AB 1644: Medi-Cal: medically supportive food and nutrition services.
- Session Year: 2023-2024
- House: Assembly
- Latest Version Date: 2023-04-27
Current Status:
Failed
(2024-02-01: From committee: Filed with the Chief Clerk pursuant to Joint Rule 56.)
Introduced
In Committee
First Chamber
In Committee
Second Chamber
Enacted
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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing law requires the department to establish the Medically Tailored Meals Pilot Program and the Short-Term Medically Tailored Meals Intervention Services Program, to operate in specified counties and during limited periods for the purpose of providing medically tailored meal intervention services to eligible Medi-Cal beneficiaries with certain health conditions, including congestive heart failure, cancer, diabetes, chronic obstructive pulmonary disease, or renal disease.
Existing law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, authorizes a Medi-Cal managed care plan to elect to cover community supports approved by the department as cost effective and medically appropriate in a comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services. Under existing law, community supports that the department is authorized to approve include, among other things, medically supportive food and nutrition services, including medically tailored meals.
This bill would make medically supportive food and nutrition interventions, as defined, a covered benefit under the Medi-Cal program, upon issuance of final guidance by the department. The bill would require medically supportive food and nutrition interventions to be covered when determined to be medically necessary by a health care provider. provider or health care plan, as specified. In order to qualify for coverage under the Medi-Cal program, the bill would require a patient to be offered at least 3 of 6 specified medically supportive food and nutrition interventions and for the interventions to be provided for a minimum duration of 12 weeks, as specified. The bill would only provide coverage for nutrition support interventions when paired with the provision of food through one of the 3 offered interventions. The bill would require a health care provider to match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention and include culturally appropriate foods whenever possible.
The bill would establish the Medically Supportive Food and Nutrition Benefit Committee a medically supportive food and nutrition benefit advisory workgroup to assist advise the department in developing final guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition interventions, the ratesetting process, determination of permitted providers, and continuing education for health care providers, as specified. The bill would require the committee workgroup to include certain stakeholders knowledgeable in medically supportive food and nutrition interventions and stakeholders from Medi-Cal consumer advocacy organizations. The bill would require the committee workgroup to meet at least quarterly and would require the department to issue final guidance on or before July 1, 2026. The bill would also include findings and declarations of the Legislature relating to the need for medically supportive food and nutrition intervention coverage under the Medi-Cal program.
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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing law requires the department to establish the Medically Tailored Meals Pilot Program and the Short-Term Medically Tailored Meals Intervention Services Program, to operate in specified counties and during limited periods for the purpose of providing medically tailored meal intervention services to eligible Medi-Cal beneficiaries with certain health conditions, including congestive heart failure, cancer, diabetes, chronic obstructive pulmonary disease, or renal disease.
Existing law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, authorizes a Medi-Cal managed care plan to elect to cover community supports approved by the department as cost effective and medically appropriate in a comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services. Under existing law, community supports that the department is authorized to approve include, among other things, medically supportive food and nutrition services, including medically tailored meals.
This bill would make medically supportive food and nutrition interventions, as defined, a covered benefit under the Medi-Cal program, upon issuance of final guidance by the department. The bill would require medically supportive food and nutrition interventions to be covered when determined to be medically necessary by a health care provider. In order to qualify for coverage under the Medi-Cal program, the bill would require a patient to be offered at least 3 of 6 specified medically supportive food and nutrition interventions and for the interventions to be provided for a minimum of 12 weeks, as specified. The bill would only provide coverage for nutrition support interventions when paired with the provision of food through one of the 3 offered interventions. The bill would require a health care provider to match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention and include culturally appropriate foods whenever possible.
The bill would establish the Medically Supportive Food and Nutrition Benefit Committee to assist the department in developing final guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition interventions, the ratesetting process, determination of permitted providers, and continuing education for health care providers, as specified. The bill would require the committee to include certain stakeholders knowledgeable in medically supportive food and nutrition interventions and stakeholders from Medi-Cal consumer advocacy organizations. The bill would require the committee to meet at least quarterly and would require the department to issue final guidance on or before July 1, 2026. The bill would also include findings and declarations of the Legislature relating to the need for medically supportive food and nutrition intervention coverage under the Medi-Cal program.
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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.Existing law requires the department to establish the Medically Tailored Meals Pilot Program and the Short-Term Medically Tailored Meals Intervention Services Program, to operate in specified counties and during limited periods for the purpose of providing medically tailored meal intervention services to eligible Medi-Cal beneficiaries with certain health conditions, including congestive heart failure, cancer, diabetes, chronic obstructive pulmonary disease, or renal disease.Existing law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, authorizes a Medi-Cal managed care plan to elect to cover community supports approved by the department as cost effective and medically appropriate in a comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services. Under existing law, community supports that the department is authorized to approve include, among other things, medically supportive food and nutrition services, including medically tailored meals.This bill would make medically supportive food and nutrition intervention plans, as defined, a covered benefit under the Medi-Cal program, upon issuance of final guidance by the department. The bill would require medically supportive food and nutrition intervention plans be covered when determined to be medically necessary by a health care provider or health care plan. In order to qualify for coverage under the Medi-Cal program, the bill would require medically supportive food and nutrition intervention plans include at least 3 of 6 specified medically supportive food and nutrition interventions. The bill would only provide coverage for nutrition support interventions when combined with the minimum 3 interventions. The bill would require health care providers or health care plans to match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention plan and include culturally appropriate foods whenever possible.The bill would establish the Medically Supportive Food and Nutrition Benefit Committee to assist the department in developing final guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition intervention plans, the ratesetting process, determination of permitted providers, and continuing education for health care providers and health care plans, as specified. The bill would require the committee to include certain stakeholders knowledgeable in medically supportive food and nutrition interventions and stakeholders from Medi-Cal consumer advocacy organizations. The bill would require the committee to meet at least quarterly and would require the department to issue final guidance on or before July 1, 2026. The bill would also include findings and declarations of the Legislature relating to the need for medically supportive food and nutrition intervention coverage under the Medi-Cal program.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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing law requires the department to establish the Medically Tailored Meals Pilot Program and the Short-Term Medically Tailored Meals Intervention Services Program, to operate in specified counties and during limited periods for the purpose of providing medically tailored meal intervention services to eligible Medi-Cal beneficiaries with certain health conditions, including congestive heart failure, cancer, diabetes, chronic obstructive pulmonary disease, or renal disease.
Existing law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, authorizes a Medi-Cal managed care plan to elect to cover community supports approved by the department as cost effective and medically appropriate in a comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services. Under existing law, community supports that the department is authorized to approve include, among other things, medically supportive food and nutrition services, including medically tailored meals.
This bill would make medically supportive food and nutrition intervention plans, as defined, a covered benefit under the Medi-Cal program, upon issuance of final guidance by the department. The bill would require medically supportive food and nutrition intervention plans be covered when determined to be medically necessary by a health care provider or health care plan. In order to qualify for coverage under the Medi-Cal program, the bill would require medically supportive food and nutrition intervention plans include at least 3 of 6 specified medically supportive food and nutrition interventions. The bill would only provide coverage for nutrition support interventions when combined with the minimum 3 interventions. The bill would require health care providers or health care plans to match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention plan and include culturally appropriate foods whenever possible.
The bill would establish the Medically Supportive Food and Nutrition Benefit Committee to assist the department in developing final guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition intervention plans, the ratesetting process, determination of permitted providers, and continuing education for health care providers and health care plans, as specified. The bill would require the committee to include certain stakeholders knowledgeable in medically supportive food and nutrition interventions and stakeholders from Medi-Cal consumer advocacy organizations. The bill would require the committee to meet at least quarterly and would require the department to issue final guidance on or before July 1, 2026. The bill would also include findings and declarations of the Legislature relating to the need for medically supportive food and nutrition intervention coverage under the Medi-Cal program.
This bill would state the intent of the Legislature to enact legislation that would, on and after July 1, 2025, make medically supportive food and nutrition services a covered benefit for all eligible beneficiaries under the Medi-Cal program, as specified.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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing law requires the department to establish the Medically Tailored Meals Pilot Program and the Short-Term Medically Tailored Meals Intervention Services Program, to operate in specified counties and during limited periods for the purpose of providing medically tailored meal intervention services to eligible Medi-Cal beneficiaries with certain health conditions, including congestive heart failure, cancer, diabetes, chronic obstructive pulmonary disease, or renal disease.
Existing law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, authorizes a Medi-Cal managed care plan to elect to cover community supports approved by the department as cost effective and medically appropriate in a comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services. Under existing law, community supports that the department is authorized to approve include, among other things, medically supportive food and nutrition services, including medically tailored meals.
This bill would state the intent of the Legislature to enact legislation that would, on and after July 1, 2025, make medically supportive food and nutrition services a covered benefit for all eligible beneficiaries under the Medi-Cal program, as specified.
The following is the schedule of benefits under this chapter:
(a)Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center, respiratory care, optometric, chiropractic, psychology, podiatric, occupational therapy, physical therapy, speech therapy, audiology, acupuncture to the extent federal matching funds are provided for acupuncture, and services of persons rendering treatment by prayer or healing by spiritual means in the practice of any church or religious denomination insofar as these can be encompassed by federal participation under an approved plan, subject to utilization controls.
(b)(1)Inpatient hospital services, including, but not limited to, physician and podiatric services, physical therapy, and occupational therapy, are covered subject to utilization controls.
(2)For a Medi-Cal fee-for-service beneficiary, emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition. This paragraph does not change the obligation of Medi-Cal managed care plans to provide emergency services and care. For the purposes of this paragraph, emergency services and care and emergency medical condition have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.
(c)Nursing facility services, subacute care services, and services provided by any category of intermediate care facility for the developmentally disabled, including podiatry, physician, nurse practitioner services, and prescribed drugs, as described in subdivision (d), are covered subject to utilization controls. Respiratory care, physical therapy, occupational therapy, speech therapy, and audiology services for patients in nursing facilities and any category of intermediate care facility for persons with developmental disabilities are covered subject to utilization controls.
(d)(1)Purchase of prescribed drugs is covered subject to the Medi-Cal List of Contract Drugs and utilization controls.
(2)Purchase of drugs used to treat erectile dysfunction or any off-label uses of those drugs are covered only to the extent that federal financial participation is available.
(3)(A)To the extent required by federal law, the purchase of outpatient prescribed drugs, for which the prescription is executed by a prescriber in written, nonelectronic form on or after April 1, 2008, is covered only when executed on a tamper resistant prescription form. The implementation of this paragraph shall conform to the guidance issued by the federal Centers for Medicare and Medicaid Services, but shall not conflict with state statutes on the characteristics of tamper resistant prescriptions for controlled substances, including Section 11162.1 of the Health and Safety Code. The department shall provide providers and beneficiaries with as much flexibility in implementing these rules as allowed by the federal government. The department shall notify and consult with appropriate stakeholders in implementing, interpreting, or making specific this paragraph.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instructions without taking regulatory action.
(4)(A)(i)For the purposes of this paragraph, nonlegend has the same meaning as defined in subdivision (a) of Section 14105.45.
(ii)Nonlegend acetaminophen-containing products, including childrens acetaminophen-containing products, selected by the department are covered benefits.
(iii)Nonlegend cough and cold products selected by the department are covered benefits.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instruction without taking regulatory action.
(e)Outpatient dialysis services and home hemodialysis services, including physician services, medical supplies, drugs, and equipment required for dialysis, are covered, subject to utilization controls.
(f)Anesthesiologist services when provided as part of an outpatient medical procedure, nurse anesthetist services when rendered in an inpatient or outpatient setting under conditions set forth by the director, outpatient laboratory services, and x-ray services are covered, subject to utilization controls. This subdivision does not require prior authorization for anesthesiologist services provided as part of an outpatient medical procedure or for portable x-ray services in a nursing facility or any category of intermediate care facility for the developmentally disabled.
(g)Blood and blood derivatives are covered.
(h)(1)Emergency and essential diagnostic and restorative dental services, except for orthodontic, fixed bridgework, and partial dentures that are not necessary for balance of a complete artificial denture, are covered, subject to utilization controls. The utilization controls shall allow emergency and essential diagnostic and restorative dental services and prostheses that are necessary to prevent a significant disability or to replace previously furnished prostheses that are lost or destroyed due to circumstances beyond the beneficiarys control. Notwithstanding the foregoing, the director may by regulation provide for certain fixed artificial dentures necessary for obtaining employment or for medical conditions that preclude the use of removable dental prostheses, and for orthodontic services in cleft palate deformities administered by the departments California Childrens Services program.
(2)For persons 21 years of age or older, the services specified in paragraph (1) shall be provided subject to the following conditions:
(A)Periodontal treatment is not a benefit.
(B)Endodontic therapy is not a benefit except for vital pulpotomy.
(C)Laboratory processed crowns are not a benefit.
(D)Removable prosthetics shall be a benefit only for patients as a requirement for employment.
(E)The director may, by regulation, provide for the provision of fixed artificial dentures that are necessary for medical conditions that preclude the use of removable dental prostheses.
(F)Notwithstanding the conditions specified in subparagraphs (A) to (E), inclusive, the department may approve services for persons with special medical disorders subject to utilization review.
(3)Paragraph (2) shall become inoperative on July 1, 1995.
(i)Medical transportation is covered, subject to utilization controls.
(j)Home health care services are covered, subject to utilization controls.
(k)(1)Prosthetic and orthotic devices and eyeglasses are covered, subject to utilization controls. Utilization controls shall allow replacement of prosthetic and orthotic devices and eyeglasses necessary because of loss or destruction due to circumstances beyond the beneficiarys control. Frame styles for eyeglasses replaced pursuant to this subdivision shall not change more than once every two years, unless the department so directs.
(2)Orthopedic and conventional shoes are covered when provided by a prosthetic and orthotic supplier on the prescription of a physician and when at least one of the shoes will be attached to a prosthesis or brace, subject to utilization controls. Modification of stock conventional or orthopedic shoes when medically indicated is covered, subject to utilization controls. If there is a clearly established medical need that cannot be satisfied by the modification of stock conventional or orthopedic shoes, custom-made orthopedic shoes are covered, subject to utilization controls.
(3)Therapeutic shoes and inserts are covered when provided to a beneficiary with a diagnosis of diabetes, subject to utilization controls, to the extent that federal financial participation is available.
(l)Hearing aids are covered, subject to utilization controls. Utilization controls shall allow replacement of hearing aids necessary because of loss or destruction due to circumstances beyond the beneficiarys control.
(m)Durable medical equipment and medical supplies are covered, subject to utilization controls. The utilization controls shall allow the replacement of durable medical equipment and medical supplies when necessary because of loss or destruction due to circumstances beyond the beneficiarys control. The utilization controls shall allow authorization of durable medical equipment needed to assist a disabled beneficiary in caring for a child for whom the disabled beneficiary is a parent, stepparent, foster parent, or legal guardian, subject to the availability of federal financial participation. The department shall adopt emergency regulations to define and establish criteria for assistive durable medical equipment in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(n)Family planning services are covered, subject to utilization controls. However, for Medi-Cal managed care plans, utilization controls shall be subject to Section 1367.25 of the Health and Safety Code.
(o)Inpatient intensive rehabilitation hospital services, including respiratory rehabilitation services, in a general acute care hospital are covered, subject to utilization controls, when either of the following criteria are met:
(1)A patient with a permanent disability or severe impairment requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to develop function beyond the limited amount that would occur in the normal course of recovery.
(2)A patient with a chronic or progressive disease requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to maintain the patients present functional level as long as possible.
(p)(1)Adult day health care is covered in accordance with Chapter 8.7 (commencing with Section 14520).
(2)Commencing 30 days after the effective date of the act that added this paragraph, and notwithstanding the number of days previously approved through a treatment authorization request, adult day health care is covered for a maximum of three days per week.
(3)As provided in accordance with paragraph (4), adult day health care is covered for a maximum of five days per week.
(4)As of the date that the director makes the declaration described in subdivision (g) of Section 14525.1, paragraph (2) shall become inoperative and paragraph (3) shall become operative.
(q)(1)Application of fluoride, or other appropriate fluoride treatment as defined by the department, and other prophylaxis treatment for children 17 years of age and under are covered.
(2)All dental hygiene services provided by a registered dental hygienist, registered dental hygienist in extended functions, and registered dental hygienist in alternative practice licensed pursuant to Sections 1753, 1917, 1918, and 1922 of the Business and Professions Code may be covered as long as they are within the scope of Denti-Cal benefits and they are necessary services provided by a registered dental hygienist, registered dental hygienist in extended functions, or registered dental hygienist in alternative practice.
(r)(1)Paramedic services performed by a city, county, or special district, or pursuant to a contract with a city, county, or special district, and pursuant to a program established under former Article 3 (commencing with Section 1480) of Chapter 2.5 of Division 2 of the Health and Safety Code by a paramedic certified pursuant to that article, and consisting of defibrillation and those services specified in subdivision (3) of former Section 1482 of the article.
(2)A provider enrolled under this subdivision shall satisfy all applicable statutory and regulatory requirements for becoming a Medi-Cal provider.
(3)This subdivision shall be implemented only to the extent funding is available under Section 14106.6.
(s)(1)In-home medical care services are covered when medically appropriate and subject to utilization controls, for a beneficiary who would otherwise require care for an extended period of time in an acute care hospital at a cost higher than in-home medical care services. The director shall have the authority under this section to contract with organizations qualified to provide in-home medical care services to those persons. These services may be provided to a patient placed in a shared or congregate living arrangement, if a home setting is not medically appropriate or available to the beneficiary.
(2)As used in this subdivision, in-home medical care service includes utility bills directly attributable to continuous, 24-hour operation of life-sustaining medical equipment, to the extent that federal financial participation is available.
(3)As used in this subdivision, in-home medical care services include, but are not limited to:
(A)Level-of-care and cost-of-care evaluations.
(B)Expenses, directly attributable to home care activities, for materials.
(C)Physician fees for home visits.
(D)Expenses directly attributable to home care activities for shelter and modification to shelter.
(E)Expenses directly attributable to additional costs of special diets, including tube feeding.
(F)Medically related personal services.
(G)Home nursing education.
(H)Emergency maintenance repair.
(I)Home health agency personnel benefits that permit coverage of care during periods when regular personnel are on vacation or using sick leave.
(J)All services needed to maintain antiseptic conditions at stoma or shunt sites on the body.
(K)Emergency and nonemergency medical transportation.
(L)Medical supplies.
(M)Medical equipment, including, but not limited to, scales, gurneys, and equipment racks suitable for paralyzed patients.
(N)Utility use directly attributable to the requirements of home care activities that are in addition to normal utility use.
(O)Special drugs and medications.
(P)Home health agency supervision of visiting staff that is medically necessary, but not included in the home health agency rate.
(Q)Therapy services.
(R)Household appliances and household utensil costs directly attributable to home care activities.
(S)Modification of medical equipment for home use.
(T)Training and orientation for use of life-support systems, including, but not limited to, support of respiratory functions.
(U)Respiratory care practitioner services as defined in Sections 3702 and 3703 of the Business and Professions Code, subject to prescription by a physician and surgeon.
(4)A beneficiary receiving in-home medical care services is entitled to the full range of services within the Medi-Cal scope of benefits as defined by this section, subject to medical necessity and applicable utilization control. Services provided pursuant to this subdivision, which are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with a home- and community-based services waiver.
(t)Home- and community-based services approved by the United States Department of Health and Human Services are covered to the extent that federal financial participation is available for those services under the state plan or waivers granted in accordance with Section 1315 or 1396n of Title 42 of the United States Code. The director may seek waivers for any or all home- and community-based services approvable under Section 1315 or 1396n of Title 42 of the United States Code. Coverage for those services shall be limited by the terms, conditions, and duration of the federal waivers.
(u)Comprehensive perinatal services, as provided through an agreement with a health care provider designated in Section 14134.5 and meeting the standards developed by the department pursuant to Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to implement the provisions of this subdivision. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented. Provisions for which waivers are obtained or for which waivers are not required shall be implemented notwithstanding any inability to obtain federal waivers for the other provisions. No provision of this subdivision shall be implemented unless matching funds from Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code are available.
(v)Early and periodic screening, diagnosis, and treatment for any individual under 21 years of age is covered, consistent with the requirements of Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code.
(w)Hospice service that is Medicare-certified hospice service is covered, subject to utilization controls. Coverage shall be available only to the extent that no additional net program costs are incurred.
(x)When a claim for treatment provided to a beneficiary includes both services that are authorized and reimbursable under this chapter and services that are not reimbursable under this chapter, that portion of the claim for the treatment and services authorized and reimbursable under this chapter shall be payable.
(y)Home- and community-based services approved by the United States Department of Health and Human Services for a beneficiary with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex, who requires intermediate care or a higher level of care.
Services provided pursuant to a waiver obtained from the Secretary of the United States Department of Health and Human Services pursuant to this subdivision, and that are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with the waiver, and subject to the terms, conditions, and duration of the waiver. These services shall be provided to a beneficiary in accordance with the clients needs as identified in the plan of care, and subject to medical necessity and applicable utilization control.
The director may, under this section, contract with organizations qualified to provide, directly or by subcontract, services provided for in this subdivision to an eligible beneficiary. Contracts or agreements entered into pursuant to this division shall not be subject to the Public Contract Code.
(z)Respiratory care when provided in organized health care systems as defined in Section 3701 of the Business and Professions Code, and as an in-home medical service as outlined in subdivision (s).
(aa)(1)There is hereby established in the department a program to provide comprehensive clinical family planning services to any person who has a family income at or below 200 percent of the federal poverty level, as revised annually, and who is eligible to receive these services pursuant to the waiver identified in paragraph (2). This program shall be known as the Family Planning, Access, Care, and Treatment (Family PACT) Program.
(2)The department shall seek a waiver in accordance with Section 1315 of Title 42 of the United States Code, or a state plan amendment adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code, which was added to Section 1396a of Title 42 of the United States Code by Section 2303(a)(2) of the federal Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148), for a program to provide comprehensive clinical family planning services as described in paragraph (8). Under the waiver, the program shall be operated only in accordance with the waiver and the statutes and regulations in paragraph (4) and subject to the terms, conditions, and duration of the waiver. Under the state plan amendment, which shall replace the waiver and shall be known as the Family PACT successor state plan amendment, the program shall be operated only in accordance with this subdivision and the statutes and regulations in paragraph (4). The state shall use the standards and processes imposed by the state on January 1, 2007, including the application of an eligibility discount factor to the extent required by the federal Centers for Medicare and Medicaid Services, for purposes of determining eligibility as permitted under Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the extent that federal financial participation is available, the program shall continue to conduct education, outreach, enrollment, service delivery, and evaluation services as specified under the waiver. The services shall be provided under the program only if the waiver and, when applicable, the successor state plan amendment are approved by the federal Centers for Medicare and Medicaid Services and only to the extent that federal financial participation is available for the services. This section does not prohibit the department from seeking the Family PACT successor state plan amendment during the operation of the waiver.
(3)Solely for the purposes of the waiver or Family PACT successor state plan amendment and notwithstanding any other law, the collection and use of an individuals social security number shall be necessary only to the extent required by federal law.
(4)Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and 24013, and any regulations adopted under these statutes shall apply to the program provided for under this subdivision. No other law under the Medi-Cal program or the State-Only Family Planning Program shall apply to the program provided for under this subdivision.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, without taking regulatory action, the provisions of the waiver after its approval by the federal Centers for Medicare and Medicaid Services and the provisions of this section by means of an all-county letter or similar instruction to providers. Thereafter, the department shall adopt regulations to implement this section and the approved waiver in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act adding this subdivision, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.
(6)If the Department of Finance determines that the program operated under the authority of the waiver described in paragraph (2) or the Family PACT successor state plan amendment is no longer cost effective, this subdivision shall become inoperative on the first day of the first month following the issuance of a 30-day notification of that determination in writing by the Department of Finance to the chairperson in each house that considers appropriations, the chairpersons of the committees, and the appropriate subcommittees in each house that considers the State Budget, and the Chairperson of the Joint Legislative Budget Committee.
(7)If this subdivision ceases to be operative, all persons who have received or are eligible to receive comprehensive clinical family planning services pursuant to the waiver described in paragraph (2) shall receive family planning services under the Medi-Cal program pursuant to subdivision (n) if they are otherwise eligible for Medi-Cal with no share of cost, or shall receive comprehensive clinical family planning services under the program established in Division 24 (commencing with Section 24000) either if they are eligible for Medi-Cal with a share of cost or if they are otherwise eligible under Section 24003.
(8)For purposes of this subdivision, comprehensive clinical family planning services means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, natural family planning, abstinence methods, and basic, limited fertility management. Comprehensive clinical family planning services include, but are not limited to, preconception counseling, maternal and fetal health counseling, general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, medical family planning treatment and procedures, including supplies and followup, and informational, counseling, and educational services. Comprehensive clinical family planning services shall not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care that is not incident to the diagnosis of pregnancy. Comprehensive clinical family planning services shall be subject to utilization control and include all of the following:
(A)Family planning related services and male and female sterilization. Family planning services for men and women shall include emergency services and services for complications directly related to the contraceptive method, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, and followup, consultation, and referral services, as indicated, which may require treatment authorization requests.
(B)All United States Department of Agriculture, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies that are in keeping with current standards of practice and from which the individual may choose.
(C)Culturally and linguistically appropriate health education and counseling services, including informed consent, that include all of the following:
(i)Psychosocial and medical aspects of contraception.
(ii)Sexuality.
(iii)Fertility.
(iv)Pregnancy.
(v)Parenthood.
(vi)Infertility.
(vii)Reproductive health care.
(viii)Preconception and nutrition counseling.
(ix)Prevention and treatment of sexually transmitted infection.
(x)Use of contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies.
(xi)Possible contraceptive consequences and followup.
(xii)Interpersonal communication and negotiation of relationships to assist individuals and couples in effective contraceptive method use and planning families.
(D)A comprehensive health history, updated at the next periodic visit (between 11 and 24 months after initial examination) that includes a complete obstetrical history, gynecological history, contraceptive history, personal medical history, health risk factors, and family health history, including genetic or hereditary conditions.
(E)A complete physical examination on initial and subsequent periodic visits.
(F)Services, drugs, devices, and supplies deemed by the federal Centers for Medicare and Medicaid Services to be appropriate for inclusion in the program.
(G)(i)Home test kits for sexually transmitted diseases, including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal or Family PACT clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(ii)For purposes of this subparagraph, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(iii)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Family PACT provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(9)In order to maximize the availability of federal financial participation under this subdivision, the director shall have the discretion to implement the Family PACT successor state plan amendment retroactively to July 1, 2010.
(ab)(1)Purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products and utilization controls.
(2)Purchase of enteral nutrition products is limited to those products to be administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube. A beneficiary under the Early and Periodic Screening, Diagnostic, and Treatment Program shall be exempt from this paragraph.
(3)Notwithstanding paragraph (2), the department may deem an enteral nutrition product, not administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube, a benefit for patients with diagnoses, including, but not limited to, malabsorption and inborn errors of metabolism, if the product has been shown to be neither investigational nor experimental when used as part of a therapeutic regimen to prevent serious disability or death.
(4)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the amendments to this subdivision made by the act that added this paragraph by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.
(5)The amendments made to this subdivision by the act that added this paragraph shall be implemented June 1, 2011, or on the first day of the first calendar month following 60 days after the date the department secures all necessary federal approvals to implement this section, whichever is later.
(ac)Diabetic testing supplies are covered when provided by a pharmacy, subject to utilization controls.
(ad)(1)Nonmedical transportation is covered, subject to utilization controls and permissible time and distance standards, for a beneficiary to obtain covered Medi-Cal services.
(2)(A)(i)Nonmedical transportation includes, at a minimum, round trip transportation for a beneficiary to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance, and mileage reimbursement when conveyance is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers, or train tickets.
(ii)Nonmedical transportation does not include the transportation of a sick, injured, invalid, convalescent, infirm, or otherwise incapacitated beneficiary by ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations.
(B)Nonmedical transportation shall be provided for a beneficiary who can attest in a manner to be specified by the department that other currently available resources have been reasonably exhausted. For a beneficiary enrolled in a managed care plan, nonmedical transportation shall be provided by the beneficiarys managed care plan. For a Medi-Cal fee-for-service beneficiary, the department shall provide nonmedical transportation when those services are not available to the beneficiary under Sections 14132.44 and 14132.47.
(3)Nonmedical transportation shall be provided in a form and manner that is accessible, in terms of physical and geographic accessibility, for the beneficiary and consistent with applicable state and federal disability rights laws.
(4)It is the intent of the Legislature in enacting this subdivision to affirm the requirement under Section 431.53 of Title 42 of the Code of Federal Regulations, in which the department is required to provide necessary transportation, including nonmedical transportation, for recipients to and from covered services. This subdivision shall not be interpreted to add a new benefit to the Medi-Cal program.
(5)The department shall seek any federal approvals that may be required to implement this subdivision, including, but not limited to, approval of revisions to the existing state plan that the department determines are necessary to implement this subdivision.
(6)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained.
(7)Prior to the effective date of any necessary federal approvals, nonmedical transportation was not a Medi-Cal managed care benefit with the exception of when provided as an Early and Periodic Screening, Diagnostic, and Treatment service.
(8)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing January 1, 2018, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(9)This subdivision shall not be implemented until July 1, 2017.
(ae)(1)No sooner than January 1, 2022, Rapid Whole Genome Sequencing, including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal beneficiary who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(af)(1)Home test kits for sexually transmitted diseases that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(2)For purposes of this subdivision, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(3)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Medi-Cal provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(4)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
(ag)(1)Violence prevention services are covered, subject to medical necessity and utilization controls.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(4)The department shall post on its internet website the date upon which violence prevention services may be provided and billed pursuant to this subdivision.
(5)Violence prevention services means evidence-based, trauma-informed, and culturally responsive preventive services provided to reduce the incidence of violent injury or reinjury, trauma, and related harms and promote trauma recovery, stabilization, and improved health outcomes.
(ah)(1)Medically Effective July 1, 2026, medically supportive food and nutrition interventions, as defined in Section 14134.1, shall be are covered when those interventions are determined to be medically necessary to a patients medical condition by a health care provider or health care plan and pursuant to Section 14134.11. 14134.11, subject to utilization controls.
(2)In order to qualify for coverage under this subdivision, an enrollee shall be offered at least three of the medically supportive food and nutrition interventions listed in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 and interventions shall be provided for a minimum of 12 weeks. Coverage shall be provided for a longer duration if deemed medically necessary. Nutrition supports, as defined in paragraph (7) of subdivision (a) of Section 14134.1, shall be covered only when paired with the provision of food through one of the offered interventions described in this paragraph.
(3)This subdivision shall not be implemented until official guidance is finalized by the Department of Health Care Services in conjunction consultation with the Medically Supportive Food and Nutrition Benefit Committee medically supportive food and nutrition benefit stakeholder advisory workgroup established pursuant to Section 14134.12.
(4)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(5)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
SEC. 2.Section 14134 is added to the Welfare and Institutions Code, to read:14134.The Legislature finds and declares the following:
(a)Too many Californians, particularly Californians of color, are living with largely preventable chronic conditions. Adequate food and nutrition are a fundamental part of preventing and treating many health conditions, and can significantly improve a patient's quality of life and health status while also reducing health care costs.
(b)California has recognized the critical role of nutrition and its influence on health outcomes and health equity through its inclusion of medically supportive food and nutrition interventions in the California Advancing and Innovating Medi-Cal Act. However, these services are optional, meaning individual health plans must voluntarily opt in to providing them and, additionally, may choose to make them available to only a small subset of their members, leaving many Medi-Cal beneficiaries without access to these critical interventions.
(c)Medically supportive food and nutrition interventions have the potential to transform our disease care system to a true health care delivery system. By fully embracing food and nutritional support as a critical and strategic investment in health outcomes and health equity, California can lead the nation in tackling root causes of health disparities and become the healthiest state in the nation.
SEC. 3.Section 14134.1 is added to the Welfare and Institutions Code, to read:14134.1.(a)For purposes of this chapter, medically supportive food and nutrition intervention means the following seven interventions that provide nutrient-rich whole food, including any fruit, vegetable, legume, nut, seed, whole grain, low-mercury and high-omega-3 fatty acid seafood, and lean animal protein, used for the prevention, reversal, or treatment of certain health conditions:
(1)Medically tailored meals means meals that are tailored to a recipients health conditions by a registered dietitian nutritionist (RDN) and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines and are typically home delivered. guidelines.
(2)Medically supportive meals means meals that follow the federal Dietary Guidelines for Americans, Americans and meet general health recommendations, and are home delivered, picked up, or consumed on site. recommendations.
(3)Food pharmacy means medically supportive food paired with additional nutrition supports, typically in a health care setting.
(4)Medically tailored groceries means boxes or packages that are tailored to a recipients health conditions by a RDN and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines. Medically tailored groceries are either home delivered or picked up.
(5)Medically supportive groceries means food boxes or packages that follow the federal Dietary Guidelines for Americans and meet general health recommendations and are typically home delivered or picked up, but may be procured in retail settings via a financial mechanism, such as vouchers or a restricted spending card. recommendations.
(6)Produce prescription means fruits and vegetables, typically procured in retail settings, such as grocery stores and farmers markets, via a financial mechanism, such as vouchers or a restricted spending card, but may also be produce boxes or packages that are home delivered or picked up.
(7)Nutrition supports includes nutrition coaching or counseling, group medical visits, cooking education and tools, including equipment and materials, and health coaching and behavioral supports based on a recipients medical conditions, when paired with the interventions described in paragraphs (1) through (6). Nutrition supports may be provided in an individual or group setting.
SEC. 4.Section 14134.11 is added to the Welfare and Institutions Code, to read:14134.11.(a)Consistent with subdivision (ah) of Section 14132, fee-for-service Medi-Cal and each Medi-Cal managed care plan shall offer at least three of the medically supportive food and nutrition interventions described in paragraphs (1) to (6), inclusive, of subdivision (a) of Section 14134.1.
(b)A Medi-Cal enrollee for whom a medically supportive food and nutrition intervention is medically necessary, as determined by their health care provider, provider or health plan, shall be eligible to receive coverage for an intervention consistent with subdivision (ah) of Section 14132. Medical conditions that would benefit from medically supportive food and nutrition interventions include, but are not limited to, the following: 14132 and this section.
(1)Metabolic conditions such as prediabetes, Type 1 and Type 2 diabetes, obesity, metabolic syndrome, polycystic ovary syndrome, and fatty liver disease.(2)Cardiovascular conditions such as hypertension, congestive heart failure, cardiomyopathy, stroke, coronary artery disease, arrhythmia, and lipid abnormalities.(3)Mental and behavioral health conditions such as depression, anxiety, and eating disorders.(4)High-risk perinatal conditions such as gestational diabetes, preeclampsia, and gestational hypertension.(5)Pulmonary conditions such as asthma, chronic obstructive pulmonary disease, and emphysema.(6)Gastrointestinal conditions such as inflammatory bowel disease.(7)Neurodegenerative conditions such as mild cognitive impairment.(8)Renal conditions such as chronic kidney disease.(9)Oncologic conditions such as gastrointestinal, breast, gynecological, and head and neck cancers.(10)Infectious conditions such as human immunodeficiency virus.(c)The department shall define the qualifying medical conditions for medically supportive food and nutrition interventions, including chronic and other conditions that evidence shows are sensitive to changes in diet. The department shall consult with the medically supportive food and nutrition benefit stakeholder advisory workgroup established pursuant to Section 14134.12 in the development of these qualifying medical conditions.
(b)(d)(1)A health care provider shall, to the extent possible, match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention and include culturally appropriate foods whenever possible. Consistent with subdivision (ah) of Section 14132, in order to qualify for coverage under Medi-Cal, a patient shall be offered at least three of the interventions described in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 and
(2)Medically supportive food and nutrition interventions shall be provided with interventions for a minimum duration of 12 weeks. Coverage for interventions shall be provided for a longer duration if deemed to be medically necessary. Nutrition
(3)Nutrition supports as described in paragraph (7) of subdivision (a) of Section 14134.1 are encouraged to be included with the interventions offered to the patient, but shall not count toward the minimum intervention requirements set forth by this subdivision and subdivision (ah) of Section 14132. In order to be covered by Medi-Cal, nutrition supports shall be paired with the provision of food through an intervention described in paragraphs (1) through (6) of subdivision (a) of Section 14134.1.
SEC. 5.Section 14134.12 is added to the Welfare and Institutions Code, to read:14134.12.(a)On or before July 1, 2025, the Department of Health Care Services shall establish the Medically Supportive Food and Nutrition Benefit Committee a medically supportive food and nutrition benefit stakeholder advisory workgroup to assist advise the department in developing the development of official guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition interventions, the ratesetting process, the determination of permitted providers, and continuing education for health care providers and other medically supportive food and nutrition providers. The committee workgroup shall include at least one knowledgeable stakeholder to represent each of the seven medically supportive food and nutrition interventions described in Section 14134.1 and also include stakeholders from Medi-Cal consumer advocacy organizations. The committee workgroup shall meet quarterly or more often as necessary.
(b)The department shall provide 30 days for the workgroup convened pursuant to subdivision (a) to comment on any proposed guidance put forth by the Medically Supportive Food and Nutrition Benefit Committee and guidance on the benefit design of the medically supportive food and nutrition benefit prior to finalizing draft guidance for public comment. The department shall provide an additional 30 days for public comment on draft guidance prior to finalizing its official guidance. The department shall issue final guidance on or before July 1, 2026. Upon issuance of the final guidance, medically supportive food and nutrition interventions shall be a covered benefit under the Medi-Cal program consistent with paragraph (3) of subdivision (ah) of Section 14132.
The following is the schedule of benefits under this chapter:
(a)Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center, respiratory care, optometric, chiropractic, psychology, podiatric, occupational therapy, physical therapy, speech therapy, audiology, acupuncture to the extent federal matching funds are provided for acupuncture, and services of persons rendering treatment by prayer or healing by spiritual means in the practice of any church or religious denomination insofar as these can be encompassed by federal participation under an approved plan, subject to utilization controls.
(b)(1)Inpatient hospital services, including, but not limited to, physician and podiatric services, physical therapy, and occupational therapy, are covered subject to utilization controls.
(2)For a Medi-Cal fee-for-service beneficiary, emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition. This paragraph does not change the obligation of Medi-Cal managed care plans to provide emergency services and care. For the purposes of this paragraph, emergency services and care and emergency medical condition have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.
(c)Nursing facility services, subacute care services, and services provided by any category of intermediate care facility for the developmentally disabled, including podiatry, physician, nurse practitioner services, and prescribed drugs, as described in subdivision (d), are covered subject to utilization controls. Respiratory care, physical therapy, occupational therapy, speech therapy, and audiology services for patients in nursing facilities and any category of intermediate care facility for persons with developmental disabilities are covered subject to utilization controls.
(d)(1)Purchase of prescribed drugs is covered subject to the Medi-Cal List of Contract Drugs and utilization controls.
(2)Purchase of drugs used to treat erectile dysfunction or any off-label uses of those drugs are covered only to the extent that federal financial participation is available.
(3)(A)To the extent required by federal law, the purchase of outpatient prescribed drugs, for which the prescription is executed by a prescriber in written, nonelectronic form on or after April 1, 2008, is covered only when executed on a tamper resistant prescription form. The implementation of this paragraph shall conform to the guidance issued by the federal Centers for Medicare and Medicaid Services, but shall not conflict with state statutes on the characteristics of tamper resistant prescriptions for controlled substances, including Section 11162.1 of the Health and Safety Code. The department shall provide providers and beneficiaries with as much flexibility in implementing these rules as allowed by the federal government. The department shall notify and consult with appropriate stakeholders in implementing, interpreting, or making specific this paragraph.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instructions without taking regulatory action.
(4)(A)(i)For the purposes of this paragraph, nonlegend has the same meaning as defined in subdivision (a) of Section 14105.45.
(ii)Nonlegend acetaminophen-containing products, including childrens acetaminophen-containing products, selected by the department are covered benefits.
(iii)Nonlegend cough and cold products selected by the department are covered benefits.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instruction without taking regulatory action.
(e)Outpatient dialysis services and home hemodialysis services, including physician services, medical supplies, drugs, and equipment required for dialysis, are covered, subject to utilization controls.
(f)Anesthesiologist services when provided as part of an outpatient medical procedure, nurse anesthetist services when rendered in an inpatient or outpatient setting under conditions set forth by the director, outpatient laboratory services, and x-ray services are covered, subject to utilization controls. This subdivision does not require prior authorization for anesthesiologist services provided as part of an outpatient medical procedure or for portable x-ray services in a nursing facility or any category of intermediate care facility for the developmentally disabled.
(g)Blood and blood derivatives are covered.
(h)(1)Emergency and essential diagnostic and restorative dental services, except for orthodontic, fixed bridgework, and partial dentures that are not necessary for balance of a complete artificial denture, are covered, subject to utilization controls. The utilization controls shall allow emergency and essential diagnostic and restorative dental services and prostheses that are necessary to prevent a significant disability or to replace previously furnished prostheses that are lost or destroyed due to circumstances beyond the beneficiarys control. Notwithstanding the foregoing, the director may by regulation provide for certain fixed artificial dentures necessary for obtaining employment or for medical conditions that preclude the use of removable dental prostheses, and for orthodontic services in cleft palate deformities administered by the departments California Childrens Services program.
(2)For persons 21 years of age or older, the services specified in paragraph (1) shall be provided subject to the following conditions:
(A)Periodontal treatment is not a benefit.
(B)Endodontic therapy is not a benefit except for vital pulpotomy.
(C)Laboratory processed crowns are not a benefit.
(D)Removable prosthetics shall be a benefit only for patients as a requirement for employment.
(E)The director may, by regulation, provide for the provision of fixed artificial dentures that are necessary for medical conditions that preclude the use of removable dental prostheses.
(F)Notwithstanding the conditions specified in subparagraphs (A) to (E), inclusive, the department may approve services for persons with special medical disorders subject to utilization review.
(3)Paragraph (2) shall become inoperative on July 1, 1995.
(i)Medical transportation is covered, subject to utilization controls.
(j)Home health care services are covered, subject to utilization controls.
(k)(1)Prosthetic and orthotic devices and eyeglasses are covered, subject to utilization controls. Utilization controls shall allow replacement of prosthetic and orthotic devices and eyeglasses necessary because of loss or destruction due to circumstances beyond the beneficiarys control. Frame styles for eyeglasses replaced pursuant to this subdivision shall not change more than once every two years, unless the department so directs.
(2)Orthopedic and conventional shoes are covered when provided by a prosthetic and orthotic supplier on the prescription of a physician and when at least one of the shoes will be attached to a prosthesis or brace, subject to utilization controls. Modification of stock conventional or orthopedic shoes when medically indicated is covered, subject to utilization controls. If there is a clearly established medical need that cannot be satisfied by the modification of stock conventional or orthopedic shoes, custom-made orthopedic shoes are covered, subject to utilization controls.
(3)Therapeutic shoes and inserts are covered when provided to a beneficiary with a diagnosis of diabetes, subject to utilization controls, to the extent that federal financial participation is available.
(l)Hearing aids are covered, subject to utilization controls. Utilization controls shall allow replacement of hearing aids necessary because of loss or destruction due to circumstances beyond the beneficiarys control.
(m)Durable medical equipment and medical supplies are covered, subject to utilization controls. The utilization controls shall allow the replacement of durable medical equipment and medical supplies when necessary because of loss or destruction due to circumstances beyond the beneficiarys control. The utilization controls shall allow authorization of durable medical equipment needed to assist a disabled beneficiary in caring for a child for whom the disabled beneficiary is a parent, stepparent, foster parent, or legal guardian, subject to the availability of federal financial participation. The department shall adopt emergency regulations to define and establish criteria for assistive durable medical equipment in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(n)Family planning services are covered, subject to utilization controls. However, for Medi-Cal managed care plans, utilization controls shall be subject to Section 1367.25 of the Health and Safety Code.
(o)Inpatient intensive rehabilitation hospital services, including respiratory rehabilitation services, in a general acute care hospital are covered, subject to utilization controls, when either of the following criteria are met:
(1)A patient with a permanent disability or severe impairment requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to develop function beyond the limited amount that would occur in the normal course of recovery.
(2)A patient with a chronic or progressive disease requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to maintain the patients present functional level as long as possible.
(p)(1)Adult day health care is covered in accordance with Chapter 8.7 (commencing with Section 14520).
(2)Commencing 30 days after the effective date of the act that added this paragraph, and notwithstanding the number of days previously approved through a treatment authorization request, adult day health care is covered for a maximum of three days per week.
(3)As provided in accordance with paragraph (4), adult day health care is covered for a maximum of five days per week.
(4)As of the date that the director makes the declaration described in subdivision (g) of Section 14525.1, paragraph (2) shall become inoperative and paragraph (3) shall become operative.
(q)(1)Application of fluoride, or other appropriate fluoride treatment as defined by the department, and other prophylaxis treatment for children 17 years of age and under are covered.
(2)All dental hygiene services provided by a registered dental hygienist, registered dental hygienist in extended functions, and registered dental hygienist in alternative practice licensed pursuant to Sections 1753, 1917, 1918, and 1922 of the Business and Professions Code may be covered as long as they are within the scope of Denti-Cal benefits and they are necessary services provided by a registered dental hygienist, registered dental hygienist in extended functions, or registered dental hygienist in alternative practice.
(r)(1)Paramedic services performed by a city, county, or special district, or pursuant to a contract with a city, county, or special district, and pursuant to a program established under former Article 3 (commencing with Section 1480) of Chapter 2.5 of Division 2 of the Health and Safety Code by a paramedic certified pursuant to that article, and consisting of defibrillation and those services specified in subdivision (3) of former Section 1482 of the article.
(2)A provider enrolled under this subdivision shall satisfy all applicable statutory and regulatory requirements for becoming a Medi-Cal provider.
(3)This subdivision shall be implemented only to the extent funding is available under Section 14106.6.
(s)(1)In-home medical care services are covered when medically appropriate and subject to utilization controls, for a beneficiary who would otherwise require care for an extended period of time in an acute care hospital at a cost higher than in-home medical care services. The director shall have the authority under this section to contract with organizations qualified to provide in-home medical care services to those persons. These services may be provided to a patient placed in a shared or congregate living arrangement, if a home setting is not medically appropriate or available to the beneficiary.
(2)As used in this subdivision, in-home medical care service includes utility bills directly attributable to continuous, 24-hour operation of life-sustaining medical equipment, to the extent that federal financial participation is available.
(3)As used in this subdivision, in-home medical care services include, but are not limited to:
(A)Level-of-care and cost-of-care evaluations.
(B)Expenses, directly attributable to home care activities, for materials.
(C)Physician fees for home visits.
(D)Expenses directly attributable to home care activities for shelter and modification to shelter.
(E)Expenses directly attributable to additional costs of special diets, including tube feeding.
(F)Medically related personal services.
(G)Home nursing education.
(H)Emergency maintenance repair.
(I)Home health agency personnel benefits that permit coverage of care during periods when regular personnel are on vacation or using sick leave.
(J)All services needed to maintain antiseptic conditions at stoma or shunt sites on the body.
(K)Emergency and nonemergency medical transportation.
(L)Medical supplies.
(M)Medical equipment, including, but not limited to, scales, gurneys, and equipment racks suitable for paralyzed patients.
(N)Utility use directly attributable to the requirements of home care activities that are in addition to normal utility use.
(O)Special drugs and medications.
(P)Home health agency supervision of visiting staff that is medically necessary, but not included in the home health agency rate.
(Q)Therapy services.
(R)Household appliances and household utensil costs directly attributable to home care activities.
(S)Modification of medical equipment for home use.
(T)Training and orientation for use of life-support systems, including, but not limited to, support of respiratory functions.
(U)Respiratory care practitioner services as defined in Sections 3702 and 3703 of the Business and Professions Code, subject to prescription by a physician and surgeon.
(4)A beneficiary receiving in-home medical care services is entitled to the full range of services within the Medi-Cal scope of benefits as defined by this section, subject to medical necessity and applicable utilization control. Services provided pursuant to this subdivision, which are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with a home- and community-based services waiver.
(t)Home- and community-based services approved by the United States Department of Health and Human Services are covered to the extent that federal financial participation is available for those services under the state plan or waivers granted in accordance with Section 1315 or 1396n of Title 42 of the United States Code. The director may seek waivers for any or all home- and community-based services approvable under Section 1315 or 1396n of Title 42 of the United States Code. Coverage for those services shall be limited by the terms, conditions, and duration of the federal waivers.
(u)Comprehensive perinatal services, as provided through an agreement with a health care provider designated in Section 14134.5 and meeting the standards developed by the department pursuant to Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to implement the provisions of this subdivision. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented. Provisions for which waivers are obtained or for which waivers are not required shall be implemented notwithstanding any inability to obtain federal waivers for the other provisions. No provision of this subdivision shall be implemented unless matching funds from Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code are available.
(v)Early and periodic screening, diagnosis, and treatment for any individual under 21 years of age is covered, consistent with the requirements of Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code.
(w)Hospice service that is Medicare-certified hospice service is covered, subject to utilization controls. Coverage shall be available only to the extent that no additional net program costs are incurred.
(x)When a claim for treatment provided to a beneficiary includes both services that are authorized and reimbursable under this chapter and services that are not reimbursable under this chapter, that portion of the claim for the treatment and services authorized and reimbursable under this chapter shall be payable.
(y)Home- and community-based services approved by the United States Department of Health and Human Services for a beneficiary with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex, who requires intermediate care or a higher level of care.
Services provided pursuant to a waiver obtained from the Secretary of the United States Department of Health and Human Services pursuant to this subdivision, and that are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with the waiver, and subject to the terms, conditions, and duration of the waiver. These services shall be provided to a beneficiary in accordance with the clients needs as identified in the plan of care, and subject to medical necessity and applicable utilization control.
The director may, under this section, contract with organizations qualified to provide, directly or by subcontract, services provided for in this subdivision to an eligible beneficiary. Contracts or agreements entered into pursuant to this division shall not be subject to the Public Contract Code.
(z)Respiratory care when provided in organized health care systems as defined in Section 3701 of the Business and Professions Code, and as an in-home medical service as outlined in subdivision (s).
(aa)(1)There is hereby established in the department a program to provide comprehensive clinical family planning services to any person who has a family income at or below 200 percent of the federal poverty level, as revised annually, and who is eligible to receive these services pursuant to the waiver identified in paragraph (2). This program shall be known as the Family Planning, Access, Care, and Treatment (Family PACT) Program.
(2)The department shall seek a waiver in accordance with Section 1315 of Title 42 of the United States Code, or a state plan amendment adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code, which was added to Section 1396a of Title 42 of the United States Code by Section 2303(a)(2) of the federal Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148), for a program to provide comprehensive clinical family planning services as described in paragraph (8). Under the waiver, the program shall be operated only in accordance with the waiver and the statutes and regulations in paragraph (4) and subject to the terms, conditions, and duration of the waiver. Under the state plan amendment, which shall replace the waiver and shall be known as the Family PACT successor state plan amendment, the program shall be operated only in accordance with this subdivision and the statutes and regulations in paragraph (4). The state shall use the standards and processes imposed by the state on January 1, 2007, including the application of an eligibility discount factor to the extent required by the federal Centers for Medicare and Medicaid Services, for purposes of determining eligibility as permitted under Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the extent that federal financial participation is available, the program shall continue to conduct education, outreach, enrollment, service delivery, and evaluation services as specified under the waiver. The services shall be provided under the program only if the waiver and, when applicable, the successor state plan amendment are approved by the federal Centers for Medicare and Medicaid Services and only to the extent that federal financial participation is available for the services. This section does not prohibit the department from seeking the Family PACT successor state plan amendment during the operation of the waiver.
(3)Solely for the purposes of the waiver or Family PACT successor state plan amendment and notwithstanding any other law, the collection and use of an individuals social security number shall be necessary only to the extent required by federal law.
(4)Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and 24013, and any regulations adopted under these statutes shall apply to the program provided for under this subdivision. No other law under the Medi-Cal program or the State-Only Family Planning Program shall apply to the program provided for under this subdivision.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, without taking regulatory action, the provisions of the waiver after its approval by the federal Centers for Medicare and Medicaid Services and the provisions of this section by means of an all-county letter or similar instruction to providers. Thereafter, the department shall adopt regulations to implement this section and the approved waiver in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act adding this subdivision, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.
(6)If the Department of Finance determines that the program operated under the authority of the waiver described in paragraph (2) or the Family PACT successor state plan amendment is no longer cost effective, this subdivision shall become inoperative on the first day of the first month following the issuance of a 30-day notification of that determination in writing by the Department of Finance to the chairperson in each house that considers appropriations, the chairpersons of the committees, and the appropriate subcommittees in each house that considers the State Budget, and the Chairperson of the Joint Legislative Budget Committee.
(7)If this subdivision ceases to be operative, all persons who have received or are eligible to receive comprehensive clinical family planning services pursuant to the waiver described in paragraph (2) shall receive family planning services under the Medi-Cal program pursuant to subdivision (n) if they are otherwise eligible for Medi-Cal with no share of cost, or shall receive comprehensive clinical family planning services under the program established in Division 24 (commencing with Section 24000) either if they are eligible for Medi-Cal with a share of cost or if they are otherwise eligible under Section 24003.
(8)For purposes of this subdivision, comprehensive clinical family planning services means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, natural family planning, abstinence methods, and basic, limited fertility management. Comprehensive clinical family planning services include, but are not limited to, preconception counseling, maternal and fetal health counseling, general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, medical family planning treatment and procedures, including supplies and followup, and informational, counseling, and educational services. Comprehensive clinical family planning services shall not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care that is not incident to the diagnosis of pregnancy. Comprehensive clinical family planning services shall be subject to utilization control and include all of the following:
(A)Family planning related services and male and female sterilization. Family planning services for men and women shall include emergency services and services for complications directly related to the contraceptive method, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, and followup, consultation, and referral services, as indicated, which may require treatment authorization requests.
(B)All United States Department of Agriculture, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies that are in keeping with current standards of practice and from which the individual may choose.
(C)Culturally and linguistically appropriate health education and counseling services, including informed consent, that include all of the following:
(i)Psychosocial and medical aspects of contraception.
(ii)Sexuality.
(iii)Fertility.
(iv)Pregnancy.
(v)Parenthood.
(vi)Infertility.
(vii)Reproductive health care.
(viii)Preconception and nutrition counseling.
(ix)Prevention and treatment of sexually transmitted infection.
(x)Use of contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies.
(xi)Possible contraceptive consequences and followup.
(xii)Interpersonal communication and negotiation of relationships to assist individuals and couples in effective contraceptive method use and planning families.
(D)A comprehensive health history, updated at the next periodic visit (between 11 and 24 months after initial examination) that includes a complete obstetrical history, gynecological history, contraceptive history, personal medical history, health risk factors, and family health history, including genetic or hereditary conditions.
(E)A complete physical examination on initial and subsequent periodic visits.
(F)Services, drugs, devices, and supplies deemed by the federal Centers for Medicare and Medicaid Services to be appropriate for inclusion in the program.
(G)(i)Home test kits for sexually transmitted diseases, including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal or Family PACT clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(ii)For purposes of this subparagraph, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(iii)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Family PACT provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(9)In order to maximize the availability of federal financial participation under this subdivision, the director shall have the discretion to implement the Family PACT successor state plan amendment retroactively to July 1, 2010.
(ab)(1)Purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products and utilization controls.
(2)Purchase of enteral nutrition products is limited to those products to be administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube. A beneficiary under the Early and Periodic Screening, Diagnostic, and Treatment Program shall be exempt from this paragraph.
(3)Notwithstanding paragraph (2), the department may deem an enteral nutrition product, not administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube, a benefit for patients with diagnoses, including, but not limited to, malabsorption and inborn errors of metabolism, if the product has been shown to be neither investigational nor experimental when used as part of a therapeutic regimen to prevent serious disability or death.
(4)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the amendments to this subdivision made by the act that added this paragraph by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.
(5)The amendments made to this subdivision by the act that added this paragraph shall be implemented June 1, 2011, or on the first day of the first calendar month following 60 days after the date the department secures all necessary federal approvals to implement this section, whichever is later.
(ac)Diabetic testing supplies are covered when provided by a pharmacy, subject to utilization controls.
(ad)(1)Nonmedical transportation is covered, subject to utilization controls and permissible time and distance standards, for a beneficiary to obtain covered Medi-Cal services.
(2)(A)(i)Nonmedical transportation includes, at a minimum, round trip transportation for a beneficiary to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance, and mileage reimbursement when conveyance is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers, or train tickets.
(ii)Nonmedical transportation does not include the transportation of a sick, injured, invalid, convalescent, infirm, or otherwise incapacitated beneficiary by ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations.
(B)Nonmedical transportation shall be provided for a beneficiary who can attest in a manner to be specified by the department that other currently available resources have been reasonably exhausted. For a beneficiary enrolled in a managed care plan, nonmedical transportation shall be provided by the beneficiarys managed care plan. For a Medi-Cal fee-for-service beneficiary, the department shall provide nonmedical transportation when those services are not available to the beneficiary under Sections 14132.44 and 14132.47.
(3)Nonmedical transportation shall be provided in a form and manner that is accessible, in terms of physical and geographic accessibility, for the beneficiary and consistent with applicable state and federal disability rights laws.
(4)It is the intent of the Legislature in enacting this subdivision to affirm the requirement under Section 431.53 of Title 42 of the Code of Federal Regulations, in which the department is required to provide necessary transportation, including nonmedical transportation, for recipients to and from covered services. This subdivision shall not be interpreted to add a new benefit to the Medi-Cal program.
(5)The department shall seek any federal approvals that may be required to implement this subdivision, including, but not limited to, approval of revisions to the existing state plan that the department determines are necessary to implement this subdivision.
(6)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained.
(7)Prior to the effective date of any necessary federal approvals, nonmedical transportation was not a Medi-Cal managed care benefit with the exception of when provided as an Early and Periodic Screening, Diagnostic, and Treatment service.
(8)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing January 1, 2018, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(9)This subdivision shall not be implemented until July 1, 2017.
(ae)(1)No sooner than January 1, 2022, Rapid Whole Genome Sequencing, including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal beneficiary who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(af)(1)Home test kits for sexually transmitted diseases that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(2)For purposes of this subdivision, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(3)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Medi-Cal provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(4)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
(ag)(1)Violence prevention services are covered, subject to medical necessity and utilization controls.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(4)The department shall post on its internet website the date upon which violence prevention services may be provided and billed pursuant to this subdivision.
(5)Violence prevention services means evidence-based, trauma-informed, and culturally responsive preventive services provided to reduce the incidence of violent injury or reinjury, trauma, and related harms and promote trauma recovery, stabilization, and improved health outcomes.
(ah)(1)Medically supportive food and nutrition interventions, as defined in Section 14134.1, shall be covered when those interventions are determined to be medically necessary to a patients medical condition by a health care provider or health care plan pursuant to Section 14134.11.
(2)In order to qualify for coverage under this subdivision, an enrollee shall be offered at least three of the medically supportive food and nutrition interventions listed in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 and interventions shall be provided for a minimum of 12 weeks. Coverage shall be provided for a longer duration if deemed medically necessary. Nutrition supports, as defined in paragraph (7) of subdivision (a) of Section 14134.1, shall be covered only when paired with the provision of food through one of the offered interventions described in this paragraph.
(3)This subdivision shall not be implemented until official guidance is finalized by the Department of Health Care Services in conjunction with the Medically Supportive Food and Nutrition Benefit Committee established pursuant to Section 14134.12.
SEC. 2.Section 14134 is added to the Welfare and Institutions Code, to read:14134.The Legislature finds and declares the following:
(a)Too many Californians, particularly Californians of color, are living with largely preventable chronic conditions. Adequate food and nutrition are a fundamental part of preventing and treating many health conditions, and can significantly improve a patient's quality of life and health status while also reducing health care costs.
(b)California has recognized the critical role of nutrition and its influence on health outcomes and health equity through its inclusion of medically supportive food and nutrition interventions in the California Advancing and Innovating Medi-Cal Act. However, these services are optional, meaning individual health plans must voluntarily opt in to providing them and, additionally, may choose to make them available to only a small subset of their members, leaving many Medi-Cal beneficiaries without access to these critical interventions.
(c)Medically supportive food and nutrition interventions have the potential to transform our disease care system to a true health care delivery system. By fully embracing food and nutritional support as a critical and strategic investment in health outcomes and health equity, California can lead the nation in tackling root causes of health disparities and become the healthiest state in the nation.
SEC. 3.Section 14134.1 is added to the Welfare and Institutions Code, to read:14134.1.(a)For purposes of this chapter, medically supportive food and nutrition intervention means the following seven interventions that provide nutrient-rich whole food, including any fruit, vegetable, legume, nut, seed, whole grain, low-mercury and high-omega-3 fatty acid seafood, and lean animal protein, used for the prevention, reversal, or treatment of certain health conditions:
(1)Medically tailored meals means meals that are tailored to a recipients health conditions by a registered dietitian nutritionist (RDN) and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines and are typically home delivered.
(2)Medically supportive meals means meals that follow the federal Dietary Guidelines for Americans, meet general health recommendations, and are home delivered, picked up, or consumed on site.
(3)Food pharmacy means medically supportive food paired with additional nutrition supports, typically in a health care setting.
(4)Medically tailored groceries means boxes or packages that are tailored to a recipients health conditions by a RDN and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines. Medically tailored groceries are either home delivered or picked up.
(5)Medically supportive groceries means food boxes or packages that follow the federal Dietary Guidelines for Americans and meet general health recommendations and are typically home delivered or picked up, but may be procured in retail settings via a financial mechanism, such as vouchers or a restricted spending card.
(6)Produce prescription means fruits and vegetables, typically procured in retail settings, such as grocery stores and farmers markets, via a financial mechanism, such as vouchers or a restricted spending card, but may also be produce boxes or packages that are home delivered or picked up.
(7)Nutrition supports includes nutrition coaching or counseling, group medical visits, cooking education and tools, and behavioral supports based on a recipients medical conditions, when paired with the interventions described in paragraphs (1) through (6).
SEC. 4.Section 14134.11 is added to the Welfare and Institutions Code, to read:14134.11.(a)A Medi-Cal enrollee for whom a medically supportive food and nutrition intervention is medically necessary, as determined by their health care provider, shall be eligible to receive coverage for an intervention consistent with subdivision (ah) of Section 14132. Medical conditions that would benefit from medically supportive food and nutrition interventions include, but are not limited to, the following:
(1)Metabolic conditions such as prediabetes, Type 1 and Type 2 diabetes, obesity, metabolic syndrome, polycystic ovary syndrome, and fatty liver disease.
(2)Cardiovascular conditions such as hypertension, congestive heart failure, cardiomyopathy, stroke, coronary artery disease, arrhythmia, and lipid abnormalities.
(3)Mental and behavioral health conditions such as depression, anxiety, and eating disorders.
(4)High-risk perinatal conditions such as gestational diabetes, preeclampsia, and gestational hypertension.
(5)Pulmonary conditions such as asthma, chronic obstructive pulmonary disease, and emphysema.
(6)Gastrointestinal conditions such as inflammatory bowel disease.
(7)Neurodegenerative conditions such as mild cognitive impairment.
(8)Renal conditions such as chronic kidney disease.
(9)Oncologic conditions such as gastrointestinal, breast, gynecological, and head and neck cancers.
(10)Infectious conditions such as human immunodeficiency virus.
(b)A health care provider shall, to the extent possible, match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention and include culturally appropriate foods whenever possible. Consistent with subdivision (ah) of Section 14132, in order to qualify for coverage under Medi-Cal, a patient shall be offered at least three of the interventions described in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 and shall be provided with interventions for a minimum of 12 weeks. Coverage for interventions shall be provided for a longer duration if deemed to be medically necessary. Nutrition supports as described in paragraph (7) of subdivision (a) of Section 14134.1 are encouraged to be included with the interventions offered to the patient, but shall not count toward the minimum intervention requirements set forth by this subdivision and subdivision (ah) of Section 14132. In order to be covered by Medi-Cal, nutrition supports shall be paired with the provision of food through an intervention described in paragraphs (1) through (6) of subdivision (a) of Section 14134.1.
SEC. 5.Section 14134.12 is added to the Welfare and Institutions Code, to read:14134.12.(a)On or before July 1, 2025, the Department of Health Care Services shall establish the Medically Supportive Food and Nutrition Benefit Committee to assist the department in developing official guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition interventions, the ratesetting process, the determination of permitted providers, and continuing education for health care providers and other medically supportive food and nutrition providers. The committee shall include at least one knowledgeable stakeholder to represent each of the seven medically supportive food and nutrition interventions described in Section 14134.1 and also include stakeholders from Medi-Cal consumer advocacy organizations. The committee shall meet quarterly or more often as necessary.
(b)The department shall provide 30 days for comment on any proposed guidance put forth by the Medically Supportive Food and Nutrition Benefit Committee and an additional 30 days for public comment prior to finalizing its official guidance. The department shall issue final guidance on or before July 1, 2026. Upon issuance of the final guidance, medically supportive food and nutrition interventions shall be a covered benefit under the Medi-Cal program consistent with paragraph (3) of subdivision (ah) of Section 14132.
SECTION 1.Section 14132 of the Welfare and Institutions Code is amended to read:14132.The following is the schedule of benefits under this chapter:(a)Outpatient services are covered as follows:Physician, hospital or clinic outpatient, surgical center, respiratory care, optometric, chiropractic, psychology, podiatric, occupational therapy, physical therapy, speech therapy, audiology, acupuncture to the extent federal matching funds are provided for acupuncture, and services of persons rendering treatment by prayer or healing by spiritual means in the practice of any church or religious denomination insofar as these can be encompassed by federal participation under an approved plan, subject to utilization controls.(b)(1)Inpatient hospital services, including, but not limited to, physician and podiatric services, physical therapy, and occupational therapy, are covered subject to utilization controls.(2)For a Medi-Cal fee-for-service beneficiary, emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition. This paragraph does not change the obligation of Medi-Cal managed care plans to provide emergency services and care. For the purposes of this paragraph, emergency services and care and emergency medical condition have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.(c)Nursing facility services, subacute care services, and services provided by any category of intermediate care facility for the developmentally disabled, including podiatry, physician, nurse practitioner services, and prescribed drugs, as described in subdivision (d), are covered subject to utilization controls. Respiratory care, physical therapy, occupational therapy, speech therapy, and audiology services for patients in nursing facilities and any category of intermediate care facility for persons with developmental disabilities are covered subject to utilization controls.(d)(1)Purchase of prescribed drugs is covered subject to the Medi-Cal List of Contract Drugs and utilization controls.(2)Purchase of drugs used to treat erectile dysfunction or any off-label uses of those drugs are covered only to the extent that federal financial participation is available.(3)(A)To the extent required by federal law, the purchase of outpatient prescribed drugs, for which the prescription is executed by a prescriber in written, nonelectronic form on or after April 1, 2008, is covered only when executed on a tamper resistant prescription form. The implementation of this paragraph shall conform to the guidance issued by the federal Centers for Medicare and Medicaid Services, but shall not conflict with state statutes on the characteristics of tamper resistant prescriptions for controlled substances, including Section 11162.1 of the Health and Safety Code. The department shall provide providers and beneficiaries with as much flexibility in implementing these rules as allowed by the federal government. The department shall notify and consult with appropriate stakeholders in implementing, interpreting, or making specific this paragraph.(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instructions without taking regulatory action.(4)(A)(i)For the purposes of this paragraph, nonlegend has the same meaning as defined in subdivision (a) of Section 14105.45.(ii)Nonlegend acetaminophen-containing products, including childrens acetaminophen-containing products, selected by the department are covered benefits.(iii)Nonlegend cough and cold products selected by the department are covered benefits.(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instruction without taking regulatory action.(e)Outpatient dialysis services and home hemodialysis services, including physician services, medical supplies, drugs, and equipment required for dialysis, are covered, subject to utilization controls.(f)Anesthesiologist services when provided as part of an outpatient medical procedure, nurse anesthetist services when rendered in an inpatient or outpatient setting under conditions set forth by the director, outpatient laboratory services, and x-ray services are covered, subject to utilization controls. This subdivision does not require prior authorization for anesthesiologist services provided as part of an outpatient medical procedure or for portable x-ray services in a nursing facility or any category of intermediate care facility for the developmentally disabled.(g)Blood and blood derivatives are covered.(h)(1)Emergency and essential diagnostic and restorative dental services, except for orthodontic, fixed bridgework, and partial dentures that are not necessary for balance of a complete artificial denture, are covered, subject to utilization controls. The utilization controls shall allow emergency and essential diagnostic and restorative dental services and prostheses that are necessary to prevent a significant disability or to replace previously furnished prostheses that are lost or destroyed due to circumstances beyond the beneficiarys control. Notwithstanding the foregoing, the director may by regulation provide for certain fixed artificial dentures necessary for obtaining employment or for medical conditions that preclude the use of removable dental prostheses, and for orthodontic services in cleft palate deformities administered by the departments California Childrens Services program.(2)For persons 21 years of age or older, the services specified in paragraph (1) shall be provided subject to the following conditions:(A)Periodontal treatment is not a benefit.(B)Endodontic therapy is not a benefit except for vital pulpotomy.(C)Laboratory processed crowns are not a benefit.(D)Removable prosthetics shall be a benefit only for patients as a requirement for employment.(E)The director may, by regulation, provide for the provision of fixed artificial dentures that are necessary for medical conditions that preclude the use of removable dental prostheses.(F)Notwithstanding the conditions specified in subparagraphs (A) to (E), inclusive, the department may approve services for persons with special medical disorders subject to utilization review.(3)Paragraph (2) shall become inoperative on July 1, 1995.(i)Medical transportation is covered, subject to utilization controls.(j)Home health care services are covered, subject to utilization controls.(k)(1)Prosthetic and orthotic devices and eyeglasses are covered, subject to utilization controls. Utilization controls shall allow replacement of prosthetic and orthotic devices and eyeglasses necessary because of loss or destruction due to circumstances beyond the beneficiarys control. Frame styles for eyeglasses replaced pursuant to this subdivision shall not change more than once every two years, unless the department so directs.(2)Orthopedic and conventional shoes are covered when provided by a prosthetic and orthotic supplier on the prescription of a physician and when at least one of the shoes will be attached to a prosthesis or brace, subject to utilization controls. Modification of stock conventional or orthopedic shoes when medically indicated is covered, subject to utilization controls. If there is a clearly established medical need that cannot be satisfied by the modification of stock conventional or orthopedic shoes, custom-made orthopedic shoes are covered, subject to utilization controls.(3)Therapeutic shoes and inserts are covered when provided to a beneficiary with a diagnosis of diabetes, subject to utilization controls, to the extent that federal financial participation is available.(l)Hearing aids are covered, subject to utilization controls. Utilization controls shall allow replacement of hearing aids necessary because of loss or destruction due to circumstances beyond the beneficiarys control.(m)Durable medical equipment and medical supplies are covered, subject to utilization controls. The utilization controls shall allow the replacement of durable medical equipment and medical supplies when necessary because of loss or destruction due to circumstances beyond the beneficiarys control. The utilization controls shall allow authorization of durable medical equipment needed to assist a disabled beneficiary in caring for a child for whom the disabled beneficiary is a parent, stepparent, foster parent, or legal guardian, subject to the availability of federal financial participation. The department shall adopt emergency regulations to define and establish criteria for assistive durable medical equipment in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).(n)Family planning services are covered, subject to utilization controls. However, for Medi-Cal managed care plans, utilization controls shall be subject to Section 1367.25 of the Health and Safety Code.(o)Inpatient intensive rehabilitation hospital services, including respiratory rehabilitation services, in a general acute care hospital are covered, subject to utilization controls, when either of the following criteria are met:(1)A patient with a permanent disability or severe impairment requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to develop function beyond the limited amount that would occur in the normal course of recovery.(2)A patient with a chronic or progressive disease requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to maintain the patients present functional level as long as possible.(p)(1)Adult day health care is covered in accordance with Chapter 8.7 (commencing with Section 14520).(2)Commencing 30 days after the effective date of the act that added this paragraph, and notwithstanding the number of days previously approved through a treatment authorization request, adult day health care is covered for a maximum of three days per week.(3)As provided in accordance with paragraph (4), adult day health care is covered for a maximum of five days per week.(4)As of the date that the director makes the declaration described in subdivision (g) of Section 14525.1, paragraph (2) shall become inoperative and paragraph (3) shall become operative.(q)(1)Application of fluoride, or other appropriate fluoride treatment as defined by the department, and other prophylaxis treatment for children 17 years of age and under are covered.(2)All dental hygiene services provided by a registered dental hygienist, registered dental hygienist in extended functions, and registered dental hygienist in alternative practice licensed pursuant to Sections 1753, 1917, 1918, and 1922 of the Business and Professions Code may be covered as long as they are within the scope of Denti-Cal benefits and they are necessary services provided by a registered dental hygienist, registered dental hygienist in extended functions, or registered dental hygienist in alternative practice.(r)(1)Paramedic services performed by a city, county, or special district, or pursuant to a contract with a city, county, or special district, and pursuant to a program established under former Article 3 (commencing with Section 1480) of Chapter 2.5 of Division 2 of the Health and Safety Code by a paramedic certified pursuant to that article, and consisting of defibrillation and those services specified in subdivision (3) of former Section 1482 of the article.(2)A provider enrolled under this subdivision shall satisfy all applicable statutory and regulatory requirements for becoming a Medi-Cal provider.(3)This subdivision shall be implemented only to the extent funding is available under Section 14106.6.(s)(1)In-home medical care services are covered when medically appropriate and subject to utilization controls, for a beneficiary who would otherwise require care for an extended period of time in an acute care hospital at a cost higher than in-home medical care services. The director shall have the authority under this section to contract with organizations qualified to provide in-home medical care services to those persons. These services may be provided to a patient placed in a shared or congregate living arrangement, if a home setting is not medically appropriate or available to the beneficiary.(2)As used in this subdivision, in-home medical care service includes utility bills directly attributable to continuous, 24-hour operation of life-sustaining medical equipment, to the extent that federal financial participation is available.(3)As used in this subdivision, in-home medical care services include, but are not limited to:(A)Level-of-care and cost-of-care evaluations.(B)Expenses, directly attributable to home care activities, for materials.(C)Physician fees for home visits.(D)Expenses directly attributable to home care activities for shelter and modification to shelter.(E)Expenses directly attributable to additional costs of special diets, including tube feeding.(F)Medically related personal services.(G)Home nursing education.(H)Emergency maintenance repair.(I)Home health agency personnel benefits that permit coverage of care during periods when regular personnel are on vacation or using sick leave.(J)All services needed to maintain antiseptic conditions at stoma or shunt sites on the body.(K)Emergency and nonemergency medical transportation.(L)Medical supplies.(M)Medical equipment, including, but not limited to, scales, gurneys, and equipment racks suitable for paralyzed patients.(N)Utility use directly attributable to the requirements of home care activities that are in addition to normal utility use.(O)Special drugs and medications.(P)Home health agency supervision of visiting staff that is medically necessary, but not included in the home health agency rate.(Q)Therapy services.(R)Household appliances and household utensil costs directly attributable to home care activities.(S)Modification of medical equipment for home use.(T)Training and orientation for use of life-support systems, including, but not limited to, support of respiratory functions.(U)Respiratory care practitioner services as defined in Sections 3702 and 3703 of the Business and Professions Code, subject to prescription by a physician and surgeon.(4)A beneficiary receiving in-home medical care services is entitled to the full range of services within the Medi-Cal scope of benefits as defined by this section, subject to medical necessity and applicable utilization control. Services provided pursuant to this subdivision, which are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with a home- and community-based services waiver.(t)Home- and community-based services approved by the United States Department of Health and Human Services are covered to the extent that federal financial participation is available for those services under the state plan or waivers granted in accordance with Section 1315 or 1396n of Title 42 of the United States Code. The director may seek waivers for any or all home- and community-based services approvable under Section 1315 or 1396n of Title 42 of the United States Code. Coverage for those services shall be limited by the terms, conditions, and duration of the federal waivers.(u)Comprehensive perinatal services, as provided through an agreement with a health care provider designated in Section 14134.5 and meeting the standards developed by the department pursuant to Section 14134.5, subject to utilization controls.The department shall seek any federal waivers necessary to implement the provisions of this subdivision. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented. Provisions for which waivers are obtained or for which waivers are not required shall be implemented notwithstanding any inability to obtain federal waivers for the other provisions. No provision of this subdivision shall be implemented unless matching funds from Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code are available.(v)Early and periodic screening, diagnosis, and treatment for any individual under 21 years of age is covered, consistent with the requirements of Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code.(w)Hospice service that is Medicare-certified hospice service is covered, subject to utilization controls. Coverage shall be available only to the extent that no additional net program costs are incurred.(x)When a claim for treatment provided to a beneficiary includes both services that are authorized and reimbursable under this chapter and services that are not reimbursable under this chapter, that portion of the claim for the treatment and services authorized and reimbursable under this chapter shall be payable.(y)Home- and community-based services approved by the United States Department of Health and Human Services for a beneficiary with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex, who requires intermediate care or a higher level of care.Services provided pursuant to a waiver obtained from the Secretary of the United States Department of Health and Human Services pursuant to this subdivision, and that are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with the waiver, and subject to the terms, conditions, and duration of the waiver. These services shall be provided to a beneficiary in accordance with the clients needs as identified in the plan of care, and subject to medical necessity and applicable utilization control.The director may, under this section, contract with organizations qualified to provide, directly or by subcontract, services provided for in this subdivision to an eligible beneficiary. Contracts or agreements entered into pursuant to this division shall not be subject to the Public Contract Code.(z)Respiratory care when provided in organized health care systems as defined in Section 3701 of the Business and Professions Code, and as an in-home medical service as outlined in subdivision (s).(aa)(1)There is hereby established in the department a program to provide comprehensive clinical family planning services to any person who has a family income at or below 200 percent of the federal poverty level, as revised annually, and who is eligible to receive these services pursuant to the waiver identified in paragraph (2). This program shall be known as the Family Planning, Access, Care, and Treatment (Family PACT) Program.(2)The department shall seek a waiver in accordance with Section 1315 of Title 42 of the United States Code, or a state plan amendment adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code, which was added to Section 1396a of Title 42 of the United States Code by Section 2303(a)(2) of the federal Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148), for a program to provide comprehensive clinical family planning services as described in paragraph (8). Under the waiver, the program shall be operated only in accordance with the waiver and the statutes and regulations in paragraph (4) and subject to the terms, conditions, and duration of the waiver. Under the state plan amendment, which shall replace the waiver and shall be known as the Family PACT successor state plan amendment, the program shall be operated only in accordance with this subdivision and the statutes and regulations in paragraph (4). The state shall use the standards and processes imposed by the state on January 1, 2007, including the application of an eligibility discount factor to the extent required by the federal Centers for Medicare and Medicaid Services, for purposes of determining eligibility as permitted under Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the extent that federal financial participation is available, the program shall continue to conduct education, outreach, enrollment, service delivery, and evaluation services as specified under the waiver. The services shall be provided under the program only if the waiver and, when applicable, the successor state plan amendment are approved by the federal Centers for Medicare and Medicaid Services and only to the extent that federal financial participation is available for the services. This section does not prohibit the department from seeking the Family PACT successor state plan amendment during the operation of the waiver.(3)Solely for the purposes of the waiver or Family PACT successor state plan amendment and notwithstanding any other law, the collection and use of an individuals social security number shall be necessary only to the extent required by federal law.(4)Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and 24013, and any regulations adopted under these statutes shall apply to the program provided for under this subdivision. No other law under the Medi-Cal program or the State-Only Family Planning Program shall apply to the program provided for under this subdivision.(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, without taking regulatory action, the provisions of the waiver after its approval by the federal Centers for Medicare and Medicaid Services and the provisions of this section by means of an all-county letter or similar instruction to providers. Thereafter, the department shall adopt regulations to implement this section and the approved waiver in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act adding this subdivision, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.(6)If the Department of Finance determines that the program operated under the authority of the waiver described in paragraph (2) or the Family PACT successor state plan amendment is no longer cost effective, this subdivision shall become inoperative on the first day of the first month following the issuance of a 30-day notification of that determination in writing by the Department of Finance to the chairperson in each house that considers appropriations, the chairpersons of the committees, and the appropriate subcommittees in each house that considers the State Budget, and the Chairperson of the Joint Legislative Budget Committee.(7)If this subdivision ceases to be operative, all persons who have received or are eligible to receive comprehensive clinical family planning services pursuant to the waiver described in paragraph (2) shall receive family planning services under the Medi-Cal program pursuant to subdivision (n) if they are otherwise eligible for Medi-Cal with no share of cost, or shall receive comprehensive clinical family planning services under the program established in Division 24 (commencing with Section 24000) either if they are eligible for Medi-Cal with a share of cost or if they are otherwise eligible under Section 24003.(8)For purposes of this subdivision, comprehensive clinical family planning services means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, natural family planning, abstinence methods, and basic, limited fertility management. Comprehensive clinical family planning services include, but are not limited to, preconception counseling, maternal and fetal health counseling, general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, medical family planning treatment and procedures, including supplies and followup, and informational, counseling, and educational services. Comprehensive clinical family planning services shall not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care that is not incident to the diagnosis of pregnancy. Comprehensive clinical family planning services shall be subject to utilization control and include all of the following:(A)Family planning related services and male and female sterilization. Family planning services for men and women shall include emergency services and services for complications directly related to the contraceptive method, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, and followup, consultation, and referral services, as indicated, which may require treatment authorization requests.(B)All United States Department of Agriculture, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies that are in keeping with current standards of practice and from which the individual may choose.(C)Culturally and linguistically appropriate health education and counseling services, including informed consent, that include all of the following:(i)Psychosocial and medical aspects of contraception.(ii)Sexuality.(iii)Fertility.(iv)Pregnancy.(v)Parenthood.(vi)Infertility.(vii)Reproductive health care.(viii)Preconception and nutrition counseling.(ix)Prevention and treatment of sexually transmitted infection.(x)Use of contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies.(xi)Possible contraceptive consequences and followup.(xii)Interpersonal communication and negotiation of relationships to assist individuals and couples in effective contraceptive method use and planning families.(D)A comprehensive health history, updated at the next periodic visit (between 11 and 24 months after initial examination) that includes a complete obstetrical history, gynecological history, contraceptive history, personal medical history, health risk factors, and family health history, including genetic or hereditary conditions.(E)A complete physical examination on initial and subsequent periodic visits.(F)Services, drugs, devices, and supplies deemed by the federal Centers for Medicare and Medicaid Services to be appropriate for inclusion in the program.(G)(i)Home test kits for sexually transmitted diseases, including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal or Family PACT clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.(ii)For purposes of this subparagraph, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.(iii)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Family PACT provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.(9)In order to maximize the availability of federal financial participation under this subdivision, the director shall have the discretion to implement the Family PACT successor state plan amendment retroactively to July 1, 2010.(ab)(1)Purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products and utilization controls.(2)Purchase of enteral nutrition products is limited to those products to be administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube. A beneficiary under the Early and Periodic Screening, Diagnostic, and Treatment Program shall be exempt from this paragraph.(3)Notwithstanding paragraph (2), the department may deem an enteral nutrition product, not administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube, a benefit for patients with diagnoses, including, but not limited to, malabsorption and inborn errors of metabolism, if the product has been shown to be neither investigational nor experimental when used as part of a therapeutic regimen to prevent serious disability or death.(4)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the amendments to this subdivision made by the act that added this paragraph by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.(5)The amendments made to this subdivision by the act that added this paragraph shall be implemented June 1, 2011, or on the first day of the first calendar month following 60 days after the date the department secures all necessary federal approvals to implement this section, whichever is later.(ac)Diabetic testing supplies are covered when provided by a pharmacy, subject to utilization controls.(ad)(1)Nonmedical transportation is covered, subject to utilization controls and permissible time and distance standards, for a beneficiary to obtain covered Medi-Cal services.(2)(A)(i)Nonmedical transportation includes, at a minimum, round trip transportation for a beneficiary to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance, and mileage reimbursement when conveyance is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers, or train tickets.(ii)Nonmedical transportation does not include the transportation of a sick, injured, invalid, convalescent, infirm, or otherwise incapacitated beneficiary by ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations.(B)Nonmedical transportation shall be provided for a beneficiary who can attest in a manner to be specified by the department that other currently available resources have been reasonably exhausted. For a beneficiary enrolled in a managed care plan, nonmedical transportation shall be provided by the beneficiarys managed care plan. For a Medi-Cal fee-for-service beneficiary, the department shall provide nonmedical transportation when those services are not available to the beneficiary under Sections 14132.44 and 14132.47.(3)Nonmedical transportation shall be provided in a form and manner that is accessible, in terms of physical and geographic accessibility, for the beneficiary and consistent with applicable state and federal disability rights laws.(4)It is the intent of the Legislature in enacting this subdivision to affirm the requirement under Section 431.53 of Title 42 of the Code of Federal Regulations, in which the department is required to provide necessary transportation, including nonmedical transportation, for recipients to and from covered services. This subdivision shall not be interpreted to add a new benefit to the Medi-Cal program.(5)The department shall seek any federal approvals that may be required to implement this subdivision, including, but not limited to, approval of revisions to the existing state plan that the department determines are necessary to implement this subdivision.(6)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained.(7)Prior to the effective date of any necessary federal approvals, nonmedical transportation was not a Medi-Cal managed care benefit with the exception of when provided as an Early and Periodic Screening, Diagnostic, and Treatment service.(8)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing January 1, 2018, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.(9)This subdivision shall not be implemented until July 1, 2017.(ae)(1)No sooner than January 1, 2022, Rapid Whole Genome Sequencing, including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal beneficiary who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit.(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.(af)(1)Home test kits for sexually transmitted diseases that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.(2)For purposes of this subdivision, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.(3)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Medi-Cal provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.(4)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.(ag)(1)Violence prevention services are covered, subject to medical necessity and utilization controls.(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.(4)The department shall post on its internet website the date upon which violence prevention services may be provided and billed pursuant to this subdivision.(5)Violence prevention services means evidence-based, trauma-informed, and culturally responsive preventive services provided to reduce the incidence of violent injury or reinjury, trauma, and related harms and promote trauma recovery, stabilization, and improved health outcomes.(ah)(1)Medically supportive food and nutrition intervention plans, as defined in Section 14134.1, shall be covered when those plans are determined to be medically necessary to a patients medical condition by a health care provider or health care plan pursuant to Section 14134.11.(2)All medically supportive food and nutrition intervention plans shall include at least three of the interventions listed in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 and be provided for a minimum of 12 weeks or longer if it is deemed medically necessary. Nutrition supports, as defined in paragraph (7) of subdivision (a) of Section 14134.1, shall be covered only when paired with the minimum three interventions described in this paragraph. (3)This subdivision shall not be implemented until official guidance is finalized by the Department of Health Care Services in conjunction with the Medically Supportive Food and Nutrition Benefit Committee established pursuant to Section 14134.12.SEC. 2.Section 14134 is added to the Welfare and Institutions Code, to read:14134.The Legislature finds and declares the following:(a)Too many Californians, particularly Californians of color, are living with largely preventable chronic conditions. Adequate food and nutrition are a fundamental part of preventing and treating many health conditions, and can significantly improve a patient's quality of life and health status while also reducing health care costs.(b)California has recognized the critical role of nutrition and its influence on health outcomes and health equity through its inclusion of medically supportive food and nutrition interventions in the California Advancing and Innovating Medi-Cal Act. However, these services are optional, meaning individual health plans must voluntarily opt in to providing them and, additionally, may choose to make them available to only a small subset of their members, leaving many Medi-Cal beneficiaries without access to these critical interventions.(c)Medically supportive food and nutrition interventions have the potential to transform our disease care system to a true health care delivery system. By fully embracing food and nutritional support as a critical and strategic investment in health outcomes and health equity, California can lead the nation in tackling root causes of health disparities and become the healthiest state in the nation.SEC. 3.Section 14134.1 is added to the Welfare and Institutions Code, to read:14134.1.(a)For purposes of this chapter, medically supportive food and nutrition intervention means the following seven interventions that provide nutrient-rich whole food, including any fruit, vegetable, legume, nut, seed, whole grain, low-mercury and high-omega-3 fatty acid seafood, and lean animal protein, used for the prevention, reversal, or treatment of certain health conditions:(1)Medically tailored meals means meals that are tailored to a recipients health conditions by a registered dietitian nutritionist (RDN) and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines and are typically home delivered.(2)Medically supportive meals means meals that follow the federal Dietary Guidelines for Americans, meet general health recommendations, and are home delivered, picked up, or consumed on site.(3)Food pharmacy means medically supportive food paired with additional nutrition supports, typically in a health care setting.(4)Medically tailored groceries means boxes or packages that are tailored to a recipients health conditions by a RDN and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines. Medically tailored groceries are either home delivered or picked up.(5)Medically supportive groceries means food boxes or packages that follow the federal Dietary Guidelines for Americans and meet general health recommendations and are typically home delivered or picked up, but may be procured in retail settings via a financial mechanism, such as vouchers or a restricted spending card.(6)Produce prescription means fruits and vegetables, typically procured in retail settings, such as grocery stores and farmers markets, via a financial mechanism, such as vouchers or a restricted spending card, but may also be produce boxes or packages that are home delivered or picked up.(7)Nutrition supports includes nutrition coaching or counseling, group medical visits, cooking education and tools, and behavioral supports based on a recipients medical conditions, when paired with the interventions described in paragraphs (1) through (6).(b)For purposes of this chapter, medically supportive food and nutrition intervention plan means a plan determined by a Medi-Cal enrollees health care provider or health plan that includes a minimum of three of the interventions described in paragraphs (1) through (6) of subdivision (a) and may also include nutrition supports, as defined in paragraph (7) of subdivision (a).SEC. 4.Section 14134.11 is added to the Welfare and Institutions Code, to read:14134.11.(a)A Medi-Cal enrollee for whom a medically supportive food and nutrition intervention plan is medically necessary, as determined by their health care provider or health plan, shall be eligible to receive coverage for a plan. Medical conditions that would benefit from medically supportive food and nutrition interventions include, but are not limited to, the following:(1)Metabolic conditions such as prediabetes, Type 1 and Type 2 diabetes, obesity, metabolic syndrome, polycystic ovary syndrome, and fatty liver disease.(2)Cardiovascular conditions such as hypertension, congestive heart failure, cardiomyopathy, stroke, coronary artery disease, arrhythmia, and lipid abnormalities.(3)Mental and behavioral health conditions such as depression, anxiety, and eating disorders.(4)High-risk perinatal conditions such as gestational diabetes, preeclampsia, and gestational hypertension.(5)Pulmonary conditions such as asthma, chronic obstructive pulmonary disease, and emphysema.(6)Gastrointestinal conditions such as inflammatory bowel disease.(7)Neurodegenerative conditions such as mild cognitive impairment.(8)Renal conditions such as chronic kidney disease.(9)Oncologic conditions such as gastrointestinal, breast, gynecological, and head and neck cancers.(10)Infectious conditions such as human immunodeficiency virus.(b)A health care provider or health plan shall, to the extent possible, match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention plan and include culturally appropriate foods whenever possible. Health care providers and health plans shall include at least three of the interventions described in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 in a patients medically supportive food and nutrition intervention plan. Nutrition supports as described in paragraph (7) of subdivision (a) of Section 14134.1 are encouraged to be included in a patients plan, but shall not count toward the minimum intervention requirements set forth by this subdivision. All medically supportive food and nutrition intervention plans shall be provided for a minimum of 12 weeks or longer if deemed medically necessary.SEC. 5.Section 14134.12 is added to the Welfare and Institutions Code, to read:14134.12.(a)On or before July 1, 2025, the Department of Health Care Services shall establish the Medically Supportive Food and Nutrition Benefit Committee to assist the department in developing official guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition interventions, the ratesetting process, the determination of permitted providers, and continuing education for health plans, health care providers, and other medically supportive food and nutrition providers. The committee shall include at least one knowledgeable stakeholder to represent each of the seven medically supportive food and nutrition interventions described in Section 14134.1 and also include stakeholders from Medi-Cal consumer advocacy organizations. The committee shall meet quarterly or more often as necessary.(b)The department shall provide 30 days for comment on any proposed guidance and an additional 30 days for public comment prior to finalizing its official guidance. The department shall issue final guidance on or before July 1, 2026.The following is the schedule of benefits under this chapter:
(a)Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center, respiratory care, optometric, chiropractic, psychology, podiatric, occupational therapy, physical therapy, speech therapy, audiology, acupuncture to the extent federal matching funds are provided for acupuncture, and services of persons rendering treatment by prayer or healing by spiritual means in the practice of any church or religious denomination insofar as these can be encompassed by federal participation under an approved plan, subject to utilization controls.
(b)(1)Inpatient hospital services, including, but not limited to, physician and podiatric services, physical therapy, and occupational therapy, are covered subject to utilization controls.
(2)For a Medi-Cal fee-for-service beneficiary, emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition. This paragraph does not change the obligation of Medi-Cal managed care plans to provide emergency services and care. For the purposes of this paragraph, emergency services and care and emergency medical condition have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.
(c)Nursing facility services, subacute care services, and services provided by any category of intermediate care facility for the developmentally disabled, including podiatry, physician, nurse practitioner services, and prescribed drugs, as described in subdivision (d), are covered subject to utilization controls. Respiratory care, physical therapy, occupational therapy, speech therapy, and audiology services for patients in nursing facilities and any category of intermediate care facility for persons with developmental disabilities are covered subject to utilization controls.
(d)(1)Purchase of prescribed drugs is covered subject to the Medi-Cal List of Contract Drugs and utilization controls.
(2)Purchase of drugs used to treat erectile dysfunction or any off-label uses of those drugs are covered only to the extent that federal financial participation is available.
(3)(A)To the extent required by federal law, the purchase of outpatient prescribed drugs, for which the prescription is executed by a prescriber in written, nonelectronic form on or after April 1, 2008, is covered only when executed on a tamper resistant prescription form. The implementation of this paragraph shall conform to the guidance issued by the federal Centers for Medicare and Medicaid Services, but shall not conflict with state statutes on the characteristics of tamper resistant prescriptions for controlled substances, including Section 11162.1 of the Health and Safety Code. The department shall provide providers and beneficiaries with as much flexibility in implementing these rules as allowed by the federal government. The department shall notify and consult with appropriate stakeholders in implementing, interpreting, or making specific this paragraph.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instructions without taking regulatory action.
(4)(A)(i)For the purposes of this paragraph, nonlegend has the same meaning as defined in subdivision (a) of Section 14105.45.
(ii)Nonlegend acetaminophen-containing products, including childrens acetaminophen-containing products, selected by the department are covered benefits.
(iii)Nonlegend cough and cold products selected by the department are covered benefits.
(B)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may take the actions specified in subparagraph (A) by means of a provider bulletin or notice, policy letter, or other similar instruction without taking regulatory action.
(e)Outpatient dialysis services and home hemodialysis services, including physician services, medical supplies, drugs, and equipment required for dialysis, are covered, subject to utilization controls.
(f)Anesthesiologist services when provided as part of an outpatient medical procedure, nurse anesthetist services when rendered in an inpatient or outpatient setting under conditions set forth by the director, outpatient laboratory services, and x-ray services are covered, subject to utilization controls. This subdivision does not require prior authorization for anesthesiologist services provided as part of an outpatient medical procedure or for portable x-ray services in a nursing facility or any category of intermediate care facility for the developmentally disabled.
(g)Blood and blood derivatives are covered.
(h)(1)Emergency and essential diagnostic and restorative dental services, except for orthodontic, fixed bridgework, and partial dentures that are not necessary for balance of a complete artificial denture, are covered, subject to utilization controls. The utilization controls shall allow emergency and essential diagnostic and restorative dental services and prostheses that are necessary to prevent a significant disability or to replace previously furnished prostheses that are lost or destroyed due to circumstances beyond the beneficiarys control. Notwithstanding the foregoing, the director may by regulation provide for certain fixed artificial dentures necessary for obtaining employment or for medical conditions that preclude the use of removable dental prostheses, and for orthodontic services in cleft palate deformities administered by the departments California Childrens Services program.
(2)For persons 21 years of age or older, the services specified in paragraph (1) shall be provided subject to the following conditions:
(A)Periodontal treatment is not a benefit.
(B)Endodontic therapy is not a benefit except for vital pulpotomy.
(C)Laboratory processed crowns are not a benefit.
(D)Removable prosthetics shall be a benefit only for patients as a requirement for employment.
(E)The director may, by regulation, provide for the provision of fixed artificial dentures that are necessary for medical conditions that preclude the use of removable dental prostheses.
(F)Notwithstanding the conditions specified in subparagraphs (A) to (E), inclusive, the department may approve services for persons with special medical disorders subject to utilization review.
(3)Paragraph (2) shall become inoperative on July 1, 1995.
(i)Medical transportation is covered, subject to utilization controls.
(j)Home health care services are covered, subject to utilization controls.
(k)(1)Prosthetic and orthotic devices and eyeglasses are covered, subject to utilization controls. Utilization controls shall allow replacement of prosthetic and orthotic devices and eyeglasses necessary because of loss or destruction due to circumstances beyond the beneficiarys control. Frame styles for eyeglasses replaced pursuant to this subdivision shall not change more than once every two years, unless the department so directs.
(2)Orthopedic and conventional shoes are covered when provided by a prosthetic and orthotic supplier on the prescription of a physician and when at least one of the shoes will be attached to a prosthesis or brace, subject to utilization controls. Modification of stock conventional or orthopedic shoes when medically indicated is covered, subject to utilization controls. If there is a clearly established medical need that cannot be satisfied by the modification of stock conventional or orthopedic shoes, custom-made orthopedic shoes are covered, subject to utilization controls.
(3)Therapeutic shoes and inserts are covered when provided to a beneficiary with a diagnosis of diabetes, subject to utilization controls, to the extent that federal financial participation is available.
(l)Hearing aids are covered, subject to utilization controls. Utilization controls shall allow replacement of hearing aids necessary because of loss or destruction due to circumstances beyond the beneficiarys control.
(m)Durable medical equipment and medical supplies are covered, subject to utilization controls. The utilization controls shall allow the replacement of durable medical equipment and medical supplies when necessary because of loss or destruction due to circumstances beyond the beneficiarys control. The utilization controls shall allow authorization of durable medical equipment needed to assist a disabled beneficiary in caring for a child for whom the disabled beneficiary is a parent, stepparent, foster parent, or legal guardian, subject to the availability of federal financial participation. The department shall adopt emergency regulations to define and establish criteria for assistive durable medical equipment in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
(n)Family planning services are covered, subject to utilization controls. However, for Medi-Cal managed care plans, utilization controls shall be subject to Section 1367.25 of the Health and Safety Code.
(o)Inpatient intensive rehabilitation hospital services, including respiratory rehabilitation services, in a general acute care hospital are covered, subject to utilization controls, when either of the following criteria are met:
(1)A patient with a permanent disability or severe impairment requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to develop function beyond the limited amount that would occur in the normal course of recovery.
(2)A patient with a chronic or progressive disease requires an inpatient intensive rehabilitation hospital program as described in Section 14064 to maintain the patients present functional level as long as possible.
(p)(1)Adult day health care is covered in accordance with Chapter 8.7 (commencing with Section 14520).
(2)Commencing 30 days after the effective date of the act that added this paragraph, and notwithstanding the number of days previously approved through a treatment authorization request, adult day health care is covered for a maximum of three days per week.
(3)As provided in accordance with paragraph (4), adult day health care is covered for a maximum of five days per week.
(4)As of the date that the director makes the declaration described in subdivision (g) of Section 14525.1, paragraph (2) shall become inoperative and paragraph (3) shall become operative.
(q)(1)Application of fluoride, or other appropriate fluoride treatment as defined by the department, and other prophylaxis treatment for children 17 years of age and under are covered.
(2)All dental hygiene services provided by a registered dental hygienist, registered dental hygienist in extended functions, and registered dental hygienist in alternative practice licensed pursuant to Sections 1753, 1917, 1918, and 1922 of the Business and Professions Code may be covered as long as they are within the scope of Denti-Cal benefits and they are necessary services provided by a registered dental hygienist, registered dental hygienist in extended functions, or registered dental hygienist in alternative practice.
(r)(1)Paramedic services performed by a city, county, or special district, or pursuant to a contract with a city, county, or special district, and pursuant to a program established under former Article 3 (commencing with Section 1480) of Chapter 2.5 of Division 2 of the Health and Safety Code by a paramedic certified pursuant to that article, and consisting of defibrillation and those services specified in subdivision (3) of former Section 1482 of the article.
(2)A provider enrolled under this subdivision shall satisfy all applicable statutory and regulatory requirements for becoming a Medi-Cal provider.
(3)This subdivision shall be implemented only to the extent funding is available under Section 14106.6.
(s)(1)In-home medical care services are covered when medically appropriate and subject to utilization controls, for a beneficiary who would otherwise require care for an extended period of time in an acute care hospital at a cost higher than in-home medical care services. The director shall have the authority under this section to contract with organizations qualified to provide in-home medical care services to those persons. These services may be provided to a patient placed in a shared or congregate living arrangement, if a home setting is not medically appropriate or available to the beneficiary.
(2)As used in this subdivision, in-home medical care service includes utility bills directly attributable to continuous, 24-hour operation of life-sustaining medical equipment, to the extent that federal financial participation is available.
(3)As used in this subdivision, in-home medical care services include, but are not limited to:
(A)Level-of-care and cost-of-care evaluations.
(B)Expenses, directly attributable to home care activities, for materials.
(C)Physician fees for home visits.
(D)Expenses directly attributable to home care activities for shelter and modification to shelter.
(E)Expenses directly attributable to additional costs of special diets, including tube feeding.
(F)Medically related personal services.
(G)Home nursing education.
(H)Emergency maintenance repair.
(I)Home health agency personnel benefits that permit coverage of care during periods when regular personnel are on vacation or using sick leave.
(J)All services needed to maintain antiseptic conditions at stoma or shunt sites on the body.
(K)Emergency and nonemergency medical transportation.
(L)Medical supplies.
(M)Medical equipment, including, but not limited to, scales, gurneys, and equipment racks suitable for paralyzed patients.
(N)Utility use directly attributable to the requirements of home care activities that are in addition to normal utility use.
(O)Special drugs and medications.
(P)Home health agency supervision of visiting staff that is medically necessary, but not included in the home health agency rate.
(Q)Therapy services.
(R)Household appliances and household utensil costs directly attributable to home care activities.
(S)Modification of medical equipment for home use.
(T)Training and orientation for use of life-support systems, including, but not limited to, support of respiratory functions.
(U)Respiratory care practitioner services as defined in Sections 3702 and 3703 of the Business and Professions Code, subject to prescription by a physician and surgeon.
(4)A beneficiary receiving in-home medical care services is entitled to the full range of services within the Medi-Cal scope of benefits as defined by this section, subject to medical necessity and applicable utilization control. Services provided pursuant to this subdivision, which are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with a home- and community-based services waiver.
(t)Home- and community-based services approved by the United States Department of Health and Human Services are covered to the extent that federal financial participation is available for those services under the state plan or waivers granted in accordance with Section 1315 or 1396n of Title 42 of the United States Code. The director may seek waivers for any or all home- and community-based services approvable under Section 1315 or 1396n of Title 42 of the United States Code. Coverage for those services shall be limited by the terms, conditions, and duration of the federal waivers.
(u)Comprehensive perinatal services, as provided through an agreement with a health care provider designated in Section 14134.5 and meeting the standards developed by the department pursuant to Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to implement the provisions of this subdivision. The provisions for which appropriate federal waivers cannot be obtained shall not be implemented. Provisions for which waivers are obtained or for which waivers are not required shall be implemented notwithstanding any inability to obtain federal waivers for the other provisions. No provision of this subdivision shall be implemented unless matching funds from Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code are available.
(v)Early and periodic screening, diagnosis, and treatment for any individual under 21 years of age is covered, consistent with the requirements of Subchapter XIX (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code.
(w)Hospice service that is Medicare-certified hospice service is covered, subject to utilization controls. Coverage shall be available only to the extent that no additional net program costs are incurred.
(x)When a claim for treatment provided to a beneficiary includes both services that are authorized and reimbursable under this chapter and services that are not reimbursable under this chapter, that portion of the claim for the treatment and services authorized and reimbursable under this chapter shall be payable.
(y)Home- and community-based services approved by the United States Department of Health and Human Services for a beneficiary with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex, who requires intermediate care or a higher level of care.
Services provided pursuant to a waiver obtained from the Secretary of the United States Department of Health and Human Services pursuant to this subdivision, and that are not otherwise included in the Medi-Cal schedule of benefits, shall be available only to the extent that federal financial participation for these services is available in accordance with the waiver, and subject to the terms, conditions, and duration of the waiver. These services shall be provided to a beneficiary in accordance with the clients needs as identified in the plan of care, and subject to medical necessity and applicable utilization control.
The director may, under this section, contract with organizations qualified to provide, directly or by subcontract, services provided for in this subdivision to an eligible beneficiary. Contracts or agreements entered into pursuant to this division shall not be subject to the Public Contract Code.
(z)Respiratory care when provided in organized health care systems as defined in Section 3701 of the Business and Professions Code, and as an in-home medical service as outlined in subdivision (s).
(aa)(1)There is hereby established in the department a program to provide comprehensive clinical family planning services to any person who has a family income at or below 200 percent of the federal poverty level, as revised annually, and who is eligible to receive these services pursuant to the waiver identified in paragraph (2). This program shall be known as the Family Planning, Access, Care, and Treatment (Family PACT) Program.
(2)The department shall seek a waiver in accordance with Section 1315 of Title 42 of the United States Code, or a state plan amendment adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code, which was added to Section 1396a of Title 42 of the United States Code by Section 2303(a)(2) of the federal Patient Protection and Affordable Care Act (PPACA) (Public Law 111-148), for a program to provide comprehensive clinical family planning services as described in paragraph (8). Under the waiver, the program shall be operated only in accordance with the waiver and the statutes and regulations in paragraph (4) and subject to the terms, conditions, and duration of the waiver. Under the state plan amendment, which shall replace the waiver and shall be known as the Family PACT successor state plan amendment, the program shall be operated only in accordance with this subdivision and the statutes and regulations in paragraph (4). The state shall use the standards and processes imposed by the state on January 1, 2007, including the application of an eligibility discount factor to the extent required by the federal Centers for Medicare and Medicaid Services, for purposes of determining eligibility as permitted under Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the extent that federal financial participation is available, the program shall continue to conduct education, outreach, enrollment, service delivery, and evaluation services as specified under the waiver. The services shall be provided under the program only if the waiver and, when applicable, the successor state plan amendment are approved by the federal Centers for Medicare and Medicaid Services and only to the extent that federal financial participation is available for the services. This section does not prohibit the department from seeking the Family PACT successor state plan amendment during the operation of the waiver.
(3)Solely for the purposes of the waiver or Family PACT successor state plan amendment and notwithstanding any other law, the collection and use of an individuals social security number shall be necessary only to the extent required by federal law.
(4)Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and 24013, and any regulations adopted under these statutes shall apply to the program provided for under this subdivision. No other law under the Medi-Cal program or the State-Only Family Planning Program shall apply to the program provided for under this subdivision.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, without taking regulatory action, the provisions of the waiver after its approval by the federal Centers for Medicare and Medicaid Services and the provisions of this section by means of an all-county letter or similar instruction to providers. Thereafter, the department shall adopt regulations to implement this section and the approved waiver in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of the act adding this subdivision, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.
(6)If the Department of Finance determines that the program operated under the authority of the waiver described in paragraph (2) or the Family PACT successor state plan amendment is no longer cost effective, this subdivision shall become inoperative on the first day of the first month following the issuance of a 30-day notification of that determination in writing by the Department of Finance to the chairperson in each house that considers appropriations, the chairpersons of the committees, and the appropriate subcommittees in each house that considers the State Budget, and the Chairperson of the Joint Legislative Budget Committee.
(7)If this subdivision ceases to be operative, all persons who have received or are eligible to receive comprehensive clinical family planning services pursuant to the waiver described in paragraph (2) shall receive family planning services under the Medi-Cal program pursuant to subdivision (n) if they are otherwise eligible for Medi-Cal with no share of cost, or shall receive comprehensive clinical family planning services under the program established in Division 24 (commencing with Section 24000) either if they are eligible for Medi-Cal with a share of cost or if they are otherwise eligible under Section 24003.
(8)For purposes of this subdivision, comprehensive clinical family planning services means the process of establishing objectives for the number and spacing of children, and selecting the means by which those objectives may be achieved. These means include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, natural family planning, abstinence methods, and basic, limited fertility management. Comprehensive clinical family planning services include, but are not limited to, preconception counseling, maternal and fetal health counseling, general reproductive health care, including diagnosis and treatment of infections and conditions, including cancer, that threaten reproductive capability, medical family planning treatment and procedures, including supplies and followup, and informational, counseling, and educational services. Comprehensive clinical family planning services shall not include abortion, pregnancy testing solely for the purposes of referral for abortion or services ancillary to abortions, or pregnancy care that is not incident to the diagnosis of pregnancy. Comprehensive clinical family planning services shall be subject to utilization control and include all of the following:
(A)Family planning related services and male and female sterilization. Family planning services for men and women shall include emergency services and services for complications directly related to the contraceptive method, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies, and followup, consultation, and referral services, as indicated, which may require treatment authorization requests.
(B)All United States Department of Agriculture, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies that are in keeping with current standards of practice and from which the individual may choose.
(C)Culturally and linguistically appropriate health education and counseling services, including informed consent, that include all of the following:
(i)Psychosocial and medical aspects of contraception.
(ii)Sexuality.
(iii)Fertility.
(iv)Pregnancy.
(v)Parenthood.
(vi)Infertility.
(vii)Reproductive health care.
(viii)Preconception and nutrition counseling.
(ix)Prevention and treatment of sexually transmitted infection.
(x)Use of contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies.
(xi)Possible contraceptive consequences and followup.
(xii)Interpersonal communication and negotiation of relationships to assist individuals and couples in effective contraceptive method use and planning families.
(D)A comprehensive health history, updated at the next periodic visit (between 11 and 24 months after initial examination) that includes a complete obstetrical history, gynecological history, contraceptive history, personal medical history, health risk factors, and family health history, including genetic or hereditary conditions.
(E)A complete physical examination on initial and subsequent periodic visits.
(F)Services, drugs, devices, and supplies deemed by the federal Centers for Medicare and Medicaid Services to be appropriate for inclusion in the program.
(G)(i)Home test kits for sexually transmitted diseases, including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal or Family PACT clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(ii)For purposes of this subparagraph, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(iii)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Family PACT provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(9)In order to maximize the availability of federal financial participation under this subdivision, the director shall have the discretion to implement the Family PACT successor state plan amendment retroactively to July 1, 2010.
(ab)(1)Purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products and utilization controls.
(2)Purchase of enteral nutrition products is limited to those products to be administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube. A beneficiary under the Early and Periodic Screening, Diagnostic, and Treatment Program shall be exempt from this paragraph.
(3)Notwithstanding paragraph (2), the department may deem an enteral nutrition product, not administered through a feeding tube, including, but not limited to, a gastric, nasogastric, or jejunostomy tube, a benefit for patients with diagnoses, including, but not limited to, malabsorption and inborn errors of metabolism, if the product has been shown to be neither investigational nor experimental when used as part of a therapeutic regimen to prevent serious disability or death.
(4)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement the amendments to this subdivision made by the act that added this paragraph by means of all-county letters, provider bulletins, or similar instructions, without taking regulatory action.
(5)The amendments made to this subdivision by the act that added this paragraph shall be implemented June 1, 2011, or on the first day of the first calendar month following 60 days after the date the department secures all necessary federal approvals to implement this section, whichever is later.
(ac)Diabetic testing supplies are covered when provided by a pharmacy, subject to utilization controls.
(ad)(1)Nonmedical transportation is covered, subject to utilization controls and permissible time and distance standards, for a beneficiary to obtain covered Medi-Cal services.
(2)(A)(i)Nonmedical transportation includes, at a minimum, round trip transportation for a beneficiary to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance, and mileage reimbursement when conveyance is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers, or train tickets.
(ii)Nonmedical transportation does not include the transportation of a sick, injured, invalid, convalescent, infirm, or otherwise incapacitated beneficiary by ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations.
(B)Nonmedical transportation shall be provided for a beneficiary who can attest in a manner to be specified by the department that other currently available resources have been reasonably exhausted. For a beneficiary enrolled in a managed care plan, nonmedical transportation shall be provided by the beneficiarys managed care plan. For a Medi-Cal fee-for-service beneficiary, the department shall provide nonmedical transportation when those services are not available to the beneficiary under Sections 14132.44 and 14132.47.
(3)Nonmedical transportation shall be provided in a form and manner that is accessible, in terms of physical and geographic accessibility, for the beneficiary and consistent with applicable state and federal disability rights laws.
(4)It is the intent of the Legislature in enacting this subdivision to affirm the requirement under Section 431.53 of Title 42 of the Code of Federal Regulations, in which the department is required to provide necessary transportation, including nonmedical transportation, for recipients to and from covered services. This subdivision shall not be interpreted to add a new benefit to the Medi-Cal program.
(5)The department shall seek any federal approvals that may be required to implement this subdivision, including, but not limited to, approval of revisions to the existing state plan that the department determines are necessary to implement this subdivision.
(6)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained.
(7)Prior to the effective date of any necessary federal approvals, nonmedical transportation was not a Medi-Cal managed care benefit with the exception of when provided as an Early and Periodic Screening, Diagnostic, and Treatment service.
(8)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing January 1, 2018, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
(9)This subdivision shall not be implemented until July 1, 2017.
(ae)(1)No sooner than January 1, 2022, Rapid Whole Genome Sequencing, including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal beneficiary who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(af)(1)Home test kits for sexually transmitted diseases that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
(2)For purposes of this subdivision, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
(3)Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Medi-Cal provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
(4)This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
(ag)(1)Violence prevention services are covered, subject to medical necessity and utilization controls.
(2)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
(3)This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
(4)The department shall post on its internet website the date upon which violence prevention services may be provided and billed pursuant to this subdivision.
(5)Violence prevention services means evidence-based, trauma-informed, and culturally responsive preventive services provided to reduce the incidence of violent injury or reinjury, trauma, and related harms and promote trauma recovery, stabilization, and improved health outcomes.
(ah)(1)Medically supportive food and nutrition intervention plans, as defined in Section 14134.1, shall be covered when those plans are determined to be medically necessary to a patients medical condition by a health care provider or health care plan pursuant to Section 14134.11.
(2)All medically supportive food and nutrition intervention plans shall include at least three of the interventions listed in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 and be provided for a minimum of 12 weeks or longer if it is deemed medically necessary. Nutrition supports, as defined in paragraph (7) of subdivision (a) of Section 14134.1, shall be covered only when paired with the minimum three interventions described in this paragraph.
(3)This subdivision shall not be implemented until official guidance is finalized by the Department of Health Care Services in conjunction with the Medically Supportive Food and Nutrition Benefit Committee established pursuant to Section 14134.12.
SEC. 2.Section 14134 is added to the Welfare and Institutions Code, to read:14134.The Legislature finds and declares the following:
(a)Too many Californians, particularly Californians of color, are living with largely preventable chronic conditions. Adequate food and nutrition are a fundamental part of preventing and treating many health conditions, and can significantly improve a patient's quality of life and health status while also reducing health care costs.
(b)California has recognized the critical role of nutrition and its influence on health outcomes and health equity through its inclusion of medically supportive food and nutrition interventions in the California Advancing and Innovating Medi-Cal Act. However, these services are optional, meaning individual health plans must voluntarily opt in to providing them and, additionally, may choose to make them available to only a small subset of their members, leaving many Medi-Cal beneficiaries without access to these critical interventions.
(c)Medically supportive food and nutrition interventions have the potential to transform our disease care system to a true health care delivery system. By fully embracing food and nutritional support as a critical and strategic investment in health outcomes and health equity, California can lead the nation in tackling root causes of health disparities and become the healthiest state in the nation.
SEC. 3.Section 14134.1 is added to the Welfare and Institutions Code, to read:14134.1.(a)For purposes of this chapter, medically supportive food and nutrition intervention means the following seven interventions that provide nutrient-rich whole food, including any fruit, vegetable, legume, nut, seed, whole grain, low-mercury and high-omega-3 fatty acid seafood, and lean animal protein, used for the prevention, reversal, or treatment of certain health conditions:
(1)Medically tailored meals means meals that are tailored to a recipients health conditions by a registered dietitian nutritionist (RDN) and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines and are typically home delivered.
(2)Medically supportive meals means meals that follow the federal Dietary Guidelines for Americans, meet general health recommendations, and are home delivered, picked up, or consumed on site.
(3)Food pharmacy means medically supportive food paired with additional nutrition supports, typically in a health care setting.
(4)Medically tailored groceries means boxes or packages that are tailored to a recipients health conditions by a RDN and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines. Medically tailored groceries are either home delivered or picked up.
(5)Medically supportive groceries means food boxes or packages that follow the federal Dietary Guidelines for Americans and meet general health recommendations and are typically home delivered or picked up, but may be procured in retail settings via a financial mechanism, such as vouchers or a restricted spending card.
(6)Produce prescription means fruits and vegetables, typically procured in retail settings, such as grocery stores and farmers markets, via a financial mechanism, such as vouchers or a restricted spending card, but may also be produce boxes or packages that are home delivered or picked up.
(7)Nutrition supports includes nutrition coaching or counseling, group medical visits, cooking education and tools, and behavioral supports based on a recipients medical conditions, when paired with the interventions described in paragraphs (1) through (6).
(b)For purposes of this chapter, medically supportive food and nutrition intervention plan means a plan determined by a Medi-Cal enrollees health care provider or health plan that includes a minimum of three of the interventions described in paragraphs (1) through (6) of subdivision (a) and may also include nutrition supports, as defined in paragraph (7) of subdivision (a).
SEC. 4.Section 14134.11 is added to the Welfare and Institutions Code, to read:14134.11.(a)A Medi-Cal enrollee for whom a medically supportive food and nutrition intervention plan is medically necessary, as determined by their health care provider or health plan, shall be eligible to receive coverage for a plan. Medical conditions that would benefit from medically supportive food and nutrition interventions include, but are not limited to, the following:
(1)Metabolic conditions such as prediabetes, Type 1 and Type 2 diabetes, obesity, metabolic syndrome, polycystic ovary syndrome, and fatty liver disease.
(2)Cardiovascular conditions such as hypertension, congestive heart failure, cardiomyopathy, stroke, coronary artery disease, arrhythmia, and lipid abnormalities.
(3)Mental and behavioral health conditions such as depression, anxiety, and eating disorders.
(4)High-risk perinatal conditions such as gestational diabetes, preeclampsia, and gestational hypertension.
(5)Pulmonary conditions such as asthma, chronic obstructive pulmonary disease, and emphysema.
(6)Gastrointestinal conditions such as inflammatory bowel disease.
(7)Neurodegenerative conditions such as mild cognitive impairment.
(8)Renal conditions such as chronic kidney disease.
(9)Oncologic conditions such as gastrointestinal, breast, gynecological, and head and neck cancers.
(10)Infectious conditions such as human immunodeficiency virus.
(b)A health care provider or health plan shall, to the extent possible, match the acuity of a patients condition to the intensity and duration of the medically supportive food and nutrition intervention plan and include culturally appropriate foods whenever possible. Health care providers and health plans shall include at least three of the interventions described in paragraphs (1) through (6) of subdivision (a) of Section 14134.1 in a patients medically supportive food and nutrition intervention plan. Nutrition supports as described in paragraph (7) of subdivision (a) of Section 14134.1 are encouraged to be included in a patients plan, but shall not count toward the minimum intervention requirements set forth by this subdivision. All medically supportive food and nutrition intervention plans shall be provided for a minimum of 12 weeks or longer if deemed medically necessary.
SEC. 5.Section 14134.12 is added to the Welfare and Institutions Code, to read:14134.12.(a)On or before July 1, 2025, the Department of Health Care Services shall establish the Medically Supportive Food and Nutrition Benefit Committee to assist the department in developing official guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition interventions, the ratesetting process, the determination of permitted providers, and continuing education for health plans, health care providers, and other medically supportive food and nutrition providers. The committee shall include at least one knowledgeable stakeholder to represent each of the seven medically supportive food and nutrition interventions described in Section 14134.1 and also include stakeholders from Medi-Cal consumer advocacy organizations. The committee shall meet quarterly or more often as necessary.
(b)The department shall provide 30 days for comment on any proposed guidance and an additional 30 days for public comment prior to finalizing its official guidance. The department shall issue final guidance on or before July 1, 2026.
SECTION 1.It is the intent of the Legislature to enact legislation that would, on and after July 1, 2025, make medically supportive food and nutrition services a covered benefit for all eligible beneficiaries under the Medi-Cal program, as an expansion to more limited eligibility or services under existing law.It is the intent of the Legislature to enact legislation that would, on and after July 1, 2025, make medically supportive food and nutrition services a covered benefit for all eligible beneficiaries under the Medi-Cal program, as an expansion to more limited eligibility or services under existing law.
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Date
|
Status
|
|---|---|
| Feb 1, 2024 | From committee: Filed with the Chief Clerk pursuant to Joint Rule 56. |
| Jan 31, 2024 | Died pursuant to Art. IV, Sec. 10(c) of the Constitution. |
| May 18, 2023 | In committee: Held under submission. |
| May 18, 2023 | Joint Rule 62(a), file notice suspended. (Page 1580.) |
| May 17, 2023 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| May 1, 2023 | Re-referred to Com. on APPR. |
| Apr 27, 2023 | Read second time and amended. |
| Apr 26, 2023 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 12. Noes 0.) (April 25). |
| Apr 18, 2023 | Re-referred to Com. on HEALTH. |
| Apr 17, 2023 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 27, 2023 | Re-referred to Com. on HEALTH. |
| Mar 23, 2023 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 23, 2023 | Referred to Com. on HEALTH. |
| Feb 18, 2023 | From printer. May be heard in committee March 20. |
| Feb 17, 2023 | Read first time. To print. |
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Date
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Description
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Location
|
Votes
|
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|---|---|---|---|---|
| Apr 25, 2023 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| 18 Reasons | ** Support | |
| Agricultural Institute of Marin | ** Support | |
| Alameda County Community Food Bank | ** Support | |
| Alameda County Deputy Sheriffs' Activities League Dba Dig Deep Farms | ** Support | |
| Alameda Health Consortium | ** Support | |
| Alameda Health System | ** Support | |
| Alchemist CDC | ** Support | |
| American Heart Association | ** Support | |
| asian pacific islander forward movement | ** Support | |
| Axis Community Health | ** Support | |
| black women for wellness | ** Support | |
| Blue Zones Project Monterey County | ** Support | |
| Blue Zones Project Tuolumne County | ** Support | |
| Blue Zones Project Upper Napa Valley | ** Support | |
| Booker T. Washington Community Service Center | ** Support | |
| California Academy Of Family Physicians | * Support | Apr 25, 2023 |
| California Academy of Nutrition and Dietetics | ** Support | |
| California Conference of Local Health Department Nutritionists | ** Support | |
| California Food and Farming Network | ** Support | |
| California Fresh Fruit Association | * Support | Apr 25, 2023 |
| California Primary Care Association | * Support | Apr 25, 2023 |
| Celiac Disease Foundation | ** Support | |
| Center For Food Safety | ** Support | |
| Ceres Community Project | ** Support | |
| Conard House | ** Support | |
| Esperanza Community Farms | ** Support | |
| Everyone's Harvest | ** Support | |
| Extrafood | ** Support | |
| Farm Discovery At Live Earth | ** Support | |
| Farming Hope | ** Support | |
| Food As Medicine Collaborative | ** Support | |
| Food as Medicine Collaborative | ** Support | Apr 25, 2023 |
| Food as Medicine Collaborative | * Support | Apr 25, 2023 |
| Food As Medicine Global | ** Support | |
| Food Bank of Contra Costa and Solano | ** Support | |
| Food for People, the Food Bank for Humboldt County | ** Support | |
| Food Forward | ** Support | |
| Foodwise | ** Support | |
| Fresh Approach | ** Support | |
| Glide | ** Support | |
| Go for Health! Santa Cruz County | ** Support | |
| Hayward Wellness Center - Alameda Health System | ** Support | |
| Health Care Without Harm | ** Support | |
| Homeless Prenatal Program | ** Support | |
| Institute for Natural Medicine | ** Support | |
| La Clinica de La Raza, Inc. | ** Support | |
| Leah's Pantry, INC. | ** Support | |
| Life Lab Science Program | ** Support | |
| Los Angeles Food Policy Council | ** Support | |
| Los Angeles Regional Food Bank | ** Support | |
| Marin Food Policy Council | ** Support | |
| Meals on Wheels of West Los Angeles INC | ** Support | |
| Meals on Wheels Orange County | ** Support | |
| Merced County Food Bank | ** Support | |
| National Produce Prescription Collaborative | ** Support | |
| Native American Health Center | ** Support | |
| North Coast Growers Association | ** Support | |
| Nutrition and Fitness Collaborative of the Central Coast | ** Support | |
| One Community Health | ** Support | |
| Open Door Community Health Centers | ** Support | |
| Open Heart Kitchen | ** Support | |
| Open Source Wellness | ** Support | |
| Pesticide Action Network | ** Support | |
| Project Open Hand | ** Support | |
| Project Openhand | ** Support | Apr 25, 2023 |
| Public Health Advocates | ** Support | |
| Public Health Institute | ** Support | Apr 25, 2023 |
| Purfoods, LLC A/k/a Mom's Meals | ** Support | |
| Reach Out | ** Support | |
| Regeneracion Pajaro Valley Climate Action | ** Support | |
| Roots of Change | * Support | Apr 25, 2023 |
| Sacramento Food Policy Council | ** Support | |
| san francisco marin medical society | ** Support | |
| San Francisco-Marin Food Bank | ** Support | |
| Santa Barbara County Food Action Network | ** Support | |
| Second Harvest Food Bank Santa Cruz County | ** Support | |
| Shape Up San Francisco Coalition | ** Support | |
| Slow Food Policy in California | ** Support | |
| Sonoma-Mendocino Lake Medical Association | ** Support | |
| SPUR | * Support | Apr 25, 2023 |
| Thai Community Development Center | ** Support | |
| The Praxis Project | ** Support | |
| The Western Center on Law and Poverty | * Support | Apr 25, 2023 |
| Tiburcio Vasquez Health Center, Inc. | ** Support | |
| UCSF | * Support | Apr 25, 2023 |
| Wholesome Wave | ** Support |
Date of Hearing: May 17, 2023
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Chris Holden, Chair
ABPCA Bill Id:AB 1644
Author:(Bonta) – As Amended Ver:April 27, 2023
Policy Committee: | Health | Vote: | 12 - 0 |
|
| ||
|
|
Urgency: No State Mandated Local Program: No Reimbursable: No
SUMMARY:
This bill requires the Medi-Cal program to cover medically supportive food and nutrition, for at least 12 weeks, when determined to be medically necessary by a health care provider or health plan, as specified. This bill also establishes a medically supportive food and nutrition benefit advisory workgroup (workgroup) to advise the Department of Health Care Services (DHCS) in developing final guidance related to developing medically supportive food and nutrition interventions, as specified.
FISCAL EFFECT:
Costs of an unknown amount, likely in the tens of millions of dollars or more, annually, to DHCS (General Fund, possibly federal funds if approved by the federal government).
COMMENTS:
- Purpose. According to the author:
Too many Californians, particularly Californians of color, are living with largely preventable chronic conditions. Adequate food and nutrition are a fundamental part of preventing and treating chronic conditions, and can significantly improve a patient's quality of life and health status while also reducing healthcare costs. Across California, numerous organizations have piloted these interventions, also commonly known as “food as medicine” programs. Evaluations from those programs, and others nationally, show that they improve health and reduce avoidable healthcare spending. AB 1644 expands medically supportive food and nutrition interventions as a covered benefit under Medi-Cal to all Medi-Cal recipients will improve the lives of the beneficiaries.
- Background.
CalAIM. CalAIM is a collection of major initiatives spearheaded by DHCS that align with the Administration’s program improvement goals, including addressing social drivers of health, reducing program complexity and increasing flexibility, and modernizing payment structures to promote better outcomes. The majority of CalAIM proposals were put forward in 2021 through two comprehensive applications to the federal government for a “Section 1115 demonstration” and “Section 1915(b) waiver” Act that authorize state and federal flexibility with Medicaid program rules to implement specific initiatives. DHCS received federal approval on December 29, 2021, for both the demonstration and waiver, effective through December 31, 2026, subject to special terms and conditions.
Community Supports. One component of CalAIM that addresses social drivers of health is called Community Supports. Community Supports are services that can be provided by Medi-Cal managed care plans as cost-effective alternatives to traditional medical services or settings. DHCS has a pre-approved list of 14 Community Supports, based on experience in prior demonstration programs to address health-related social needs. Medically supportive food or tailored meals can potentially provide similar health improvements and avoidance of expensive, high-intensity health care services.
Cost Considerations for Food Interventions as a Medi-Cal Benefit. Making services a benefit, versus a Community Support offered through a temporary demonstration project, will result in broader eligibility for services. This could add to program costs significantly for the provision of the benefit and could result in offsetting health care cost savings or health improvements as a result of broader coverage. Currently, managed care plans have the discretion to define criteria for the level of services determined to be both medically appropriate and cost-effective for members. One provider of medically tailored meals (MTMs) through the current Medi-Cal Community Supports indicates the price range is $7 to $12 per meal. According to the sponsors, over a third of Medi-Cal beneficiaries is expected to have one or more of the medical diagnoses included in the bill. - Prior Legislation.
- AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, established statutory authority for various aspects of the CalAIM initiative, including authority to provide “ILOS”, which was later renamed as “Community Supports.”
- AB 3118 (Rob Bonta), of the 2019-20 Legislative Session, would have created a Medi-Cal pilot program in Alameda County to provide a “medically supportive food assistance” benefit for a Medi-Cal beneficiary with a chronic health condition, as specified, for a three-year period, and requires the department to evaluate the pilot and make recommendations for its expansion or continuation. AB 3118 was held on the suspense file of this committee.
- SB 97 (Committee on Budget and Fiscal Review), Chapter 52, Statutes of 2017, authorized the MTM Pilot Program, which launched on April 1, 2018, in eight counties. DHCS oversees the program and contracted with Project Open Hand to provide services. The pilot was planned to run for four years with a total budget of $6 million, and is being evaluated to determine effects on hospital, emergency department, and skilled nursing facility admissions. The program has served three MTMs per day for 12 weeks to 1,413 eligible beneficiaries with congestive heart failure during the four-year period.
Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081
Date of Hearing: April 25, 2023
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
ABPCA Bill Id:AB 1644
Author:(Bonta) – As Amended Ver:April 17, 2023
SUBJECT: Medi-Cal: medically supportive food and nutrition services.
SUMMARY: Adds medically supportive food and nutrition interventions as a covered Medi-Cal benefit. Specifically, this bill:
- Adds medically supportive food and nutrition interventions as a covered Medi-Cal benefit when medically necessary, as ordered by a health care provider or by a Medi-Cal managed care plan directly.
- Requires an enrollee to be offered at least three of six medically supportive food and nutrition interventions for a minimum of 12 weeks and longer as deemed medically necessary.
- Conditions implementation on the issuance of final guidance by the Department of Health Care Services (DHCS) in conjunction with the Medically Supportive Food and Nutrition Benefit Committee, as specified.
- Defines the following terms:
- “Medically supportive food and nutrition intervention” means the seven interventions specified in 4)b) through h) below, that provide nutrient-rich whole food, including any fruit, vegetable, legume, nut, seed, whole grain, low-mercury and high-omega-3 fatty acid seafood, and lean animal protein, used for the prevention, reversal, or treatment of certain health conditions.
- “Medically tailored meals (MTM)” means meals that are tailored to a recipient’s health conditions by a registered dietitian nutritionist (RDN) and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines and are typically home-delivered.
- “Medically supportive meals” means meals that follow the federal Dietary Guidelines for Americans, meet general health recommendations, and are home delivered, picked up, or consumed on site.
- “Food pharmacy” means medically supportive food paired with additional nutrition supports, typically in a health care setting.
- “Medically tailored groceries” means boxes or packages that are tailored to a recipient’s health conditions by a RDN and reflect standards informed by available dietary recommendations for specific health conditions or dietary therapies based on evidence-based nutritional practice guidelines. Medically tailored groceries are either home delivered or picked up.
- “Medically supportive groceries” means food boxes or packages that follow the federal Dietary Guidelines for Americans and meet general health recommendations and are typically home delivered or picked up, but may be procured in retail settings via a financial mechanism, such as vouchers or a restricted spending card.
- “Produce prescription” means fruits and vegetables, typically procured in retail settings, such as grocery stores and farmer’s markets, via a financial mechanism, such as vouchers or a restricted spending card, but may also be produce boxes or packages that are home delivered or picked up.
- “Nutrition supports” includes nutrition coaching or counseling, group medical visits, cooking education and tools, and behavioral supports based on a recipient’s medical conditions, when paired with the interventions described in 4) b) through g) above.
- Specifies medical conditions that would benefit from medically supportive food and nutrition interventions include, but are not limited to, the following:
- Metabolic conditions such as prediabetes, Type 1 and Type 2 diabetes, obesity, metabolic syndrome, polycystic ovary syndrome, and fatty liver disease;
- Cardiovascular conditions such as hypertension, congestive heart failure, cardiomyopathy, stroke, coronary artery disease, arrhythmia, and lipid abnormalities;
- Mental and behavioral health conditions such as depression, anxiety, and eating disorder;
- High-risk perinatal conditions such as gestational diabetes, preeclampsia, and gestational hypertension;
- Pulmonary conditions such as asthma, chronic obstructive pulmonary disease, and emphysema;
- Gastrointestinal conditions such as inflammatory bowel disease;
- Neurodegenerative conditions such as mild cognitive impairment;
- Renal conditions such as chronic kidney disease;
- Oncologic conditions such as gastrointestinal, breast, gynecological, and head and neck cancers; and,
- Infectious conditions such as human immunodeficiency virus (HIV).
- Requires a health care provider, to the extent possible, to match the acuity of a patient’s condition to the intensity and duration of the medically supportive food and nutrition intervention and include culturally appropriate foods whenever possible.
- Specifies nutrition supports, as defined in 4) h) above, are encouraged to be included with the interventions offered to the patient, but do not count toward the minimum intervention requirements. Limits the provision of nutrition supports, as defined, to be covered only when paired with the provision of food through one of the six specified interventions.
- Requires, on or before July 1, 2025, DHCS to establish the Medically Supportive Food and Nutrition Benefit Committee to assist in developing official guidance related to eligible populations, the duration and dosage of medically supportive food and nutrition interventions, the rate-setting process, the determination of permitted providers, and continuing education for health care providers and other medically supportive food and nutrition providers. Requires the committee to include at least one knowledgeable stakeholder to represent each of the seven medically supportive food and nutrition interventions described in 4) b) through h) above, and also include stakeholders from Medi-Cal consumer advocacy organizations. Requires the committee to meet quarterly or more often as necessary.
- Requires DHCS to provide a 30 day-public comment period on any proposed guidance put forth by the Medically Supportive Food and Nutrition Benefit Committee and an additional 30 days for public comment, prior to finalizing its official guidance.
- Requires DHCS to issue final guidance on or before July 1, 2026, and requires, upon issuance of the final guidance, medically supportive food and nutrition interventions to be a covered benefit consistent with the definitions above.
EXISTING LAW:
- Establishes the Medi-Cal Program, administered by DHCS, to provide comprehensive health benefits to low-income individuals who meet specified eligibility criteria. [Welfare and Institutions Code (WIC) § 14000 et seq.]
- Establishes a schedule of benefits under the Medi-Cal program, which includes federally required and optional Medicaid benefits, subject to utilization controls. [WIC §14132]
- Establishes the California Advancing and Innovating Medi-Cal (CalAIM) Act, and requires the implementation of CalAIM to support the following goals:
- Identify and manage the risk and needs of Medi-Cal beneficiaries through whole-person-care approaches and addressing social determinants of health;
- Transition and transform the Medi-Cal program to a more consistent and seamless system by reducing complexity and increasing flexibility; and,
- Improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through value-based initiatives, modernization of systems, and payment reform. [WIC §14184.100]
- Establishes a CalAIM term of January 1, 2022, to December 31, 2026, inclusive, and any extensions. [WIC §14184.101]
- Requires DHCS to seek federal approval for specific CalAIM components, including those related to Medi-Cal managed care, specialty mental health, behavioral health payment reform, Drug Medi-Cal, pre-release services for justice-involved individuals, county administration of Medi-Cal, the Providing Access and Transforming Health program to build CalAIM implementation capacity, and other components. [WIC §14184.102]
- Authorizes medically supportive food and nutrition services, including MTMs, under CalAIM as “Community Supports” that a Medi-Cal managed care plan may elect to cover. Specifies Community Supports are provided “in lieu of” typical Medi-Cal covered services, in accordance with the federally approved CalAIM Terms and Conditions. [WIC §14184.206]
FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. This bill is sponsored by the Food as Medicine Collaborative and SPUR, a nonprofit public policy organization in the San Francisco Bay area, to expand access to medically supportive food and nutrition interventions. According to the author, too many Californians, particularly Californians of color, are living with largely preventable chronic conditions. The author asserts adequate food and nutrition are a fundamental part of preventing and treating chronic conditions, and can significantly improve a patient's quality of life and health status while also reducing healthcare costs. Across California, the author indicates, numerous organizations have piloted these interventions, also commonly known as “food as medicine” programs. The author notes evaluations from those programs, and others nationally, show that they improve health and reduce avoidable healthcare spending. Accordingly, the author concludes, this bill expands medically supportive food and nutrition interventions as a covered benefit to all eligible Medi-Cal recipients and will improve the lives of beneficiaries.
- BACKGROUND.
- CalAIM. CalAIM is a collection of major initiatives spearheaded by the DHCS that align with the Administration’s program improvement goals, including addressing social drivers of health, reducing program complexity and increasing flexibility, and modernizing payment structures to promote better outcomes. The majority of CalAIM proposals were put forward in 2021 through two comprehensive applications to the federal government for a “Section 1115 demonstration” and “Section 1915(b) waiver”—both named for the sections of the Social Security Act that authorize state and federal flexibility with Medicaid program rules to implement specific initiatives. DHCS received federal approval on December 29, 2021, for both the demonstration and waiver, effective through December 31, 2026, subject to Special Terms and Conditions (STC) that govern the state’s implementation of the initiatives.
- Community Supports. One component of CalAIM that addresses social drivers of health is called Community Supports. Community Supports are services that can be provided by Medi-Cal managed care plans as cost-effective alternatives to traditional medical services or settings. DHCS has a pre-approved list of 14 Community Supports, based on experience in prior demonstration programs to address health-related social needs. These supports are designed to provide flexibility to address specific needs of complex populations. For instance, home modifications, adaptations, and remediation can support individuals in maintaining or improving their health and reduce emergency department visits and inpatient stays. Similarly, medically supportive food or tailored meals can potentially provide similar health improvements and avoidance of expensive, high-intensity health care services.
Every Medicaid program has a Medicaid State Plan that specifies the benefits and services covered by that program. Community Supports, as defined through CalAIM, are alternative services to those covered under the Medi-Cal State Plan, but are delivered by a different provider or in a different setting than is described in the State Plan. Community Supports can only be covered if the state determines they are medically-appropriate and cost-effective substitutes or settings for a State Plan service. - “Food as Medicine” concept. Behaviors related to diet, exercise and smoking are major factors in determining health status and the likelihood of chronic disease. Food as medicine programs aim to leverage targeted interventions to prevent, manage, treat and, in some instances, reverse disease by improving nutrition to help children and adults get well and stay healthy. These programs exist in the context of other food assistance programs, such as the CalFresh Program and the Women, Infants and Children program; other efforts such as the MTMs pilot program; and other state efforts to improve the provision of preventive and outpatient care, as well as non-medical interventions, to maintain health and prevent inpatient admissions and institutionalization.
- Food and Nutrition Interventions. According to the bill sponsors, the spectrum of medically supportive food and nutrition interventions includes: MTMs, medically supportive meals, food pharmacies, medically tailored groceries, medically supportive groceries, produce prescriptions, and nutrition supports when paired with food provision. The sponsors indicate providing the full spectrum of food-based services allows a medical provider to match the acuity of a patient’s condition to the intensity of the intervention.
The proposed benefit is structured to be flexible by providing a choice of interventions to managed care plans. MTMs and groceries are more targeted at a particular health condition, while medically “supportive” meals and groceries includes food that meets dietary guidelines for general health support, including any fruit, vegetable, legume, nut, seed, whole grain, low-mercury and high-omega-3 fatty acid seafood, and lean animal protein. In addition to these two broad categories, nutrition support can be paired with the food benefit. For instance, a cooking class could be offered to demonstrate how to prepare seasonal vegetables that are offered in a “food pharmacy” set in a community clinic.
- Cost Considerations for adding Food Interventions as a Medi-Cal Benefit. As noted above, Community Supports are currently authorized through a demonstration program and the offer of Community Supports is subject to specific rules. Specifically, because Community Supports must overall be medically appropriate and cost-effective substitutes or settings for the State Plan service, this imposes a cost-benefit calculation on the provision of Community Supports. Making services a benefit, versus a Community Support offered through a temporary demonstration project, will result in broader eligibility for services. This could add to program costs significantly for the provision of the benefit and could result in offsetting health care cost savings or health improvements as a result of broader coverage. Currently, managed care plans have the discretion to define criteria for the level of services determined to be both medically appropriate and cost-effective for members. One provider of MTMs through the current Medi-Cal Community Supports indicates the price range is $7 to $12 a meal. According to the sponsors, over a third of Medi-Cal beneficiaries is expected to have one or more of the medical diagnoses currently included in the bill. However, a medical condition would not automatically translate into meeting the medical necessity criteria for the intervention. DHCS could also establish additional criteria.
- Current MTMs/Medically-Supportive Food Community Support. DHCS’s January 2023 “Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide” includes the following description of the Community Support:
- Description/Overview: Malnutrition and poor nutrition can lead to devastating health outcomes, higher utilization, and increased costs, particularly among Members with chronic conditions. Meals help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. Results include improved Member health outcomes, lower hospital readmission rates, a well-maintained nutritional health status, and increased Member satisfaction.
- Meals delivered to the home immediately following discharge from a hospital or nursing home when Members are most vulnerable to readmission.
- MTMs: meals provided to the Member at home that meet the unique dietary needs of those with chronic diseases.
- MTMs are tailored to the medical needs of the Member by a Registered Dietitian or other certified nutrition professional, reflecting appropriate dietary therapies based on evidence-based nutritional practice guidelines to address medical diagnoses, symptoms, allergies, medication management, and/or side effects to ensure the best possible nutrition-related health outcomes.
- Medically-supportive food and nutrition services, including medically tailored groceries, healthy food vouchers, and food pharmacies.
- Behavioral, cooking, and/or nutrition education is included when paired with direct food assistance as enumerated above.
- Description/Overview: Malnutrition and poor nutrition can lead to devastating health outcomes, higher utilization, and increased costs, particularly among Members with chronic conditions. Meals help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. Results include improved Member health outcomes, lower hospital readmission rates, a well-maintained nutritional health status, and increased Member satisfaction.
- Current MTMs/Medically-Supportive Food Community Support. DHCS’s January 2023 “Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide” includes the following description of the Community Support:
Managed care plans have the discretion to define criteria for the level of services determined to be both medically appropriate and cost-effective for Members (e.g., MTMs, groceries, food vouchers, etc.).
- Eligibility:
- Individuals with chronic conditions, such as but not limited to diabetes, cardiovascular disorders, congestive heart failure, stroke, chronic lung disorders, HIV, cancer, gestational diabetes, or other high risk perinatal conditions, and chronic or disabling mental/behavioral health disorders;
- Individuals being discharged from the hospital or a skilled nursing facility or at high risk of hospitalization or nursing facility placement; or,
- Individuals with extensive care coordination needs.
- Restrictions/Limitations
- Up to two (2) meals per day and/or medically-supportive food and nutrition services for up to 12 weeks, or longer if medically necessary;
- Meals that are eligible for or reimbursed by alternate programs are not eligible; and,
- Meals are not covered to respond solely to food insecurities.
- Eligibility:
Community supports shall supplement and not supplant services received by the Medi-Cal beneficiary through other State, local, or federally funded programs, in accordance with the CalAIM STCs and federal and DHCS guidance.
- Licensing/Allowable Providers. Providers must have experience and expertise with providing these unique services. This list is provided as an example of the types of providers Medi-Cal managed care plans may choose to contract with, but it is not an exhaustive list of providers who may offer the services:
- Home delivered meal Providers;
- Area Agencies on Aging;
- Nutritional Education Services to help sustain healthy cooking and eating habits;
- Meals on Wheels Providers; and,
- Medically-Supportive Food & Nutrition Providers.
- Licensing/Allowable Providers. Providers must have experience and expertise with providing these unique services. This list is provided as an example of the types of providers Medi-Cal managed care plans may choose to contract with, but it is not an exhaustive list of providers who may offer the services:
- MTMs Pilot Program, SB 97 (Committee on Budget and Fiscal Review), Chapter 52, Statutes of 2017, authorized the MTM Pilot Program, which launched on April 1, 2018, in eight counties. DHCS oversees the program and contracted with Project Open Hand for the Provision of services. The pilot was planned to run for four years with a total budget of $6 million, and an evaluation is being conducted to determine the impact of the MTM program on hospital, emergency department, and skilled nursing facility admissions. The program has served three MTMs per day for 12 weeks to 1,413 eligible beneficiaries with congestive heart failure during the four-year period.
- Evidence of Effectiveness. DHCS has presented findings that MTMs are effective in improving health. According to DHCS, one study found a 17% reduction in patients with poorly controlled diabetes when patients were providing diabetes appropriate MTMs. Other research on MTM delivery among older adults found that 79% of individuals who fallen in the past did not fall again during the study period compared to 46% in the control group, showing a 33% increase in fall prevention. Finally, a 2014 study on MTMs recipients with diabetes, HIV, and comorbid conditions found a 50% increase in medication adherence among recipients. Studies have also found double-digit percentage point decreases in emergency department visits, inpatient admissions, and 30-day hospital readmissions among MTM recipients.
- SUPPORT. Numerous community-based organizations, including food and chronic disease advocacy organizations, consumer advocates, and food banks, support this bill. Food for People, the Food Bank for Humboldt County, states in support that California should seize the opportunity to build on the historic progress made through CalAIM to permanently address social drivers of health through food-based interventions. The Food As Medicine Collaborative, a cosponsor of the bill, asserts along with a large coalition of supporters that transitioning medically supportive food and nutrition interventions from optional services under a time-limited waiver in healthcare to covered Medi-Cal benefits will improve health outcomes, advance health equity across California, reduce avoidable healthcare costs and support the prevention, not just the treatment, of chronic conditions.
- RELATED LEGISLATION. AB 1085 (Maienschein) requires DHCS to seek federal approval to add housing support services, which are currently Community Supports, as a Medi-Cal benefit. AB 1085 is pending in the Assembly Appropriations Committee.
- PREVIOUS LEGISLATION.
- AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, established statutory authority for various aspects of the CalAIM initiative, including authority to provide “ILOS”, which was later renamed as “Community Supports.”
- SB 97 authorized the MTM Pilot Program.
- AB 3118 (Rob Bonta) of 2020 would have created a Medi-Cal pilot program in Alameda County to provide a “medically supportive food assistance” benefit for a Medi-Cal beneficiary who has a chronic health condition, as specified, for a three-year period, and requires the department to evaluate the pilot and make recommendations for its expansion or continuation. AB 3118 was held on the Suspense File of the Assembly Appropriations Committee.
- AMENDMENTS. Following conversations between the Committee, author, and sponsors, the author has agreed to amend this bill to address several substantive and clarifying issues, as follows:
- Effective date. The current bill requires DHCS to form a committee on or before July 1, 2025 and issue final guidance by July 1, 2026, and states medically supportive food and nutrition interventions is a covered benefit upon issuance of the final guidance. Amendments will provide clarity that the effective date for the benefit is July 1, 2026.
- Utilization Controls. To create consistency with other Medi-Cal benefits, amendments will specify the new benefit is covered, subject to utilization controls.
- Nutrition Supports. Amendments will clarify the definition of “nutrition supports” does not include group medical visits, but provide that nutrition supports may be provided in an individual or group setting; clarify cooking tools includes equipment and materials; and clarify that the definition includes health coaching in addition to behavioral supports based on a recipient’s medical conditions.
- Offer of Three Interventions. Amendments clarify the author’s intent that instead of a beneficiary being offered at least three of the medically supportive food and nutrition interventions, that fee-for-service Medi-Cal and each Medi-Cal managed care plan must offer at least three of the medically supportive food and nutrition interventions to Medi-Cal beneficiaries.
- Medical Conditions. Amendments strike the list of medical conditions that would make someone medical eligible for the benefit, and instead require DHCS to define the qualifying medical conditions for benefit, including chronic and other conditions that evidence shows are sensitive to changes in diet, and require DHCS to consult with the stakeholder advisory workgroup in the development of qualifying medical conditions.
- Stakeholder Committee. This bill also requires the convening of a committee to assist DHCS in developing official guidance on the benefit. Although stakeholders can inform benefit design, determining utilization controls generally is appropriately, and should remain, within the scope of DHCS’s authority. Amendments will reframe the committee as a stakeholder advisory workgroup, clarify stakeholder input is advisory, and clarify requirements for DHCS to accept input from the workgroup prior to issuing guidance.
- Federal Approval and Authority to Issue Guidance. Consistent with other benefits and to ensure the availability of federal matching funds to fund the benefit, amendments will allow DHCS to issue non-regulatory guidance to implement the benefit and requires implementation only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
REGISTERED SUPPORT / OPPOSITION:
Support
Food As Medicine Collaborative (cosponsor)
SPUR (cosponsor)
18 Reasons
Agricultural Institute of Marin
Alameda County Community Food Bank
Alameda County Deputy Sheriffs' Activities League Dba Dig Deep Farms
Alameda Health Consortium
Alameda Health System
Alchemist CDC
American Heart Association
Asian Pacific Islander Forward Movement
Axis Community Health
Black Women for Wellness
Blue Zones Project Monterey County
Blue Zones Project Tuolumne County
Blue Zones Project Upper Napa Valley
Booker T. Washington Community Service Center
California Academy of Nutrition and Dietetics
California Conference of Local Health Department Nutritionists
California Food and Farming Network
California Fresh Fruit Association
Celiac Disease Foundation
Center for Food Safety
Ceres Community Project
Conard House
Esperanza Community Farms
Everyone's Harvest
Extrafood
Farm Discovery At Live Earth
Farming Hope
Food As Medicine Global
Food Bank of Contra Costa and Solano
Food for People, the Food Bank for Humboldt County
Food Forward
Foodwise
Fresh Approach
Glide
Go for Health! Santa Cruz County
Hayward Wellness Center - Alameda Health System
Health Care Without Harm
Homeless Prenatal Program
Institute for Natural Medicine
La Clinica de La Raza, INC.
Leah's Pantry, INC.
Life Lab Science Program
Los Angeles Food Policy Council
Los Angeles Regional Food Bank
Marin Food Policy Council
Meals on Wheels of West Los Angeles INC
Meals on Wheels Orange County
Merced County Food Bank
National Produce Prescription Collaborative
Native American Health Center
North Coast Growers Association
Nutrition and Fitness Collaborative of the Central Coast
One Community Health
Open Door Community Health Centers
Open Heart Kitchen
Open Source Wellness
Pesticide Action Network
Project Open Hand
Public Health Advocates
Purfoods, LLC A/k/a Mom's Meals
Reach Out
Regeneration Pajaro Valley Climate Action
Roots of Change
Sacramento Food Policy Council
San Francisco Marin Medical Society
San Francisco-Marin Food Bank
Santa Barbara County Food Action Network
Second Harvest Food Bank Santa Cruz County
Shape Up San Francisco Coalition
Slow Food Policy in California
Sonoma-Mendocino Lake Medical Association
Thai Community Development Center
The Praxis Project
Tiburcio Vasquez Health Center, INC.
Western Center on Law & Poverty, INC.
Wholesome Wave
Opposition
None on file.
Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097
Bill Author
