SB 323: Medi-Cal: federally qualified health centers and rural health centers: Drug Medi-Cal and specialty mental health services.

Existing law establishes 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 establishes the Drug Medi-Cal Treatment Program (Drug Medi-Cal), under which the department is authorized to enter into contracts with each county for the provision of various alcohol and drug treatment services, including substance use disorder services, narcotic treatment program services, naltrexone services, and outpatient drug-free services, to Medi-Cal beneficiaries. Existing law provides that specialty mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries and coverage for those services is provided through mental health managed care plans. Existing law requires the department to implement managed mental health care for the delivery of specialty mental health services to eligible Medi-Cal beneficiaries through contracts with mental health plans under the Medi-Cal Specialty Mental Health Services Consolidation 1915(b) waiver.

Existing law provides that federally qualified health center (FQHC) services and rural health clinic (RHC) services, as defined, are covered benefits under the Medi-Cal program, to be reimbursed, to the extent that federal financial participation is obtained, to providers on a per-visit basis. Existing law authorizes FQHCs and RHCs to elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services and requires those costs to be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. If FQHC or RHC services are partially reimbursed by a 3rd-party payer, existing law requires the department to reimburse an FQHC or RHC for the difference between its per-visit prospective payment system (PPS) rate and receipts from other plans or programs on a contract-by-contract basis, as specified.

This bill, only to the extent that federal financial participation is available, would authorize FQHCs and RHCs to provide Drug Medi-Cal services pursuant to the terms of a mutually agreed upon contract entered into between the FQHC or RHC and the county or county designee, or department, as specified, and would set forth the reimbursement requirements for these services. The bill, only to the extent that federal financial participation is available, would authorize an FQHC or RHC to provide specialty mental health services to Medi-Cal beneficiaries as part of a mental health plans provider network pursuant to the terms of a mutually agreed upon contract entered into between the FQHC or RHC and one or more mental health plans. The bill would prohibit the costs associated with providing Drug Medi-Cal services or specialty mental health services from being included in the FQHCs or RHCs per-visit PPS rate, and would require the costs associated with providing Drug Medi-Cal services or specialty mental health services to be adjusted out of the FQHCs or RHCs clinic base PPS rate as a scope-of-service change if the costs associated with providing Drug Medi-Cal services or specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as specified. The bill would exempt the department from the reimbursement requirement described above for any payment received by an FQHC or RHC that contracts with a county or the department to provide Drug Medi-Cal services or that contracts with a mental health plan to provide specialty mental health services, as applicable. The bill would authorize the Director of Health Care Services, to implement, interpret, or make specific these provisions by means of provider bulletins or similar instructions, and would require the department to notify and consult with interested parties and appropriate stakeholders in implementing these provisions, as specified.

This bill would incorporate additional changes to Section 14132.100 of the Welfare and Institutions Code proposed by AB 1591 to be operative only if this bill and AB 1591 are enacted and this bill is enacted last.