SB 447: Medi-Cal: clinics: drugs, devices, and supplies.

Session Year: 2015-2016
House: Senate

Version:

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions.

The Medi-Cal program administers a program known as the Family Planning, Access, Care, and Treatment (Family PACT) Program, to provide comprehensive clinical family planning services to any person who has a family income at or below 200% of the federal poverty level and who is eligible to receive those services. Existing law specifies various requirements relating to reimbursement for the provision of drugs and supplies under the Medi-Cal program and the Family PACT Program that are applicable to licensed community clinics, free clinics, or intermittent clinics. Existing law requires reimbursement for drugs and supplies covered under the Medi-Cal program and the Family PACT Program and provided by these clinics to be the lesser of the amount billed or the Medi-Cal reimbursement rate and caps reimbursement at the net cost of the drugs or products as provided by retail pharmacies under the Medi-Cal program. Existing law sets the costs for drugs and supplies covered under those programs at an aggregate amount equivalent to the sum of the actual acquisition cost of a drug or supply plus a clinic dispensing fee not to exceed $12 per billing unit, as specified. Existing law also sets the cost for a take-home drug that is dispensed for use by the patient within a specific timeframe of 5 or fewer days from the date medically indicated at the actual acquisition cost for that drug plus a clinic dispensing fee, not to exceed $17 per prescription.

Existing law requires the State Department of Health Care Services to approve the application of an affiliate clinic, as defined, for enrollment into the Family PACT Program within 30 days of receiving the application, as specified. Existing law also requires the State Department of Public Health to implement a process that allows an applicant for licensure as a primary care clinic, as defined, to submit an application for review of the clinics qualifications for enrollment and certification in the Medi-Cal program, and, among others, the Family PACT Program. Existing law requires the State Department of Health Care Services, within 30 days after receiving confirmation of certification for enrollment of an affiliate clinic in the Medi-Cal program, to enroll the clinic in the Medi-Cal program retroactive to the date of certification.

This bill would eliminate the requirement that the State Department of Health Care Services approve an application for enrollment into the Family PACT Program, and would instead require a primary care clinic or an affiliate clinic that is seeking to enroll in the program to submit an application to the State Department of Public Health. The bill would require a clinic not enrolled in the Medi-Cal program to submit a consolidated application for enrollment in both the Medi-Cal program and the Family PACT program, and would require a clinic already enrolled in the Medi-Cal program to submit an application for enrollment in the Family PACT Program. The bill would require the State Department of Public Health to review that application to certify the clinic for enrollment in those programs, as applicable, and to notify the State Department of Health Care Services of that certification within 15 days after it is granted. The bill would require the State Department of Health Care Services to enroll the clinic in those programs within 15 days after receiving notification from the State Department of Public Health, as specified. The bill would require the State Department of Public Health to develop consolidated application forms, as specified.

This bill would also require reimbursement for devices covered under the Medi-Cal Program and the Family PACT Program. The bill would revise the reimbursement formula described above and would instead specify separate reimbursement formulas for contraceptive drugs, devices, and supplies, and non-contraceptive drugs, devices, and supplies. The bill would, for contraceptive drugs, devices, and supplies, require a clinic to bill the Medi-Cal program and the Family PACT Program at the Medi-Cal reimbursement rate. The bill would, for non-contraceptive drugs, devices, and supplies, require a clinic to bill the Medi-Cal program or the Family PACT Program at the lesser of the clinics usual charge made to the general public, or its cost, defined as an aggregate amount equivalent to the sum of the actual acquisition cost of the drug, device, or supply plus a clinic dispensing fee. The bill would provide that the clinic dispensing fee shall be determined by the department, as specified, or, if not determined by the department, shall be the difference between the actual acquisition cost and the Medi-Cal reimbursement rate. The bill would require reimbursement for non-contraceptive drugs, devices, and supplies to be the lesser of the amount billed, as described above, or the Medi-Cal reimbursement rate, and would cap reimbursement at the net cost of the drug, device, or supply when provided by retail pharmacies under the Medi-Cal program. The bill would require the department to seek federal approval of any state plan amendments necessary to implement these provisions. The bill would require the department, by July 1, 2018, to adopt regulations to implement these provisions, as specified. Until those regulations are adopted the bill would require the department to implement these provisions by provider bulletins or similar instructions and provide the Legislature with a semiannual status report, as specified.

Discussed in Hearing