SB 1287: Medi-Cal: medically necessary services.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive medically necessary health care services, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for an individual under 21 years of age who is covered under the Medi-Cal program, subject to utilization controls, and consistent with federal requirements. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Under existing state law, a service is medically necessary if it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

This bill would revise the Medi-Cal definition of medically necessary for purposes of an individual under 21 years of age to incorporate the existing federal standards related to EPSDT services. The bill would require the department and its contractors to update any model evidence of specified materials to ensure the medical necessity standard for coverage for individuals under 21 years of age is accurately reflected in all materials. The bill would require the department to implement, interpret, and make specific these provisions by means of all-county letters or similar instructions until regulations are revised or adopted by July 1, 2022.

The bill would also clarify the meaning of medically necessary with regard to prior authorization controls in the Medi-Cal program.