessary to retain eligibility, benefits or services from Medi-Cal and subsidized programs under Covered California, as defined. The August 15, 2016 amendments deleted the previous content and inserted the above-described language.

The Pharmacy Act authorizes pharmacists to furnish compounded drug products, transmit a valid prescription to another pharmacist, and administer drugs and biologicals pursuant to a prescriber's order. SB 493 (Hernandez), Chapter 469, Statutes of 2013, expanded the scope of pharmacists to authorize them to furnish self-administered hormonal contraceptives, vaccines, nicotine replacement products, and travel medications. Additionally, SB 493 authorized the BOP to recognize Advance Practice Pharmacists (APP) who can perform patient assessments, order and interpret drug therapy-related tests, refer patients to other health care providers, participate in the evaluation and management of diseases and health conditions in collaboration with other health care providers, and initiate, adjust, or discontinue drug therapy. AB 1535 (Bloom), Chapter 326, Statutes of 2014, additionally authorized pharmacists to furnish naloxone hydrochloride. Regulations were adopted by the BOP on the furnishing of naloxone and nicotine replacement products on January 2016 and the furnishing of self-administered hormonal contraceptives were adopted in April 2016. The regulations for the furnishing of travel medications, and administration of vaccinations are currently pending.

Medi-Cal reimbursement to pharmacies currently consists of two components: a) a professional dispensing fee; and, b) payment for the drug dispensed or referred to as "drug ingredient costs." The current dispensing fee is $7.25 per prescription and $8 per prescription for drugs dispensed to beneficiaries in skilled nursing and intermediate care facilities. This bill establishes a separate reimbursement structure for pharmacist services.

DHCS provided technical language on this bill, and points out that this bill only applies to fee-for-service. For an item to be added as a pharmacist-reimbursable service, the service must already be a Medi-Cal benefit, and the service must be within the pharmacist's scope of practice. Under this bill, medical evaluation, consultation, and prescription, as appropriate, would be reimbursed for hormonal contraception, smoking cessation, and naloxone hydrochloride. A list of pharmacist services will be determined by DHCS in a provider bulletin and all-plan letter (if applicable) then followed up with updated regulations.

DHCS indicates if a pharmacist counsels the patient under their expanded scope of practice and prescribes a medication under their current scope of practice, and then dispenses the prescribed drug, these would be two billable services. Under this bill, the pharmacy would be reimbursed for a medical service provided by a pharmacist. This service is separate and distinct from the dispensing of the drug, for which they also would be reimbursed for the drug, plus the $7.25 dispensing fee.

On the federal level, H.R. 592 is currently pending and establishes the Pharmacy and Medically Underserved Areas Enhancement Act which includes pharmacist in the list of healthcare providers under Medicare, and provides for reimbursement for pharmacist services either at an 80% of the lesser of the actual charge or 85% of the fee schedule amount, if such service had been furnished by a physician.

1. RELATED LEGISLATION. AB 2084 (Wood) of the current legislative session would have provided Medi-Cal coverage for comprehensive medication management, would have defined the process of care that ensured each beneficiary's medications were appropriate, safe, and effective, and are being used as intended. It would have also defined beneficiaries, goals, and related requirements, and required DHCS to study the effectiveness and costs. AB 2084 was held on the Assembly Appropriations Committee suspense file.
2. SUPPORT. The California Pharmacists Association (CPhA) states that this bill will expand access to a number of important preventative health care services for Medi-Cal beneficiaries. CPhA argues regulations finalized this year provide pharmacists with new authority, including furnishing hormonal contraceptives, certain tobacco cessation drugs, recommended travel medicines, and the opioid overdose drug naloxone directly to patients, allowing pharmacists to provide patients with direct access to important health care services. This bill ensures that Medi-Cal patients can benefit from the direct access to these health care services envisioned by the Legislature. Under existing law, pharmacists are not eligible "providers" in Medi-Cal and their services cannot be reimbursed. Pharmacies are reimbursed for drugs and a limited dispensing fee to cover the cost of dispensing. Federal rules do not allow a dispensing fee to cover the costs associated with these new pharmacist services.

This bill allows pharmacies to bill for services provided by pharmacists to Medi-Cal patients. Pharmacies would be reimbursed at 85% of the physician reimbursement rate, offering increased access to patients and savings to the state. As the state looks to manage the cost, quality of care, and access challenges posed by the over 12 million Californians enrolled in the Medi-Cal program, CPhA concludes the state needs to concentrate its efforts on smart solutions such as this.

CPhA notes that this bill was substantially amended in the Senate, in which the subject matter was not heard in an Assembly policy committee this legislative session.

Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0004948

 THIRD READING  

Bill No: AB 1114

Author: Eggman (D)

Amended: 8/24/16 in Senate

Vote: 27 - Urgency

PRIOR VOTES NOT RELEVANT

SENATE HEALTH COMMITTEE: 7-0, 8/22/16 (pursuant to Senate Rule 29.10)

AYES: Hernandez, Hall, Mitchell, Monning, Pan, Roth, Wolk

NO VOTE RECORDED: Nguyen, Nielsen

SENATE APPROPRIATIONS COMMITTEE: 6-0, 8/23/16

AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza

NO VOTE RECORDED: Nielsen

SUBJECT: Medi-Cal: pharmacist services

SOURCE: Author

DIGEST: This bill requires pharmacist services to be a benefit under the Medi-Cal program, establishes a list of covered pharmacist services that may be provided to a Medi-Cal beneficiary, and requires the Department of Health Care Services (DHCS) to establish a fee schedule for the list of pharmacist services to be 85% of the fee schedule for physician services under the Medi-Cal program.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS, under which qualified low-income individuals receive health care services, including certain prescription drugs.
2. Establishes a schedule of benefits under the Medi-Cal program, which includes outpatient prescription drugs, subject to utilization controls and the Medi-Cal list of contract drugs. Requires reimbursement to Medi-Cal pharmacy providers for drugs, as prescribed, and authorizes the department to establish a new reimbursement methodology based on average acquisition cost, as defined.
3. Requires, under the Pharmacy Law, pharmacists to be licensed and regulated by the California State Board of Pharmacy in the Department of Consumer Affairs. Establishes, under the Pharmacy Law, the functions pharmacists are authorized to perform, including administering drugs and biological products that have been ordered by a prescriber, furnishing self-administered hormonal contraceptives, nicotine replacement products, prescription medications not requiring a diagnosis that are recommended for international travelers, and naloxone hydrochloride.

This bill:

1. Requires pharmacist services to be a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services.
2. Requires the following services are covered pharmacist services that may be provided to a Medi-Cal beneficiary:
   1. Furnishing travel medications;
   2. Furnishing naloxone hydrochloride (for opioid overdoes treatment);
   3. Furnishing self-administered hormonal contraception;
   4. Initiating and administering immunizations; and,
   5. Providing tobacco cessation counseling and furnishing nicotine replacement therapy.
3. Requires covered pharmacist services to be subject to DHCS protocols and utilization controls.
4. Requires DHCS to establish a fee schedule for the list of pharmacist services, and requires the rate of reimbursement for pharmacist services to be 85% of the fee schedule for physician services under the Medi-Cal program.
5. Requires a pharmacist to be enrolled as an ordering, referring, and prescribing provider under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement.
6. Prohibits this bill from restricting or prohibiting any services currently provided by pharmacists as authorized by law, including but not limited to, under the Medi-Cal program or California’s Medicaid state plan.
7. Requires the DHCS director to seek any necessary federal approvals to implement this bill. Implements this bill only when necessary federal approvals are obtained, and only to the extent that federal financial participation is available.
8. Permits DHCS to implement, interpret, or make specific this bill, and any applicable federal waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.
9. Requires DHCS, by July 1, 2021, to adopt regulations in accordance with the requirements of the Administrative Procedure Act. Requires DHCS, commencing July 1, 2017, to provide a status report to the Legislature on a semiannual basis until regulations have been adopted.
10. Contains an urgency clause that will make this bill effective upon enactment.

Background

Medi-Cal reimbursement to pharmacies currently consists of two components: (a) a professional dispensing fee and (b) payment for the drug dispensed (referred to as “drug ingredient costs”). The dispensing fee is currently $7.25 per prescription and $8 per prescription for drugs dispensed to beneficiaries in skilled nursing and intermediate care facilities. The purpose of this bill is to require Medi-Cal to establish a separate reimbursement structure for pharmacist services.

The Pharmacy Law provides for the licensing and regulation of pharmacists by the California State Board of Pharmacy in the Department of Consumer Affairs. The law specifies the scope of practice pharmacists are authorized to perform, including to administer, orally or topically, drugs and biologicals pursuant to a prescriber’s order, and to administer immunizations pursuant to a protocol with a prescriber. Pharmacists may also furnish emergency contraception drug therapy pursuant to standardized procedures if they have completed a training program.

SB 493 (Hernandez, Chapter 469, Statutes of 2013) and AB 1535 (Bloom, Chapter 326, Statutes of 2014), expanded the scope of practice of pharmacists. Among other provisions, SB 493 authorizes pharmacists to furnish self-administered hormonal contraceptives, nicotine replacement products, and prescription medications not requiring a diagnosis that are recommended for international travelers, as specified. Additionally, SB 493 authorized pharmacists to order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies, and to independently initiate and administer routine vaccinations, as specified. AB 1535 authorized a pharmacist to furnish naloxone hydrochloride in accordance with standardized procedures or protocols developed and approved by both Pharmacy Board and the Medical Board of California, in consultation with specified entities. Board of Pharmacy regulations implementing these bills took effect in 2016.

DHCS has provided technical assistance on the language in this bill. As drafted, DHCS indicates this bill would only apply to fee-for-service (FFS), as the change is being made to the provisions of the Welfare and Institutions Code specific to the Medi-Cal FFS benefit, and describes Medi-Cal direct reimbursement to FFS pharmacy providers. DHCS’ criteria for an item to be added as a pharmacist-reimbursable service is the service must already a Medi-Cal benefit (currently paid as a medical service and the billing codes would remain the same), and the service must be within the pharmacist’s scope of practice.

DHCS indicates the proposed pharmacist services currently include the medical evaluation and consultation (and prescription, if appropriate) for hormonal contraception, smoking cessation, and the opioid antagonist naloxone. DHCS will identify the list of pharmacist services in a provider bulletin and all-plan letter (if applicable), then follow up with updated regulations.

DHCS indicates if a pharmacist counsels the patient under their expanded scope of practice and prescribes a medication under their current scope of practice, and then dispenses the prescribed drug, these would be two billable services. Under this bill, the pharmacy will be reimbursed for a medical service provided by a pharmacist. DHCS indicates this service is separate and distinct from the dispensing of the drug, for which they also would be reimbursed for the drug ingredient cost, plus the $7.25 dispensing fee.

Comments

Author’s statement. According to the author, according to the author, regulations finalized in 2016 allow California pharmacists to provide hormonal contraceptives, the opioid overdose drug naloxone, and nicotine replacing products for smoking cessation directly to patients. This bill will improve access to these vital health services by authorizing DHCS to establish a system for pharmacists to provide services in the Medi-Cal program.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee:

1. One-time costs of $400,000 to $600,000 to make changes to the system for processing Medi-Cal payments to allow pharmacist services to be reimbursed at the rate level specified in the bill (25% General Fund and 75% federal funds).
2. Unknown cost savings due to a shift from services being provided by physicians to those services being provided by pharmacists (General Fund and federal funds). Under this bill, Medi-Cal beneficiaries would be able to access certain services from a pharmacist without the need to see a physician to get a prescription. This bill requires pharmacists to be reimbursed at 85% of the rate paid to physicians. The extent of the cost savings from shifting from physician services to pharmacist services is unknown.
3. Likely overall cost savings to the Medi-Cal program due to increased utilization of certain drugs prescribed and dispensed by pharmacists (General Fund and federal funds). Under this bill, it is likely that there will be increased utilization of certain drugs, because it will be easier for some Medi-Cal beneficiaries to access those drugs directly from pharmacist without the need for a physician visit. Under current law, the drugs that can be provided by a pharmacist in this manner include smoking cessation drugs, contraceptives, naloxone (a drug that prevents opioid overdoses), and immunizations. These types of drugs have been shown to result in overall health care cost savings, so it is likely that any overall increase in their utilization by Medi-Cal beneficiaries is likely to reduce long-term Medi-Cal spending.

SUPPORT: (Verified 8/23/16)

California Pharmacists Association

California Retailers Association

National Association of Chain Drug Stores

Rite Aid Pharmacies

OPPOSITION: (Verified 8/23/16)

None received

ARGUMENTS IN SUPPORT: The California Pharmacists Association (CPhA) writes in support that this bill will establish a system for pharmacists to provide services in the Medi-Cal program. CPhA argues this bill will expand access to a number of important preventative health care services for Medi-Cal beneficiaries. CPhA argues regulations finalized this year provide pharmacists with new authority, including furnishing hormonal contraceptives, certain tobacco cessation drugs, recommended travel medicines, and the opioid overdose drug naloxone directly to patients. These authorities allow pharmacists to provide patients with direct access to important health care services. CPhA argues this bill ensures that Medi-Cal patients can benefit from the direct access to these health care services envisioned by the Legislature. Under existing law, pharmacists are not eligible “providers” in Medi-Cal and their services cannot be reimbursed. Pharmacies are reimbursed for drugs and a limited dispensing fee to cover the cost of dispensing. Federal rules do not allow a dispensing fee to cover the costs associated with these new pharmacist services.

This bill allows pharmacies to bill for services provided by pharmacists to Medi-Cal patients. Pharmacies would be reimbursed at 85% of the physician reimbursement rate, offering increased access to patients and savings to the state. As the state looks to manage the cost, quality of care, and access challenges posed by the over 12 million Californians enrolled in the Medi-Cal program, CPhA concludes the state needs to concentrate its efforts on smart solutions such as this bill.

Prepared by: Scott Bain / HEALTH / (916) 651-4111

8/24/16 18:31:51

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

AB 1114 (Eggman) - Medi-Cal: pharmacist services

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

AB 1114 would require pharmacist services to be a covered benefit in the Medi-Cal program, with specified requirements.

Fiscal Impact:

• One-time costs of $400,000 to $600,000 to make changes to the system for processing Medi-Cal payments to allow pharmacist services to be reimbursed at the rate level specified in the bill (25% General Fund and 75% federal funds).
• Unknown cost savings due to a shift from services being provided by physicians to those services being provided by pharmacists (General Fund and federal funds). Under the bill, Medi-Cal beneficiaries would be able to access certain services from a pharmacist without the need to see a physician to get a prescription. The bill requires pharmacists to be reimbursed at 85% of the rate paid to physicians. The extent of the cost savings from shifting from physician services to pharmacist services is unknown.
• Likely overall cost savings to the Medi-Cal program due to increased utilization of certain drugs prescribed and dispensed by pharmacists (General Fund and federal funds). Under the bill, it is likely that there will be increased utilization of certain drugs, because it will be easier for some Medi-Cal beneficiaries to access those drugs directly from pharmacist without the need for a physician visit. Under current law, the drugs that can be provided by a pharmacist in this manner include smoking cessation drugs, contraceptives, naloxone (a drug that prevents opioid overdoses), and immunizations. These types of drugs have been shown to result in overall health care cost savings, so it is likely that any overall increase in their utilization by Medi-Cal beneficiaries is likely to reduce long-term Medi-Cal spending.

Background:

Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. Medi-Cal provides coverage to childless adults and parents with household income up to 138% of the federal poverty level and to children with household income up to 266% of the federal poverty level. The federal government provides matching funds that vary from 50% to 90% of expenditures depending on the category of beneficiary.

Under current law, Medi-Cal reimburses pharmacists for drugs dispensed (including both the cost of the drug and the administrative costs of dispensing drugs). Medi-Cal does not reimburse pharmacists for medical evaluations, consultations with patients or prescribing drugs to patients.

Current law allows pharmacists who meet specified requirements to prescribe certain drugs directly, without the need for a prescription from a physician (or other practitioner such as a nurse practitioner). Under these laws, a pharmacist can prescribe and dispense contraceptives, smoking cessation drugs, and naloxone (a drug used to prevent opioid overdoses) and other drugs or services. The implementing regulations for those laws have recently been adopted, allowing certain pharmacists to begin prescribing those drugs.

Proposed Law:

AB 1114 would require pharmacist services to be a covered benefit in the Medi-Cal program, with specified requirements.

Specific provisions of the bill would:

• Establish pharmacist services as a Medi-Cal benefit, subject to federal approval;
• Require the Department of Health Care Services to develop a list of pharmacist services that are reimbursable under the Medi-Cal program;
• Require the Department to establish a fee schedule for pharmacist services, with reimbursement rates set at 85% of physician services;
• Require covered pharmacist services to only include services provided consistent with the laws governing the scope of practice of pharmacists;
• Require covered pharmacist services to be subject to department protocols and utilization controls;
• Require a pharmacist to be enrolled as a Medi-Cal provider prior to rendering a pharmacist service;
• Require the Department to seek any necessary federal approvals;
• Authorize the Department to implement the bill without adopting regulations, but also require the Department to adopt regulations by July 1, 2021.

This bill is an urgency measure.

Related legislation: AB 2084 (Wood) would have provided Medi-Cal coverage for comprehensive medication management. AB 2084 was held on the Assembly Appropriations Committee’s suspense file.

Staff comments: This bill previously addressed enrollment and eligibility requirements for Covered California and the Medi-Cal program.

As drafted, the requirements of the bill would only directly impact the fee-for-service Medi-Cal program. However, because Medi-Cal managed care plans are required by law to provide equivalent benefits to the fee-for-service benefits, the bill will indirectly require Medi-Cal managed care plans to provide coverage for equivalent services. Because all of the services addressed by the bill are already Medi-Cal benefits, Medi-Cal managed care plans would likely have some latitude to offer those benefits through pharmacists or continue to provide them through their contracted physicians.

Committee amendments:

Staff recommends the bill be amended to specify which services shall be eligible for coverage by Medi-Cal as pharmacist services – specifically, furnishing contraceptives, providing tobacco cessation counseling and furnishing nicotine replacement therapy, furnishing naloxone, administering immunizations, and furnishing travel medications.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 1114

PURSANT TO SENATE RULE 29.10

SUBJECT: Medi-Cal: pharmacist services

SUMMARY:

Requires pharmacist services to be a benefit under the Medi-Cal program, requires the Department of Health Care Services (DHCS) to develop a list of pharmacist services that are reimbursable to an enrolled Medi-Cal pharmacy provider, and requires DHCS to establish a fee schedule for the list of pharmacist services to be 85% of the fee schedule for physician services under the Medi-Cal program.

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS, under which qualified low-income individuals receive health care services, including certain prescription drugs.
   
2. Establishes a schedule of benefits under the Medi-Cal program, which includes outpatient prescription drugs, subject to utilization controls and the Medi-Cal list of contract drugs. Requires reimbursement to Medi-Cal pharmacy providers for drugs, as prescribed, and authorizes the department to establish a new reimbursement methodology based on average acquisition cost, as defined.
   
3. Requires, under the Pharmacy Law, pharmacists to be licensed and regulated by the California State Board of Pharmacy in the Department of Consumer Affairs. Establishes, under the Pharmacy Law, the functions pharmacists are authorized to perform, including administering drugs and biological products that have been ordered by a prescriber, furnishing self-administered hormonal contraceptives, nicotine replacement products, prescription medications not requiring a diagnosis that are recommended for international travelers, and naloxone hydrochloride.

This bill:

1. Requires pharmacist services to be a benefit under the Medi-Cal program, subject to approval by the federal Centers for Medicare and Medicaid Services.
2. Requires DHCS to develop a list of pharmacist services that are reimbursable to an enrolled Medi-Cal pharmacy provider.
3. Requires DHCS to establish a fee schedule for the list of pharmacist services, and requires the rate of reimbursement for pharmacist services to be 85% of the fee schedule for physician services under the Medi-Cal program.
4. Limits covered pharmacist services provided to a Medi-Cal beneficiary to include only those services provided by a pharmacist consistent with the laws governing his or her scope of practice.
5. Requires covered pharmacist services to be subject to DHCS protocols and utilization controls.
6. Requires a pharmacist to be enrolled as an ordering, referring, and prescribing provider under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement.
7. Requires the DHCS director to seek any necessary federal approvals to implement this bill. Implements this bill only when necessary federal approvals are obtained, and only to the extent that federal financial participation is available.
8. Permits DHCS to implement, interpret, or make specific this bill, and any applicable federal waivers and state plan amendments, by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.
9. Requires DHCS, by July 1, 2021, to adopt regulations in accordance with the requirements of the Administrative Procedure Act. Requires DHCS, commencing July 1, 2017, to provide a status report to the Legislature on a semiannual basis until regulations have been adopted.
10. Contains an urgency clause that will make this bill effective upon enactment.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, according to the author, regulations finalized in 2016 allow California pharmacists to provide hormonal contraceptives, the opioid overdose drug naloxone, and nicotine replacing products for smoking cessation directly to patients. This bill will improve access to these vital health services by authorizing DHCS to establish a system for pharmacists to provide services in the Medi-Cal program.
   
2. Background. This previous version of this bill dealt with forms and notices issued through CalHEERS, the Covered California eligibility and enrollment system. The August 15, 2016 deleted the previous contents and inserted the above-described language.
   
   The Pharmacy Law provides for the licensing and regulation of pharmacists by the California State Board of Pharmacy in the Department of Consumer Affairs. The law specifies the scope of practice pharmacists are authorized to perform, including to administer, orally or topically, drugs and biologicals pursuant to a prescriber’s order, and to administer immunizations pursuant to a protocol with a prescriber. Pharmacists may also furnish emergency contraception drug therapy pursuant to standardized procedures if they have completed a training program.

SB 493 (Hernandez, Chapter 469, Statutes of 2013) and AB 1535 (Bloom, Chapter 326, Statutes of 2014), expanded the scope of practice of pharmacists. Among other provisions, SB 493 authorizes pharmacists to furnish self-administered hormonal contraceptives, nicotine replacement products, and prescription medications not requiring a diagnosis that are recommended for international travelers, as specified. Additionally, SB 493 authorized pharmacists to order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies, and to independently initiate and administer routine vaccinations, as specified. AB 1535 authorized a pharmacist to furnish naloxone hydrochloride in accordance with standardized procedures or protocols developed and approved by both Pharmacy Board and the Medical Board of California, in consultation with specified entities. Board of Pharmacy regulations implementing these bills took effect in 2016.

Medi-Cal reimbursement to pharmacies currently consists of two components: (a) a professional dispensing fee and (b) payment for the drug dispensed (referred to as “drug ingredient costs”). The dispensing fee is currently $7.25 per prescription and $8 per prescription for drugs dispensed to beneficiaries in skilled nursing and intermediate care facilities. The purpose of this bill is to require Medi-Cal to establish a separate reimbursement structure for pharmacist services.

DHCS has provided technical assistance on the language in this bill. As drafted, DHCS indicates this bill would only apply to fee-for-service (FFS), as the change is being made to the provisions of the Welfare and Institutions Code specific to the Medi-Cal FFS benefit, and describes Medi-Cal direct reimbursement to FFS pharmacy providers. DHCS’ criteria for an item to be added as a pharmacist-reimbursable service is the service must already a Medi-Cal benefit (currently paid as a medical service and the billing codes would remain the same), and the service must be within the pharmacist’s scope of practice.

DHCS indicates the proposed pharmacist services currently include the medical evaluation and consultation (and prescription, if appropriate) for hormonal contraception, smoking cessation, and the opioid antagonist naloxone. DHCS will identify the list of pharmacist services in a provider bulletin and all-plan letter (if applicable), then follow up with updated regulations.

DHCS indicates if a pharmacist counsels the patient under their expanded scope of practice and prescribes a medication under their current scope of practice, and then dispenses the prescribed drug, these would be two billable services.  Under this bill, the pharmacy would be reimbursed for a medical service provided by a pharmacist. DHCS indicates this service is separate and distinct from the dispensing of the drug, for which they also would be reimbursed for the drug ingredient cost, plus the $7.25 dispensing fee.

1. Related legislation. AB 2084 (Wood) would have provided Medi-Cal coverage for comprehensive medication management, is defined as the process of care that ensures each beneficiary’s medications are appropriate, safe, and effective, and are being used as intended. AB 2084 also defines beneficiaries, goals, and related requirements, and requires DHCS to study the effectiveness and costs. AB 2084 was held on the Assembly Appropriations Committee suspense file.
2. Support. The California Pharmacists Association (CPhA) writes in support that this bill would establish a system for pharmacists to provide services in the Medi-Cal program. CPhA argues this bill will expand access to a number of important preventative health care services for Medi-Cal beneficiaries. CPhA argues regulations finalized this year provide pharmacists with new authority, including furnishing hormonal contraceptives, certain tobacco cessation drugs, recommended travel medicines, and the opioid overdose drug naloxone directly to patients. These authorities allow pharmacists to provide patients with direct access to important health care services. CPhA argues this bill ensures that Medi-Cal patients can benefit from the direct access to these health care services envisioned by the Legislature. Under existing law, pharmacists are not eligible “providers” in Medi-Cal and their services cannot be reimbursed. Pharmacies are reimbursed for drugs and a limited dispensing fee to cover the cost of dispensing. Federal rules do not allow a dispensing fee to cover the costs associated with these new pharmacist services.

This bill allows pharmacies to bill for services provided by pharmacists to Medi-Cal patients. Pharmacies would be reimbursed at 85% of the physician reimbursement rate, offering increased access to patients and savings to the state. As the state looks to manage the cost, quality of care, and access challenges posed by the over 12 million Californians enrolled in the Medi-Cal program, CPhA concludes the state needs to concentrate its efforts on smart solutions such as this bill.

SUPPORT AND OPPOSITION:

Support: California Pharmacists Association

California Retailers Association

National Association of Chain Drug Stores

Rite Aid Pharmacies

Oppose: None received

-- END --

 THIRD READING  

Bill No: AB 1114

Author: Bonilla (D)

Amended: 9/1/15 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 6/24/15

AYES: Hernandez, Nguyen, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

NO VOTE RECORDED: Hall

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/27/15

AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

ASSEMBLY FLOOR: 79-0, 6/1/15 - See last page for vote

SUBJECT: Health care: eligibility and enrollment

SOURCE: Western Center on Law and Poverty

DIGEST: This bill defines “forms and notices” for purposes of existing requirements for insurance affordability program-related application forms and notices to mean application and renewal forms and notices of action needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, thereby requiring these forms and notices to be translated in the same threshold languages as required for Medi-Cal managed care plans.

ANALYSIS:

Existing law:

1. Requires a single, accessible, standardized paper, electronic, and telephone application for insurance affordability programs to be developed by the Department of Health Care Services (DHCS) in consultation with the Covered California board, as part of a stakeholder process.
   
   

2. Requires the application to be used by all entities authorized to make an eligibility determination for any of the insurance affordability programs and by their agents.
   
   

3. Permits DHCS to develop and require the use of supplemental forms to collect additional information needed to determine eligibility on a basis other than Modified Adjusted Gross Income.
   
   

4. Establishes requirements for the required forms, including using simple, user-friendly language and instructions, and to only require necessary information. Requires notices developed under the above-described provisions to be accessible and standardized, as appropriate, and to comply with federal and state laws, regulations, and guidance prohibiting discrimination, to be developed using plain language and to be provided in a manner that affords meaningful access to limited-English-proficient (LEP) individuals, in accordance with applicable state and federal law, and at a minimum, provided in the same threshold languages as required for Medi-Cal managed care plans.

This bill defines “forms and notices” for purposes of existing requirements for insurance affordability program-related application forms and notices to mean application and renewal forms and notices of action needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, thereby requiring these forms and notices to be translated in the same threshold languages as required for Medi-Cal managed care plans.

Background

AB 1296 (Bonilla, Chapter 641, Statutes of 2011), the Health Care Eligibility, Enrollment, and Retention Act, requires the California Health and Human Services Agency, in consultation with other state departments and stakeholders, to undertake a planning process to develop plans and procedures regarding these provisions relating to enrollment in state health programs and federal law. AB 1296 also established the existing law requirements for the application form for insurance affordability programs, which are Medi-Cal and coverage with premium or cost-sharing subsidies in Covered California.

In 2014, a lawsuit was filed alleging that DHCS failed, among other requirements, to perform its duty to translate the 2014 redetermination forms in the Medi-Cal threshold languages. The petitioners contended that DHCS is responsible for ensuring languages access in the Medi-Cal program pursuant to Title VI of the federal Civil Rights Act of 1964, Government Code Section 11135, and California’s Dymally-Alatorre Bilingual Services Act, and that DHCS translated redetermination forms into the eleven written Medi-Cal threshold languages in prior years. The petitioners sought an injunction preventing DHCS from terminating any Medi-Cal benefits until the 2014 redetermination forms were translated into the eleven threshold languages and sent to beneficiaries.

The court denied the request for a preliminary injunction, finding that the Dymally-Alatorre Bilingual Services Act provided an alternative to translation of the redetermination forms through the use of translation aids, translation guides or through the use of qualified bilingual individuals. The court also found that the requirements governing Medi-Cal redetermination forms were in a code section separate from the provisions of Health Care Eligibility, Enrollment, and Retention Act. The court stated that if the Legislature wanted to mandate translation of redetermination forms into threshold languages for LEP individuals, it could have included such language in the redetermination statute rather than simply requiring such redetermination forms and notices to be “accessible” to LEP individuals.

Comments

Author’s statement. According to the author, language is a significant barrier to health care access and coverage for many Californians statewide. Forty percent of Medi-Cal members speak a language other than English, with 500,000 of those members speaking a language other than Spanish. This bill will help ensure that those who have limited proficiency in English will not only be able to access health care through Medi-Cal and Covered California, but can continue to renew their coverage and understand their notices to receive the care necessary for their health and well-being.

FISCAL EFFECT: Appropriation: No Fiscal Com.: No Local: No

According to the Senate Appropriations Committee, unknown costs to make programmatic changes to information technology systems (General Fund, federal funds, special fund). Through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) system, eligibility determinations and notifications for Medi-Cal and Covered California are largely automated. Currently, CalHEERs has only been programmed to issue redetermination forms or notices of action in English or Spanish (depending on the applicant’s stated language preference). In order to issue redetermination forms, notices of action, and other documents in the applicant/enrollee’s language of preference, the CalHEERs system will need programming changes.

SUPPORT: (Verified 8/31/15)

Western Center on Law and Poverty (source)

Alameda Health Consortium

American Federation of State, County and Municipal Employees

Asian Americans Advancing Justice – Los Angeles

Asian Law Alliance

California Pan-Ethnic Health Network

California Primary Care Association

Community Clinic Association of Los Angeles County

Community Health Councils, Inc.

Consumers Union

Health Access

Justice in Aging

National Health Law Program

National Immigration Law Center

Project Inform

Southeast Asian Resource Action Center

OPPOSITION: (Verified 8/31/15)

Department of Finance

ARGUMENTS IN SUPPORT: This bill is sponsored by Western Center on Law and Poverty (WCLP) and supported by other consumer groups to clarify that Medi-Cal and Covered California renewal forms and notices must be translated into and issued in the thirteen Medi-Cal threshold languages. WCLP states California's population is incredibly diverse racially, culturally and linguistically. WCLP states Medi-Cal has a tradition of translating its vital documents including applications, renewal forms and notices of action into the Medi-Cal threshold languages to provide needed language access for its diverse LEP members.

Prior to adoption of the Affordable Care Act (ACA) the Medi-Cal annual redetermination forms were translated into the Medi-Cal threshold languages. When the state developed its joint paper health care application for Medi-Cal and Covered California in 2013, that application was similarly translated into all the threshold languages. However, in 2014 neither Medi-Cal nor Covered California redetermination forms or notices nor notices of action were issued into languages other than Spanish. The 2015 Medi-Cal pre-populated renewal form was translated into the threshold languages and issued in January 2013 but it has not yet been programmed and put into use. WCLP states the result is that, while the single streamlined application asks applicants what their preferred written language is and the state has a record of this language, forms and notices have not been sent in the applicants' language. WCLP believes existing law was intended to require translation of the renewal form, but neither the Medi-Cal nor Covered California renewal forms or notices were translated into the threshold languages in 2014 and DHCS has given conflicting accounts of whether it believes it is obligated to do so. WCLP is sponsoring this clarification that "forms and notices" requiring translation include renewal forms and all forms and notices related to either eligibility or benefits as its local legal services partners have been helping consumers who cannot understand the termination notices they receive because they did not understand any of the requests for information they were sent and did not understand what they needed to do to keep their health coverage. This creates undue stress for beneficiaries and missed appointments or prescriptions.

ARGUMENTS IN OPPOSITION: The Department of Finance (DOF) writes in opposition to the prior version of this bill that this bill would result in costs not included in the current fiscal plan and because of its impact on the CalHEERS and the Statewide Automated Welfare System systems (CalHEERS and SAWs are the Covered California and Medi-Cal eligibility computer systems). DOF argues introducing new requirements to CalHEERS and SAWS is not prudent at this time given the significant workload to update these systems for requirements related to the ACA.

ASSEMBLY FLOOR: 79-0, 6/1/15

AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Waldron, Weber, Wilk, Williams, Wood, Atkins

NO VOTE RECORDED: Wagner

Prepared by: Scott Bain / HEALTH /

9/1/15 21:20:00

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

AB 1114 (Bonilla) - Health care: eligibility and enrollment

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on August 27, 2015

Bill Summary:

AB 1114 would define the “forms and notices” that are required to be translated into threshold languages as part of the application and enrollment process for Medi-Cal and coverage through Covered California.

Fiscal Impact:

• Unknown costs to make programmatic changes to information technology systems (General Fund, federal funds, special fund). Through the CalHEERs system, eligibility determinations and notifications for Medi-Cal and Covered California are largely automated. Currently, CalHEERs has only been programmed to issue redetermination forms or notices of action in English or Spanish (depending on the applicant’s stated language preference). In order to issue redetermination forms, notices of action, and other documents in the applicant/enrollee’s language of preference, the CalHEERs system will need programming changes.

Committee Amendments:

Narrow the definition of “forms and notices” to only include application and renewal forms and notices of action.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

AB 1114 (Bonilla) - Health care: eligibility and enrollment

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

AB 1114 would define the “forms and notices” that are required to be translated into threshold languages as part of the application and enrollment process for Medi-Cal and coverage through Covered California.

Fiscal Impact:

• Ongoing costs of about $200,000 per year to oversee the translation of documents and incorporation of those translated documents into the automated systems for establishing eligibility and enrollment in health care coverage (General Fund and federal funds).

• One-time costs up to $2 million to translate documents into the required threshold languages (General Fund and federal funds). Under current law, the Department is required to translate the single application into the threshold languages. However, the Department is not specifically required to translate redetermination forms, notices of action, or forms and letters explaining benefits into the threshold languages. According to the Department, the exact number of documents or pages within those documents in not known, but could be as high as 1,000 total pages. The estimated cost for translation of these kind of documents is about $1,000 per page.

• Unknown costs to make programmatic changes to information technology systems (General Fund, federal funds, special fund). Through the CalHEERs system, eligibility determinations and notifications for Medi-Cal and Covered California are largely automated. Currently, CalHEERs has only been programmed to issue redetermination forms or notices of action in English or Spanish (depending on the applicant’s stated language preference). In order to issue redetermination forms, notices of action, and other documents in the applicant/enrollee’s language of preference, the CalHEERs system will need programming changes.

Background:

Under current law, Medi-Cal and Covered California are required to provide the single application for coverage in “threshold languages”. The threshold depends on the size of the plan’s enrollment and the number of limited-English proficient enrollees. Currently there are thirteen threshold languages in the state with regards to Medi-Cal (Spanish, Vietnamese, Cantonese, Mandarin, Farsi, Cambodian, Korean, Tagalog, Russian, Armenian, Arabic, Hmong and other Chinese languages).

Prior to the implementation of CalHEERs and the joint application process for Medi-Cal and Covered California, redetermination forms were translated into threshold languages and sent to enrollees based on the enrollee’s language preference. However, after the implementation of the single application process, redetermination forms and notices of action have only been sent in English and Spanish.

AB 1296 (Bonilla, Statutes of 2011) created a process for the Department of Health Care Services and Covered California to develop plans and procedures for enrollment in state health care programs. The sponsors of that bill indicate that their intention was to require enrollment applications as well as redetermination forms and notices to be translated into the Medi-Cal threshold languages. However, the Department of Health Care Services has not done so and a court has ruled that current law only requires the enrollment form to be translated into the threshold languages. (Although there are more general requirements in state and federal law requiring access to services for limited English-speaking populations.)

Proposed Law:

AB 1114 would define the “forms and notices” that are required to be translated into threshold languages as part of the application and enrollment process for Medi-Cal and coverage through Covered California.

The bill would define “forms and notices” to include application, renewal, and other forms and letters needed to obtain or retain eligibility, benefits, or services, and all notices affecting the legal rights of applicants, beneficiaries, and enrollees.

Staff Comments:

The definition of “forms and notices” in the bill is very broad, and could encompass documents including application forms and notices of action, but also information on Medi-Cal managed care plan choices, benefits covered by Medi-Cal, processes for appealing decisions by the Medi-Cal program and/or a Medi-Cal managed care plan, and many other documents.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 1114

SUBJECT: Health care: eligibility and enrollment.

SUMMARY:

Defines “forms and notices” for purposes of existing requirements for insurance affordability program-related application forms and notices to mean application, renewal, and other forms and letters needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, and all notices affecting the legal rights of applicants, beneficiaries, and enrollees, thereby requiring these forms and notices to be translated in the same threshold languages as required for Medi-Cal managed care plans.

Existing law:

1. Requires a single, accessible, standardized paper, electronic, and telephone application for insurance affordability programs to be developed by the Department of Health Care Services (DHCS) in consultation with the Covered California board, as part of a stakeholder process.
   
   

2. Requires the application to be used by all entities authorized to make an eligibility determination for any of the insurance affordability programs and by their agents.
   
   

3. Permits DHCS to develop and require the use of supplemental forms to collect additional information needed to determine eligibility on a basis other than Modified Adjusted Gross Income.
   
   

4. Establishes requirements for the required forms, including using simple, user-friendly language and instructions, and to only require necessary information. Requires notices developed under the above-described provisions to be accessible and standardized, as appropriate, and to comply with federal and state laws, regulations, and guidance prohibiting discrimination, to be developed using plain language and to be provided in a manner that affords meaningful access to limited-English-proficient (LEP) individuals, in accordance with applicable state and federal law, and at a minimum, provided in the same threshold languages as required for Medi-Cal managed care plans.

This bill defines “forms and notices” for purposes of existing requirements for insurance affordability program-related application forms and notices to mean application, renewal, and other forms and letters needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, and all notices affecting the legal rights of applicants, beneficiaries, and enrollees, thereby requiring these forms and notices to be translated in the same threshold languages as required for Medi-Cal managed care plans.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. Implementation costs for translation and information technology (IT) services to Covered California/DHCS, which are joint sponsors of the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS), potentially in the range of $2 million (General Fund (GF)/federal funds/special funds). The vast majority of this cost is for IT.

2. Unknown, potential ongoing cost pressure to the state (GF/federal funds/special funds) for county administrative costs. Counties determine eligibility for Medi-Cal and Covered California, and would incur additional costs if additional translations are necessary beyond the standard translations included in the automated CalHEERS system.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, language is a significant barrier to health care access and coverage for many Californians statewide. Forty percent of Medi-Cal members speak a language other than English, with 500,000 of those members speaking a language other than Spanish. This bill will help ensure that those who have limited proficiency in English will not only be able to access health care through Medi-Cal and Covered California, but can continue to renew their coverage and understand their notices to receive the care necessary for their health and well-being.

2. Background. AB 1296 (Bonilla, Chapter 641, Statutes of 2011), the Health Care Eligibility, Enrollment, and Retention Act, requires the California Health and Human Services Agency, in consultation with other state departments and stakeholders, to undertake a planning process to develop plans and procedures regarding these provisions relating to enrollment in state health programs and federal law. AB 1296 also established the existing law requirements for the application form for insurance affordability programs, which are Medi-Cal and coverage with premium or cost-sharing subsidies in Covered California.

In 2014, a lawsuit was filed alleging that DHCS failed, among other requirements, to perform its duty to translate the 2014 redetermination forms in the Medi-Cal threshold languages. The petitioners contended that DHCS is responsible for ensuring languages access in the Medi-Cal program pursuant to Title VI of the federal Civil Rights Act of 1964, Government Code Section 11135, and California’s Dymally-Alatorre Bilingual Services Act, and that DHCS translated redetermination forms into the eleven written Medi-Cal threshold languages in prior years. The petitioners sought an injunction preventing DHCS from terminating any Medi-Cal benefits until the 2014 redetermination forms were translated into the eleven threshold languages and sent to beneficiaries.

The court denied the request for a preliminary injunction, finding that the Dymally-Alatorre Bilingual Services Act provided an alternative to translation of the redetermination forms through the use of translation aids, translation guides or through the use of qualified bilingual individuals. The court also found that the requirements governing Medi-Cal redetermination forms were in a code section separate from the provisions of Health Care Eligibility, Enrollment, and Retention Act. The court stated that if the Legislature wanted to mandate translation of redetermination forms into threshold languages for LEP individuals, it could have included such language in the redetermination statute rather than simply requiring such redetermination forms and notices to be “accessible” to LEP individuals.

3. Support. This bill is sponsored by Western Center on Law and Poverty (WCLP) and supported by other consumer groups to clarify that Medi-Cal and Covered California renewal forms and notices must be translated into and issued in the thirteen Medi-Cal threshold languages. WCLP states California's population is incredibly diverse racially, culturally and linguistically. WCLP states Medi-Cal has a tradition of translating its vital documents including applications, renewal forms and notices of action into the Medi-Cal threshold languages to provide needed language access for its diverse LEP members.
   
   Prior to adoption of the Affordable Care Act (ACA) the Medi-Cal annual redetermination forms were translated into the Medi-Cal threshold languages. When the state developed its joint paper health care application for Medi­-Cal and Covered California in 2013, that application was similarly translated into all the threshold languages. However, in 2014 neither Medi-Cal nor Covered California redetermination forms or notices nor notices of action were issued into languages other than Spanish. The 2015 Medi-Cal pre-populated renewal form was translated into the threshold languages and issued in January 2013 but it has not yet been programmed and put into use. The result is that, while the single streamlined application asks applicants what their preferred written language is and the state has a record of this language, forms and notices have not been sent in the applicants' language. WCLP believes existing law was intended to require translation of the renewal form, but neither the Medi-Cal nor Covered California renewal forms or notices were translated into the threshold languages in 2014 and DHCS has given conflicting accounts of whether it believes it is obligated to do so. WCLP is sponsoring this clarification that "forms and notices" requiring translation include renewal forms and all forms and notices related to either eligibility or benefits as its local legal services partners have been helping consumers who cannot understand the termination notices they receive because they did not understand any of the requests for information they were sent and did not understand what they needed to do to keep their health coverage. This creates undue stress and missed appointments or prescriptions.

SUPPORT AND OPPOSITION:

Support: Western Center on Law and Poverty (sponsor)

Alameda Health Consortium

American Federation of State, County and Municipal Employees

Asian Americans Advancing Justice – Los Angeles

Asian Law Alliance

California Pan-Ethnic Health Network

California Primary Care Association

Community Clinic Association of Los Angeles County

Community Health Councils, Inc.

Consumers Union

Health Access

Justice in Aging

National Health Law Program

National Immigration Law Center

Project Inform

Southeast Asian Resource Action Center

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1114

Author:(Bonilla)

As Amended Ver:April 16, 2015

Majority vote

SUMMARY: Clarifies existing law regarding the documents necessary to retain eligibility, benefits or services from Medi-Cal and subsidized programs under Covered California, as defined. Specifically, this bill:

1. Defines "forms, letters, and notices" as all application, renewal, and other forms and letters needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, and all notices affecting the legal rights of applicants, beneficiaries and enrollees.

2. Requires all forms, letters and notices developed pursuant to this bill to be accessible, standardized, and in compliance with federal and state laws, regulation, and guidance.

3. Requires all forms, letters, and notices developed pursuant to this bill to be written in plain language, be accessible to limited English proficient (LEP) individuals in accordance with state and federal law, and at a minimum, provided at the same threshold of languages as required for Medi-Cal managed care plans.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. Implementation costs for translation and information technology (IT) services to Covered California / Department of Health Care Services, which are joint sponsors of the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS), potentially in the range of $2 million (General Fund (GF)/federal funds/special funds). The vast majority of this cost is for IT.

2. Unknown, potential ongoing cost pressure to the state (GF/federal funds/special funds) for county administrative costs. Counties determine eligibility for Medi-Cal and Covered California, and would incur additional costs if additional translations are necessary beyond the standard translations included in the automated CalHEERS system.

COMMENTS: The author states language is a significant barrier to health care access and coverage to Californians. While the Health Care Eligibility, Enrollment, and Retention Act has made progress in ensuring that Californians are in compliance with the Patient Protection and Affordable Care Act (ACA) and receiving the health care coverage they need, significant challenges remain for many LEP individuals. The author states this bill will help ensure LEP individuals not only have access to health care for the first time, but also continue to renew their coverage to receive sustained care.

Western Center on Law & Poverty, the sponsor of this bill, states that the lack of translated and language-accessible renewal materials is resulting in many consumers not understanding requests for information required to maintain their health coverage. This has led to undue stress and discontinued access to necessary health care services for LEP Medi-Cal beneficiaries, following receipt of Medi-Cal termination notices. The sponsor notes that some counties within the state have begun to translate some of the forms into their own threshold languages; however this is a piecemeal solution to a statewide issue. The sponsor concludes this bill is necessary to clarify which health care forms are required to be translated for consumers, as a court recently ruled that existing statute does not explicitly contain translation requirements for all forms. Supporters of this bill state that any notice to a consumer not provided in his or her primary language is legally insufficient to be considered proper notice in terms of a consumer's due process rights. Supporters note this bill is necessary to clarify existing law and ensure Californians better understand their healthcare coverage.

This bill has no known opposition.

Analysis Prepared by: An-Chi Tsou / HEALTH / (916) 319-2097 FN: 0000718

Date of Hearing: May 6, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

ABPCA Bill Id:AB 1114

Author:(Bonilla) – As Amended Ver:April 16, 2015

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill clarifies the type of documents related to state health insurance affordability programs that must be accessible, standardized, and provided in multiple languages. Specifically, it defines such "forms, letters, and notices” as application, renewal, and other forms and letters needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, and all notices affecting the legal rights of applicants, beneficiaries, and enrollees.

FISCAL EFFECT:

1. Implementation costs for translation and information technology (IT) services to Covered California / Department of Health Care Services, which are joint sponsors of the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS), potentially in the range of $2 million (GF/federal/special funds). The vast majority of this cost is for IT.

2. Unknown, potential ongoing cost pressure to the state (GF/federal/special funds) for county administrative costs. Counties determine eligibility for Medi-Cal and Covered California, and would incur additional costs if additional translations are necessary beyond the standard translations included in the automated CalHEERS system.

COMMENTS:

1. Purpose. According to the author, this bill is necessary to ensure renewal notices for state health insurance affordability programs are provided in multiple languages.

2. Background. Pursuant to the federal Affordable Care Act (ACA), California has a "no wrong door" for state health insurance affordability programs, whereby applicants can be found eligible for Medi-Cal or premium subsidies through Covered California, depending on income. Although related application forms for the programs are currently available in 12 languages, renewal forms for these programs in multiple languages, though they exist, are not currently being used.

3. Recent Litigation. On November 17, 2014, the Western Center on Law & Poverty and other consumer advocacy groups filed a petition for a writ of mandate against DHCS due to its failure to use 2014 Medi-Cal renewal forms that were in languages other than English and Spanish. The plaintiffs alleged DHCS was in acting in violation of existing federal and state law that requires more expansive language accessibility. On February 19, 2015, the court denied part of the motion, citing that existing law on renewal forms does not explicitly require such translation.

4. Staff Comments. Covered California states their strategic plan for CalHEERS includes translation and automation in all threshold languages. However, this bill will take effect in 2016, requiring them to implement these provisions faster than planned. Given technical and clarity issues with notices that Covered California is still sorting through, the accelerated implementation could lead to inefficiency—for example, increased costs to re-translate notices or re-deploy and re-test in multiple languages rather than ironing out issues in English, then translating. Given this, the author may wish to consider whether a phased-in or delayed implementation is worthwhile in order to better align with the existing Covered California strategic IT implementation plans.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 21, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

ABPCA Bill Id:AB 1114

Author:(Bonilla) – As Amended Ver:April 16, 2015

SUBJECT: Health care: eligibility and enrollment.

SUMMARY: Clarifies existing law regarding the documents necessary to retain eligibility, benefits or services from Medi-Cal and subsidized programs under Covered California, as defined. Specifically, this bill:

1. Defines “forms, letters, and notices” as all application, renewal, and other forms and letters needed to obtain or retain eligibility, benefits, or services from an insurance affordability program, and all notices affecting the legal rights of applicants, beneficiaries and enrollees.
   
   
   

2. Requires all forms, letters and notices developed pursuant to this bill to be accessible, standardized, and in compliance with federal and state laws, regulation, and guidance.
   
   
   

3. Requires all forms, letters, and notices developed pursuant to this bill to be written in plain language, be accessible to limited English proficient (LEP) individuals in accordance with state and federal law, and at a minimum, provided at the same threshold of languages as required for Medi-Cal managed care plans.

EXISTING LAW:

1. Requires the California Health and Human Services Agency, in consultation with specified entities, to establish standardized single, accessible application forms and related renewal procedures for state subsidy programs.
   
   
   

2. Requires all forms and notices developed according to the Health Care Eligibility, Enrollment, and Retention Act (Act) be accessible and standardized, as appropriate, and must comply with federal and state laws, regulations, and guidance prohibiting discrimination.
   
   

3. Requires all forms and notices be developed using plain language and provided in a manner that affords meaningful access to LEP individuals in accordance with state and federal law, and at a minimum, provided at the same threshold languages as required for Medi-Cal managed care plans.

FISCAL EFFECT: None

COMMENTS:

1. PURPOSE OF THIS BILL. The author states language is a significant barrier to health care access and coverage to Californians. While the Health Care Eligibility, Enrollment, and Retention Act has made progress in ensuring that Californians are in compliance with the Patient Protection and Affordable Care Act (ACA) and receiving the health care coverage they need, significant challenges remain for many LEP individuals. The author states this bill will help ensure LEP individuals not only have access to health care for the first time, but also continue to renew their coverage to receive sustained care.

2. BACKGROUND.
   
   

   1. Federal and State Authority. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, and ethnic origin in all state programs that receive federal financial assistance. Federal courts have interpreted discrimination by national origin to include language. The Dymally-Alatorre Bilingual Services Act of 1973 was enacted by California to ensure that individuals who do not speak or write English still maintain access to public services; the law specifically requires state and local agencies to ensure they provide services and assistance in their constituents’ languages.
      
      

   2. Primary Languages of Medi-Cal-Eligible Californians. State regulations require California to define threshold languages to help determine the need for services for various LEP populations. Forty percent of Medi-Cal eligible individuals statewide reported a language other than English as their primary language, and met the statutory criteria for a threshold language population. Thirteen languages qualified as threshold languages.
      
      

   3. Covered California and Medi-Cal Forms and Notices. The ACA expanded private health insurance to millions of previously uninsured Californians through its health benefit exchange, also known as Covered California. Medi-Cal is California’s state Medicaid program, which provides health insurance to low-income individuals with incomes at 138% of the federal poverty level. The Covered California and Medi-Cal application forms are currently available in 12 languages. Renewal forms for these programs are not currently available in these languages.
      
      

   4. Recent Litigation. On November 17, 2014, the Western Center on Law & Poverty and other consumer advocacy groups filed a petition for a writ of mandate against the Department of Health Care Services (DHCS) due to the failure of DHCS to translate 2014 Medi-Cal renewal forms into languages other than English and Spanish. The plaintiffs alleged DHCS was in acting in violation of Title VI of the Civil Rights Act and California’s Dymally-Alatorre Bilingual Services Act. On February 19, 2015, the court denied part of the motion, citing that existing law on renewal forms does not explicitly require such translation.
      
      

3. SUPPORT. Western Center on Law & Poverty, the sponsor of this bill, states that the lack of translated and language-accessible renewal materials is resulting in many consumers not understanding requests for information required to maintain their health coverage. This has led to undue stress and discontinued access to necessary health care services for LEP Medi-Cal beneficiaries, following receipt of Medi-Cal termination notices. The sponsor notes that some counties within the state have begun to translate some of the forms into their own threshold languages; however this is a piecemeal solution to a statewide issue. The sponsor asserts Californians should receive important information about their health coverage in their primary language. The sponsor concludes this bill is necessary to clarify which health care forms are required to be translated for consumers, as a court recently ruled that existing statute does not explicitly contain translation requirements for all forms.
   
   

Supporters of this bill state that any notice to a consumer not provided in his or her primary language is legally insufficient to be considered proper notice in terms of a consumer’s due process rights. Supporters note this bill is necessary to clarify existing law and ensure Californians better understand their healthcare coverage.

4. RELATED LEGISLATION. AB 635 (Toni G. Atkins) establishes the Medi-Cal Medical Interpretation services program at DHCS to provide and reimburse for certified medical interpretation services to LEP Medi-Cal enrollees. AB 635 passed this Committee on April 14, 2015 by a vote of 16-0 is currently pending in the Assembly Appropriations Committee.
   
   

5. PREVIOUS LEGISLATION.
   
   

   1. AB 505 (Nazarian), Chapter 788, Statutes of 2014, requires all managed care plans contracting with the DHCS to provide Medi-Cal services, except as specified, to provide language assistance services, which includes oral interpretation and translation services, to LEP Medi-Cal beneficiaries.
      
      

   2. AB 411 (Pan) of 2014 would have provided that DHCS require all Medi-Cal managed care plans to analyze quality performance measures, by race, ethnicity, and primary language to identify disparities in medical treatment and to implement strategies to reduce disparities. AB 411 was vetoed by the Governor, in his veto message, he stated existing law already allows DHCS to procure the additional data, if it sees a need or benefit that justifies the cost.
      
      

   3. AB 1263 (John A. Pérez) of 2013 would have established the Medi-Cal Patient Centered Communication (CommuniCal) program at DHCS to provide and reimburse for certified medical interpretation services to LEP Medi-Cal enrollees. Would have established a certification process and registry of CommuniCal certified medical interpreters at the California Department of Human Resources and granted CommuniCal certified medical interpreters collective bargaining rights with the state. AB 1623 was vetoed by the Governor.
      
      

   4. AB 1296 (Bonilla), Chapter 641, Statutes of 2011, establishes the Health Care Eligibility, Enrollment, and Retention Act, and requires the California Health and Human Services Agency, in consultation with other state departments and stakeholders, to have undertaken a planning process to develop plans and procedures regarding these provisions relating to enrollment in state health programs and federal law.

REGISTERED SUPPORT / OPPOSITION:

Support

Western Center on Law & Poverty (sponsor)

Asian Americans Advancing Justice – Los Angeles

Alameda Health Consortium

Asian Law Alliance

California Primary Care Association

Community Health Councils, Inc.

California Pan-Ethnic Health Network

Health Access California

National Health Law Program

National Immigration Law Center

Southeast Asian Resource Action Center

Opposition

None on file.

Analysis Prepared by: An-Chi Tsou / HEALTH / (916) 319-2097