AB 365: Medi-Cal: diabetes management.
- Session Year: 2023-2024
- House: Assembly
- Latest Version Date: 2023-09-08
Current Status:
Failed
(2024-08-30: Ordered to inactive file at the request of Senator Gonzalez.)
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 sets forth a schedule of benefits under the Medi-Cal program.
This bill would add continuous glucose monitors and related supplies required for use with those monitors as a covered benefit under the Medi-Cal program, program for the treatment of diabetes when medically necessary, subject to utilization controls. The bill would require the department, by July 1, 2024, to review and update, review, and update as appropriate, coverage policies for continuous glucose monitors, as specified. The bill would authorize the department to require a manufacturer of a continuous glucose monitor to enter into a rebate agreement with the department. The bill would limit its implementation to the extent that any necessary federal approvals are obtained and federal financial participation is not otherwise jeopardized. available. The bill would make related findings and declarations.
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 sets forth a schedule of benefits under the Medi-Cal program.
This bill would add continuous glucose monitors and related supplies required for use with those monitors as a covered benefit under the Medi-Cal program, subject to utilization controls based on clinical practice guidelines, as specified. controls. The bill would require the department, by July 1, 2024, to review and update, as appropriate, coverage policies for continuous glucose monitors, as specified. The bill would authorize the department to require a manufacturer of a continuous glucose monitor to enter into a rebate agreement with the department. The bill would limit its implementation to the extent that any necessary federal approvals are obtained and federal financial participation is not otherwise jeopardized. The bill would make related findings and declarations.
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 sets forth a schedule of benefits under the Medi-Cal program.
This bill would add continuous glucose monitors and related supplies required for use with those monitors as a covered benefit under the Medi-Cal program, subject to utilization controls based on clinical practice guidelines, as specified. The bill would authorize the department to require a manufacturer of a continuous glucose monitor to enter into a rebate agreement with the department. The bill would limit its implementation to the extent that any necessary federal approvals are obtained and federal financial participation is not otherwise jeopardized. The bill would make related findings and declarations.
The Legislature finds and declares all of the following:
(a)One in seven adults, or approximately 4 million people, in California have diabetes.
(b)In the United States, California has the highest level of new cases of diabetes annually.
(c)Diabetes is the seventh leading cause of death in California.
(d)Diabetes is the leading cause of cardiovascular disease, adult blindness, kidney failure, and amputation of the lower extremities.
SEC. 2.Section 14132.12 is added to the Welfare and Institutions Code, to read:14132.12.(a)(1)Continuous glucose monitors and related supplies required for use with those monitors shall be a covered benefit under the Medi-Cal program for the treatment of diabetes when medically necessary, subject to utilization controls.
(2)By July 1, 2024, the department shall review, and update as appropriate, coverage policies for continuous glucose monitors. The department shall consider current evidence-based clinical guidelines and coverage policies of other payers for purposes of this paragraph.
(b)The department may require the manufacturer of a continuous glucose monitor to enter into a rebate agreement with the department.
(c)This section shall be implemented only to the extent that any necessary federal approvals have been obtained and federal financial participation is available.
All matter omitted in this version of the bill appears in the bill as amended in the Assembly, March 15, 2023. (JR11)The Legislature finds and declares all of the following:
(a)One in seven adults, or approximately 4 million people in California have diabetes.
(b)In the United States, California has the highest level of new cases of diabetes annually.
(c)Diabetes is the seventh leading cause of death in California.
(d)Diabetes is the leading cause of cardiovascular disease, adult blindness, kidney failure, and amputation of the lower extremities.
SEC. 2.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 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 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. controls. 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. controls.
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 the 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 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 the 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)(A)Continuous glucose monitors and related supplies required for use with those monitors are covered for the treatment of diabetes when medically necessary, subject to utilization controls. Utilization controls shall be based on clinical practice guidelines for continuous glucose monitor utilization for the treatment and management of diabetes by a nationally recognized third-party organization of experts in the treatment of diabetes, including, but not limited to, the American Diabetes Association or the American Association of Clinical Endocrinology.
(B)The department shall review and consider updating the utilization control pursuant to subparagraph (A) on an annual basis.(B)By July 1, 2024, the department shall review, and update, as appropriate, coverage policies for continuous glucose monitors. The department shall consider current evidence-based clinical guidelines and coverage policies of other payers for purposes of this subparagraph.
(2)The department may require the manufacturer of a continuous glucose monitor to enter into a rebate agreement with the department.
(3)This subdivision shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
The Legislature finds and declares all of the following:
(a)One in seven adults, or approximately 4 million people in California have diabetes.
(b)In the United States, California has the highest level of new cases of diabetes annually.
(c)Diabetes is the seventh leading cause of death in California.
(d)Diabetes is the leading cause of cardiovascular disease, adult blindness, kidney failure, and amputation of the lower extremities.
SEC. 2.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)(A)Continuous glucose monitors and related supplies required for use with those monitors are covered for the treatment of diabetes when medically necessary, subject to utilization controls. Utilization controls shall be based on clinical practice guidelines for continuous glucose monitor utilization for the treatment and management of diabetes by a nationally recognized third-party organization of experts in the treatment of diabetes, including, but not limited to, the American Diabetes Association or the American Association of Clinical Endocrinology.
(B)The department shall review and consider updating the utilization control pursuant to subparagraph (A) on an annual basis.
(2)The department may require the manufacturer of a continuous glucose monitor to enter into a rebate agreement with the department.
(3)This subdivision shall be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
|
Date
|
Status
|
|---|---|
| Aug 30, 2024 | Ordered to inactive file at the request of Senator Gonzalez. |
| Aug 21, 2024 | Read second time. Ordered to third reading. |
| Aug 20, 2024 | Ordered to second reading. |
| Aug 20, 2024 | From inactive file. |
| Sep 12, 2023 | Ordered to inactive file at the request of Senator Limón. |
| Sep 11, 2023 | Read second time. Ordered to third reading. |
| Sep 8, 2023 | Read third time and amended. Ordered to second reading. |
| Aug 24, 2023 | Ordered to third reading. |
| Aug 24, 2023 | From Consent Calendar. |
| Aug 22, 2023 | Read second time. Ordered to Consent Calendar. |
| Aug 21, 2023 | From committee: Be ordered to second reading file pursuant to Senate Rule 28.8 and ordered to Consent Calendar. |
| Jun 22, 2023 | From committee: Do pass and re-refer to Com. on APPR with recommendation: To Consent Calendar. (Ayes 12. Noes 0.) (June 21). Re-referred to Com. on APPR. |
| Jun 14, 2023 | Referred to Com. on HEALTH. |
| Jun 1, 2023 | In Senate. Read first time. To Com. on RLS. for assignment. |
| May 31, 2023 | Read third time. Passed. Ordered to the Senate. (Ayes 80. Noes 0. Page 1972.) |
| May 18, 2023 | Read second time. Ordered to third reading. |
| May 18, 2023 | From committee: Do pass. (Ayes 15. Noes 0.) (May 18). |
| Apr 19, 2023 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| Mar 22, 2023 | From committee: Do pass and re-refer to Com. on APPR. with recommendation: To Consent Calendar. (Ayes 14. Noes 0.) (March 21). Re-referred to Com. on APPR. |
| Mar 16, 2023 | Re-referred to Com. on HEALTH. |
| Mar 15, 2023 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 6, 2023 | In committee: Hearing postponed by committee. |
| Feb 9, 2023 | Referred to Com. on HEALTH. |
| Feb 2, 2023 | From printer. May be heard in committee March 4. |
| Feb 1, 2023 | Read first time. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Jun 21, 2023 | Do pass, but first be re-referred to the Committee on [Appropriations] with the recommendation: To Consent Calendar | Senate Standing Committee on Health |
Passed |
|
| May 31, 2023 | AB 365 Aguiar-Curry Assembly Third Reading | Assembly Floor |
Passed |
|
| May 18, 2023 | Do pass. | Assembly Standing Committee on Appropriations |
Passed |
|
| Mar 21, 2023 | Do pass and be re-referred to the Committee on [Appropriations] with recommendation: To Consent Calendar | 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
|
|---|---|---|
| American Diabetes Association | ** Support | |
| Biocom California | ** Support | |
| California Academy Of Family Physicians | ** Support | |
| California Black Health Network | ** Support | |
| California chapter of the American College of Cardiology | ** Support | |
| California Chronic Care Coalition | ** Support | |
| California Dialysis Council | ** Support | |
| California Life Sciences | ** Support | |
| California Long Term Care Ombudsman Association | ** Support | |
| CaliforniaHealth+ Advocates | ** Support | |
| Center For Elders Independence | ** Support | |
| Children'S Specialty Care Coalition | ** Support | |
| County Health Executives Association Of California | ** Support | |
| Department Of Finance | ** Against | |
| Diabetes Patient Advocacy Coalition | ** Support | |
| western center on law & poverty | ** Support |
SENATE RULES COMMITTEE Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB 365 |
THIRD READING
Bill No: AB 365
Author: Aguiar-Curry (D)
Amended: 9/8/23 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 12-0, 6/21/23
AYES: Eggman, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
ASSEMBLY FLOOR: 80-0, 5/31/23 - See last page for vote
SUBJECT: Medi-Cal: diabetes management
SOURCE: American Diabetes Association
DIGEST:
This bill adds continuous glucose monitors (CGMs) as a benefit in the Medi-Cal schedule of benefits. This bill requires the Department of Health Care Services to review and update as appropriate the coverage policies for CGMs by July 1, 2024.
Senate Floor Amendments of 9/8/23 solely move the contents of the bill to a new section of the Welfare and Institutions Code to avoid a chaptering out problem as multiple, unrelated bills were modifying § 14132.
ANALYSIS:
Existing law:
- Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
- Establishes a schedule of benefits for the Medi-Cal program, which includes federally required and optional Medicaid benefits, including durable medical equipment (DME) and medical supplies, and coverage of diabetic test supplies when provided by a pharmacy. [WIC §14132]
This bill:
- Adds CGMs and related supplies required for use with those monitors to the Medi-Cal schedule of benefits for the treatment of diabetes when medically necessary, subject to utilization controls.
- Requires DHCS to review, and update, as appropriate, coverage policies for CGMs by July 1, 2024. Requires DHCS to consider current evidence-based clinical guidelines and coverage policies of other payers for purposes of this review.
- Authorizes DHCS to require the manufacturer of a CGM to enter into a rebate agreement with DHCS.
- Conditions implementation of this bill upon the receipt of federal approval and federal financial participation.
- Makes legislative findings that one in seven adults, or approximately four million people in California have diabetes; California has the highest level in the nation of new diabetes cases annually; diabetes is the seventh leading cause of death in California; and diabetes is the leading cause of cardiovascular disease, adult blindness, kidney failure, and amputation of the lower extremities.
Comments
- Author’s statement. According to the author, three million Californians, or around one in seven adults, have diabetes. Among U.S. states, California has the highest level of new cases of diabetes annually. Additionally, the number of persons with diabetes in California has increased 32% in 10 years. With this increase in diabetes, CGMs provide significant, potentially life-changing benefits for diabetes management and avoid or delay serious co-morbidities, hospitalizations and even death. DHCS’s current Medi-Cal coverage of CGMs unnecessarily restricts access to CGMs to people with certain types of diabetes. This bill codifies Medi-Cal coverage of CGMs and requires DHCS to review and update their coverage policies for CGMs while considering current medical standards of care.
- Diabetes in California. According to the California Department of Public Health (CDPH), diabetes is the seventh leading cause of death in California, with African Americans, Native Americans, and Latinos dying at greater rates than white or Asian American/Pacific Islanders. People who are lower income are also more likely to have diabetes: over 10% of adults with family incomes below 200% of the federal poverty level (FPL) have Type 2 diabetes, while 6% of adults with family incomes above 300% of FPL have Type 2 diabetes. Not only are low-income and people of color more impacted by the disease itself, they experience far worse complications due to inadequate access to health care. For example, a Kaiser Health News analysis found that in California, where doctors performed more than 82,000 diabetic amputations from 2011 to 2017, people who were black or Latino were more than twice as likely as non-Hispanic whites to undergo amputations related to diabetes. A 2014 study by UCLA researchers found that people with diabetes in poorer neighborhoods in Los Angeles County were twice as likely to have a foot or leg amputated than those in wealthier areas. The difference was more than tenfold in some parts of the county. Complications from diabetes also lead to end stage renal disease, ophthalmic complications including blindness, and put individuals at risk of additional comorbidities such as cardiovascular disease, hypertension, high blood cholesterol and arthritis. Management of diabetes is important in keeping these other conditions under control as well.
- Medi-Cal coverage of CGMs. In 2021, funding for Medi-Cal coverage for CGMs for adults with Type 1 diabetes starting in January of 2022 was included in the Budget Act of 2021 (AB 128 (Ting, Chapter 21, Statutes of 2021)), though CGMs were not specifically enumerated in the Act or accompanying trailer bill language. The following year, the health trailer bill, SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022), recognized CGMs as a covered benefit in that it specifically exempted CGMs from payment reductions that apply to other benefits and services.
A CGM is a device used to monitor blood glucose on a continual basis for people with diabetes who require insulin. Currently approved CGMs use an enzymatic technology which reacts with glucose molecules and require a wearer to have a sensor placed under the skin, a transmitter on the body, and a receiver device that reads the signal. These are generally a replacement for traditional finger prick testing that people with diabetes who use insulin use throughout the day. Several studies have demonstrated that CGMs reduce the time wearers spend in hypoglycemia and appears to lower hemoglobin A1c levels, particularly when used by individuals with poorly controlled diabetes, particularly if a CGM is used together with an integrated insulin pump. Like many medically necessary specific devices, supplies, and services, CGMs are not specifically listed in state law as a Medi-Cal benefit, though DHCS describes when Medi-Cal will cover CGMs in the Medi-Cal provider manual.
- Current Medi-Cal requirements for CGMs. According to the Medi-Cal provider manual, Medi-Cal recipients must meet all of the following criteria in order to have a CGM:
- Is under the immediate and ongoing care of, and the CGM is ordered by, an endocrinologist or a healthcare practitioner with experience in diabetes management and continuous subcutaneous insulin infusion therapy;
- Has Type 1 insulin-dependent diabetes;
- Is on an insulin treatment plan that requires three or more daily injections of insulin or a continuous subcutaneous insulin infusion pump;
- Is on an insulin treatment regimen that requires frequent adjustments of insulin dosing on the basis of self-monitoring blood glucose testing an average of three times or more per day or CGM testing results;
- Is within the manufacturer’s recommendations for appropriate age range;
- Has completed a comprehensive diabetes education program or diabetes prevention program within the last 12 months;
- The beneficiary and/or caregiver demonstrates the ability to understand and appropriately respond to information displayed on a CGM receiver;
- The beneficiary and/or caregiver demonstrates a high level of motivation to achieve tighter glucose control and competency to accurately use the CGM system and comply with recommended use and as instructed in the manufacturers’ current labeling;
- The beneficiary and/or caregiver agrees that the beneficiary will wear the CGM at least five days per week of use or 20 days of use per month;
- Has been seen and evaluated by an endocrinologist or a healthcare practitioner with experience in diabetes management and continuous subcutaneous insulin infusion therapy at least every six months, either in person or virtually through video or telephone conferencing, to evaluate their diabetes control and determines that criteria above have been met and documented;
- The initial prior authorization period must not exceed six months; and
- An average blood sugar level value measured within six months must be documented on the prior authorization request.
For therapeutic CGM and beneficiaries residing in a long-term care facility setting, clinical justification must be included and demonstrate why traditional use of a Self-Monitoring Blood Glucose Test System administered by licensed care staff and continuous medical support reimbursed by state or federal resources does not meet the patient’s clinical needs.
By definition, this criteria excludes recipients with Type 2 and gestational diabetes, as well as many patients with Type 1 diabetes with inadequate access to specialty care. CGM has been recognized as the standard of care for all patients who are able to use the devices with Type 1 diabetes by various professional societies, including the Endocrine Society, American Diabetes Association, and the American Association of Clinical Endocrinology, and can be the standard of care for some forms of Type 2 or gestational diabetes depending on how frequently insulin injections are needed and other individual patient factors.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No
SUPPORT: (Verified 9/6/23)
American Diabetes Association (source)
Biocom California
California Academy of Family Physicians
California Black Health Network
California Chapter of the American College of Cardiology
California Chronic Care Coalition
CaliforniaHealth+ Advocates
California Life Sciences
California Long Term Care Ombudsman Association
Center for Elders’ Independence
Children's Specialty Care Coalition
County Health Executives Association of California
Diabetes Patient Advocacy Coalition
OPPOSITION: (Verified 9/6/23)
Department of Finance
ARGUMENTS IN SUPPORT: This bill’s sponsor, the American Diabetes Association (ADA), and several other supporters write that Medi-Cal’s current utilization criteria for CGMs does not appear to be based on scientific guidelines, and instead are over burdensome and will unnecessarily act as a barrier to potentially life-saving technology. For people living with diabetes, CGMs provide significant benefits for diabetes management because provide greater detail than traditional blood glucose meters, which can aid in achieving glycemic targets and help providers and patients determine effective insulin dosing. CGMs continuously monitor blood glucose levels and use alarms and alerts to inform patients when blood glucose levels are exceeding or falling below specified thresholds. CGM systems provides information about the direction and magnitude of blood glucose levels, and as a result, these devices facilitate the making of optimal treatment decisions by and for individuals with diabetes. They also point to a 2015 DHCS report, which found that Medi-Cal program associated with adult individuals treated for diabetes totaled $3.6 billion, which is approximately 14% of total spending on non-dual eligible adults. Additionally, an ADA study shows that individuals enrolled in Medicaid are two to five times less likely to use a CGM than those with a commercial health plan and that states with higher rates of whites enrolled in their Medicaid programs have higher CGM use than states with higher rates of Black enrollees. Finally, they point out that during the COVID-19 pandemic, approximately 40% of the COVID-19 deaths occurred among people with diabetes.
ARGUMENTS IN OPPOSITION: The Department of Finance (DOF) writes in opposition to this bill stating that it is duplicative of current practice. According to DOF, while this bill conforms with current DHCS policy on product category review processes and does not add another benefit (given that CGMs are already covered in the Medi-Cal program), they note that codifying these administrative policies into statute would minimize DHCS’ administrative flexibility to respond and adapt to potential changes in federal requirements or technology. DOF notes that SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022), the Health Omnibus Trailer Bill, specifically exempted CGMs from payment reductions. DOF also states that this bill does not result in significant costs for the Medi-Cal program.
ASSEMBLY FLOOR: 80-0, 5/31/23
AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon
Prepared by: Jen Flory / HEALTH / (916) 651-4111
9/11/23 13:09:20
**** END ****
SENATE RULES COMMITTEE Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB 365 |
THIRD READING
Bill No: AB 365
Author: Aguiar-Curry (D)
Amended: 3/15/23 in Assembly
Vote: 21
SENATE HEALTH COMMITTEE: 12-0, 6/21/23
AYES: Eggman, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
ASSEMBLY FLOOR: 80-0, 5/31/23 - See last page for vote
SUBJECT: Medi-Cal: diabetes management
SOURCE: American Diabetes Association
DIGEST:
This bill adds continuous glucose monitors (CGMs) as a benefit in the Medi-Cal schedule of benefits. This bill requires the Department of Health Care Services to review and update as appropriate the coverage policies for CGMs by July 1, 2024.
ANALYSIS:
Existing law:
- Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
- Establishes a schedule of benefits for the Medi-Cal program, which includes federally required and optional Medicaid benefits, including durable medical equipment (DME) and medical supplies, and coverage of diabetic test supplies when provided by a pharmacy. [WIC §14132]
This bill:
- Adds CGMs and related supplies required for use with those monitors to the Medi-Cal schedule of benefits for the treatment of diabetes when medically necessary, subject to utilization controls.
- Requires DHCS to review, and update, as appropriate, coverage policies for CGMs by July 1, 2024. Requires DHCS to consider current evidence-based clinical guidelines and coverage policies of other payers for purposes of this review.
- Authorizes DHCS to require the manufacturer of a CGM to enter into a rebate agreement with DHCS.
- Conditions implementation of this bill upon the receipt of federal approval and federal financial participation.
- Makes legislative findings that one in seven adults, or approximately four million people in California have diabetes; California has the highest level in the nation of new diabetes cases annually; diabetes is the seventh leading cause of death in California; and diabetes is the leading cause of cardiovascular disease, adult blindness, kidney failure, and amputation of the lower extremities.
Comments
- Author’s statement. According to the author, three million Californians, or around one in seven adults, have diabetes. Among U.S. states, California has the highest level of new cases of diabetes annually. Additionally, the number of persons with diabetes in California has increased 32% in 10 years. With this increase in diabetes, CGMs provide significant, potentially life-changing benefits for diabetes management and avoid or delay serious co-morbidities, hospitalizations and even death. DHCS’s current Medi-Cal coverage of CGMs unnecessarily restricts access to CGMs to people with certain types of diabetes. This bill codifies Medi-Cal coverage of CGMs and requires DHCS to review and update their coverage policies for CGMs while considering current medical standards of care.
- Diabetes in California. According to the California Department of Public Health (CDPH), diabetes is the seventh leading cause of death in California, with African Americans, Native Americans, and Latinos dying at greater rates than white or Asian American/Pacific Islanders. People who are lower income are also more likely to have diabetes: over 10% of adults with family incomes below 200% of the federal poverty level (FPL) have Type 2 diabetes, while 6% of adults with family incomes above 300% of FPL have Type 2 diabetes. Not only are low-income and people of color more impacted by the disease itself, they experience far worse complications due to inadequate access to health care. For example, a Kaiser Health News analysis found that in California, where doctors performed more than 82,000 diabetic amputations from 2011 to 2017, people who were black or Latino were more than twice as likely as non-Hispanic whites to undergo amputations related to diabetes. A 2014 study by UCLA researchers found that people with diabetes in poorer neighborhoods in Los Angeles County were twice as likely to have a foot or leg amputated than those in wealthier areas. The difference was more than tenfold in some parts of the county. Complications from diabetes also lead to end stage renal disease, ophthalmic complications including blindness, and put individuals at risk of additional comorbidities such as cardiovascular disease, hypertension, high blood cholesterol and arthritis. Management of diabetes is important in keeping these other conditions under control as well.
- Medi-Cal coverage of CGMs. In 2021, funding for Medi-Cal coverage for CGMs for adults with Type 1 diabetes starting in January of 2022 was included in the Budget Act of 2021 (AB 128, Ting, Chapter 21, Statutes of 2021), though CGMs were not specifically enumerated in the Act or accompanying trailer bill language. The following year, the health trailer bill, SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022), recognized CGMs as a covered benefit in that it specifically exempted CGMs from payment reductions that apply to other benefits and services.
A CGM is a device used to monitor blood glucose on a continual basis for people with diabetes who require insulin. Currently approved CGMs use an enzymatic technology which reacts with glucose molecules and require a wearer to have a sensor placed under the skin, a transmitter on the body, and a receiver device that reads the signal. These are generally a replacement for traditional finger prick testing that people with diabetes who use insulin use throughout the day. Several studies have demonstrated that CGMs reduce the time wearers spend in hypoglycemia and appears to lower hemoglobin A1c levels, particularly when used by individuals with poorly controlled diabetes, particularly if a CGM is used together with an integrated insulin pump. Like many medically necessary specific devices, supplies, and services, CGMs are not specifically listed in state law as a Medi-Cal benefit, though DHCS describes when Medi-Cal will cover CGMs in the Medi-Cal provider manual.
- Current Medi-Cal requirements for CGMs. According to the Medi-Cal provider manual, Medi-Cal recipients must meet all of the following criteria in order to have a CGM:
- Is under the immediate and ongoing care of, and the CGM is ordered by, an endocrinologist or a healthcare practitioner with experience in diabetes management and continuous subcutaneous insulin infusion therapy;
- Has Type 1 insulin-dependent diabetes;
- Is on an insulin treatment plan that requires three or more daily injections of insulin or a continuous subcutaneous insulin infusion pump;
- Is on an insulin treatment regimen that requires frequent adjustments of insulin dosing on the basis of self-monitoring blood glucose testing an average of three times or more per day or CGM testing results;
- Is within the manufacturer’s recommendations for appropriate age range;
- Has completed a comprehensive diabetes education program or diabetes prevention program within the last 12 months;
- The beneficiary and/or caregiver demonstrates the ability to understand and appropriately respond to information displayed on a CGM receiver;
- The beneficiary and/or caregiver demonstrates a high level of motivation to achieve tighter glucose control and competency to accurately use the CGM system and comply with recommended use and as instructed in the manufacturers’ current labeling;
- The beneficiary and/or caregiver agrees that the beneficiary will wear the CGM at least five days per week of use or 20 days of use per month;
- Has been seen and evaluated by an endocrinologist or a healthcare practitioner with experience in diabetes management and continuous subcutaneous insulin infusion therapy at least every six months, either in person or virtually through video or telephone conferencing, to evaluate their diabetes control and determines that criteria above have been met and documented;
- The initial prior authorization period must not exceed six months; and
- An average blood sugar level value measured within six months must be documented on the prior authorization request.
For therapeutic CGM and beneficiaries residing in a long-term care facility setting, clinical justification must be included and demonstrate why traditional use of a Self-Monitoring Blood Glucose Test System administered by licensed care staff and continuous medical support reimbursed by state or federal resources does not meet the patient’s clinical needs.
By definition, this criteria excludes recipients with Type 2 and gestational diabetes, as well as many patients with Type 1 diabetes with inadequate access to specialty care. CGM has been recognized as the standard of care for all patients who are able to use the devices with Type 1 diabetes by various professional societies, including the Endocrine Society, American Diabetes Association, and the American Association of Clinical Endocrinology, and can be the standard of care for some forms of Type 2 or gestational diabetes depending on how frequently insulin injections are needed and other individual patient factors.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No
SUPPORT: (Verified 8/21/23)
American Diabetes Association (source)
Biocom California
California Academy of Family Physicians
California Black Health Network
California Chapter of the American College of Cardiology
California Chronic Care Coalition
CaliforniaHealth+ Advocates
California Life Sciences
Children's Specialty Care Coalition
County Health Executives Association of California
Diabetes Patient Advocacy Coalition
Western Center on Law & Poverty
OPPOSITION: (Verified 8/21/23)
Department of Finance
ARGUMENTS IN SUPPORT: This bill’s sponsor, the American Diabetes Association (ADA), and several other supporters write that Medi-Cal’s current utilization criteria for CGMs does not appear to be based on scientific guidelines, and instead are over burdensome and will unnecessarily act as a barrier to potentially life-saving technology. For people living with diabetes, CGMs provide significant benefits for diabetes management because provide greater detail than traditional blood glucose meters, which can aid in achieving glycemic targets and help providers and patients determine effective insulin dosing. CGMs continuously monitor blood glucose levels and use alarms and alerts to inform patients when blood glucose levels are exceeding or falling below specified thresholds. CGM systems provides information about the direction and magnitude of blood glucose levels, and as a result, these devices facilitate the making of optimal treatment decisions by and for individuals with diabetes. They also point to a 2015 DHCS report, which found that Medi-Cal program associated with adult individuals treated for diabetes totaled $3.6 billion, which is approximately 14% of total spending on non-dual eligible adults. Additionally, an ADA study shows that individuals enrolled in Medicaid are two to five times less likely to use a CGM than those with a commercial health plan and that states with higher rates of whites enrolled in their Medicaid programs have higher CGM use than states with higher rates of Black enrollees. Finally, they point out that during the COVID-19 pandemic, approximately 40% of the COVID-19 deaths occurred among people with diabetes.
ARGUMENTS IN OPPOSITION: The Department of Finance (DOF) writes in opposition to this bill because stating it is duplicative of current practice. According to DOF, while this bill conforms with current DHCS policy on product category review processes and does not add another benefit (given that CGMs are already covered in the Medi-Cal program), they note that codifying these administrative policies into statute would minimize DHCS’ administrative flexibility to respond and adapt to potential changes in federal requirements or technology. DOF notes that SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022), the Health Omnibus Trailer Bill, specifically exempted CGMs from payment reductions. DOF also states that this bill does not result in significant costs for the Medi-Cal program.
ASSEMBLY FLOOR: 80-0, 5/31/23
AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon
Prepared by: Jen Flory / HEALTH / (916) 651-4111
8/24/23 11:11:43
SENATE COMMITTEE ON HEALTH
Senator Dr. Susan Talamantes Eggman, Chair
BILL NO: AB 365
AUTHOR: | Aguiar-Curry | ||
VERSION: | March 15, 2023 | ||
HEARING DATE: | June 21, 2023 | ||
CONSULTANT: | Jen Flory | ||
SUBJECT: Medi-Cal: diabetes management
SUMMARY:
Adds continuous glucose monitors (CGMs) as a benefit in the Medi-Cal schedule of benefits. Requires the Department of Health Care Services to review and update as appropriate the coverage policies for CGMs by July 1, 2024.
Existing law:
- Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
- Establishes a schedule of benefits for the Medi-Cal program, which includes federally required and optional Medicaid benefits, including durable medical equipment (DME) and medical supplies, and coverage of diabetic test supplies when provided by a pharmacy. [WIC §14132]
This bill:
- Adds continuous glucose monitors (CGMs) and related supplies required for use with those monitors as covered benefits under the Medi-Cal program for the treatment of diabetes when medically necessary, subject to utilization controls.
- Requires DHCS to review, and update, as appropriate, coverage policies for CGMs by July 1, 2024. Requires DHCS to consider current evidence-based clinical guidelines and coverage policies of other payers for purposes of this review.
- Authorizes DHCS to require the manufacturer of a CGM to enter into a rebate agreement with DHCS.
- Conditions implementation of this bill upon the receipt of federal approval and federal financial participation.
- Makes legislative findings that one in seven adults, or approximately four million people in California have diabetes; California has the highest level in the nation of new diabetes cases annually; diabetes is the seventh leading cause of death in California; and diabetes is the leading cause of cardiovascular disease, adult blindness, kidney failure, and amputation of the lower extremities.
FISCAL EFFECT:
According to the Assembly Appropriations Committee:
Unknown costs to DHCS, possibly low-to mid-tens of millions of dollars (General Fund (GF) and federal funds (FF)). These costs would likely be offset, at least in part, by reduced health care costs associated with better control of diabetes. According to the November 2022 Medi-Cal Local Assistance Estimate, utilization of CGMs leads to improvement in diabetes management, fewer emergency room visits and hospitalizations, and reduced complications, which may include stroke, kidney disease, amputations, and blindness.
The November 2022 Medi-Cal Local Assistance Estimate estimates full-year total costs of $15 million ($5.6 million GF, $9.4 million FF) for the provision of CGMs for beneficiaries with Type 1 diabetes meeting specific criteria. The Medi-Cal estimate appears to incorporate an annual savings of approximately $300 per beneficiary for self-monitoring of blood glucose when transitioning to GCMs. There are approximately ten Type II diabetics for every Type I, but type II diabetes is much less likely to be treated with insulin. If the expansion of eligibility to beneficiaries with Type II diabetes triples the number who would receive CGMs through Medi-Cal, the cost of CGMs could also approximately triple.
PRIOR VOTES:
Assembly Floor: | 80 - 0 |
Assembly Appropriations Committee: | 15 - 0 |
Assembly Health Committee: | 14 - 0 |
COMMENTS:
- Author’s statement. According to the author three million Californians, or around one in seven adults, have diabetes. Among U.S. states, California has the highest level of new cases of diabetes annually. Additionally, the number of persons with diabetes in California has increased 32% in ten years. With this increase in diabetes, CGMs provide significant, potentially life-changing benefits for diabetes management and avoid or delay serious co-morbidities, hospitalizations and even death. DHCS’s current Medi-Cal coverage of CGMs unnecessarily restricts access to CGMs to people with certain types of diabetes. This bill codifies Medi-Cal coverage of CGMs and requires DHCS to review and update their coverage policies for CGMs while considering current medical standards of care.
- Diabetes in California. According to the California Department of Public Health (CDPH), diabetes is the seventh leading cause of death in California, with African Americans, Native Americans, and Latinos dying at greater rates than white or Asian American/Pacific Islanders. People who are lower income are also more likely to have diabetes: over 10% of adults with family incomes below 200% of the federal poverty level (FPL) have type 2 diabetes, while 6% of adults with family incomes above 300% of FPL have type 2 diabetes. Not only are low-income and people of color more impacted by the disease itself, they experience far worse complications due to inadequate access to health care. For example, a Kaiser Health News analysis found that in California, where doctors performed more than 82,000 diabetic amputations from 2011 to 2017, people who were black or Latino were more than twice as likely as non-Hispanic whites to undergo amputations related to diabetes. A 2014 study by UCLA researchers found that people with diabetes in poorer neighborhoods in Los Angeles County were twice as likely to have a foot or leg amputated than those in wealthier areas. The difference was more than tenfold in some parts of the county. Complications from diabetes also lead to end stage renal disease, ophthalmic complications including blindness, and put individuals at risk of additional comorbidities such as cardiovascular disease, hypertension, high blood cholesterol and arthritis. Management of diabetes is important in keeping these other conditions under control as well.
- Medi-Cal coverage of CGMs. In 2021, funding for Medi-Cal coverage for CGMs for adults with Type 1 diabetes starting in January of 2022 was included in the Budget Act of 2021 [AB 128 (Ting, Chapter 21, Statutes of 2021)], though CGMs were not specifically enumerated in the Act or accompanying trailer bill language. The following year, the health trailer bill, SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022), recognizes CGMs as a covered benefit in that it specifically exempted CGMs from payment reductions that apply to other benefits and services.
A CGM is a device used to monitor blood glucose on a continual basis for people with diabetes who require insulin. Currently approved CGMs use an enzymatic technology which reacts with glucose molecules and require a wearer to have a sensor placed under the skin, a transmitter on the body, and a receiver device that reads the signal. These are generally a replacement for traditional fingerprick testing that people with diabetes who use insulin use throughout the day. Several studies have demonstrated that CGMs reduce the time wearers spend in hypoglycemia and appears to lower hemoglobin A1c levels, particularly when used by individuals with poorly controlled diabetes, particularly if a CGM is used together with an integrated insulin pump. Like many medically necessary specific devices, supplies, and services, CGMs are not specifically listed in state law as a Medi-Cal benefit, though DHCS describes when Medi-Cal will cover CGMs in the Medi-Cal provider manual.
- Current Medi-Cal requirements for CGMs. According to the Medi-Cal provider manual, Medi-Cal recipients must meet all of the following criteria in order to have a CGM:
- Is under the immediate and ongoing care of, and the CGM is ordered by, an endocrinologist or a healthcare practitioner with experience in diabetes management and continuous subcutaneous insulin infusion therapy;
- Has Type 1 insulin-dependent diabetes;
- Is on an insulin treatment plan that requires three or more daily injections of insulin or a continuous subcutaneous insulin infusion pump;
- Is on an insulin treatment regimen that requires frequent adjustments of insulin dosing on the basis of self-monitoring blood glucose testing an average of three times or more per day or CGM testing results;
- Is within the manufacturer’s recommendations for appropriate age range;
- Has completed a comprehensive diabetes education program or diabetes prevention program within the last 12 months;
- The beneficiary and/or caregiver demonstrates the ability to understand and appropriately respond to information displayed on a CGM receiver;
- The beneficiary and/or caregiver demonstrates a high level of motivation to achieve tighter glucose control and competency to accurately use the CGM system and comply with recommended use and as instructed in the manufacturers’ current labeling;
- The beneficiary and/or caregiver agrees that the beneficiary will wear the CGM at least five days per week of use or 20 days of use per month;
- Has been seen and evaluated by an endocrinologist or a healthcare practitioner with experience in diabetes management and continuous subcutaneous insulin infusion therapy at least every six months, either in person or virtually through video or telephone conferencing, to evaluate their diabetes control and determines that criteria above have been met and documented;
- The initial prior authorization period must not exceed six months; and
- An average blood sugar level value measured within six months must be documented on the prior authorization request.
For therapeutic CGM and beneficiaries residing in a long-term care facility setting, clinical justification must be included and demonstrate why traditional use of a Self-Monitoring Blood Glucose Test System administered by licensed care staff and continuous medical support reimbursed by state or federal resources does not meet the patient’s clinical needs.
By definition, this criteria excludes recipients with Type 2 and gestational diabetes, as well as many patients with Type 1 diabetes with inadequate access to specialty care. CGM has been recognized as the standard of care for all patients who are able to use the devices with Type 1 diabetes by various professional societies, including the Endocrine Society, American Diabetes Association, and the American Association of Clinical Endocrinology, and can be the standard of care for some forms of Type 2 or gestational diabetes depending on how frequently insulin injections are needed and other individual patient factors.
- Related legislation. A number of bills this session add additional Medi-Cal benefits:
SB 694 (Eggman) adds self-measured blood pressure (SMBP) devices and SMBP services, as defined, as covered benefits under Medi-Cal for the treatment of high blood pressure. SB 694 is set for hearing on June 20, 2023 in the Assembly Health Committee.
AB 425 (Alvarez) adds pharmacogenomic testing as a covered benefit under Medi-Cal. AB 425 is set for hearing on June 28, 2023 in this Committee.
AB 847 (L. Rivas) extends the Medi-Cal pediatric palliative care benefit to individuals over age 21 for those who were determined eligible for the benefit prior to age 21. AB 847 is pending in this committee.
AB 1085 (Maienschein) adds housing supports as a covered benefit under Medi-Cal. AB 1085 is pending in the Senate Appropriations Committee.
AB 1644 (Bonta) adds medically supportive food and nutrition intervention plans to the Medi-Cal schedule of benefits. AB 1644 was held on the Assembly Appropriations suspense file.
- Prior legislation. SB 184, (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2021), the health trailer bill, exempted CGMs and related supplies and accessories, from ten percent rate reductions in Medi-Cal fee-for-service rates.
AB 128, (Ting, Chapter 21, Statutes of 2021), the Budget Act of 2021, included funding for CGMs in the Medi-Cal program, though it is not specifically enumerated in the bill.
AB 447 (Gray of 2017) would have added CGMs and related supplies to the Medi-Cal schedule of benefits, for the treatment of diabetes when medically necessary, subject to utilization controls. AB 447 was vetoed along with another bill by Governor Brown who stated in his veto message, “These bills expand benefits in the Medi-Cal program, one for asthma preventative services and one for CGM medical devices. DHCS, however, has considerable administrative authority to make changes to benefits based upon new medical evidence and clinical guidelines. Therefore, these statutory changes are unnecessary”
- Support. Sponsors, the American Diabetes Association (ADA), and several other supporters write that Medi-Cal’s current utilization criteria for CGMs does not appear to be based on scientific guidelines, and instead are over burdensome and will unnecessarily act as a barrier to potentially life-saving technology. For people living with diabetes, CGMs provide significant benefits for diabetes management because provide greater detail than traditional blood glucose meters, which can aid in achieving glycemic targets and help providers and patients determine effective insulin dosing. CGMs continuously monitor blood glucose levels and use alarms and alerts to inform patients when blood glucose levels are exceeding or falling below specified thresholds. CGM systems provides information about the direction and magnitude of blood glucose levels, and as a result, these devices facilitate the making of optimal treatment decisions by and for individuals with diabetes. They also point to a 2015 DHCS report, which found that Medi-Cal program associated with adult individuals treated for diabetes totaled $3.6 billion, which is approximately 14% of total spending on non-dual eligible adults. Additionally, an ADA study shows that individuals enrolled in Medicaid are two to five times less likely to use a CGM than those with a commercial health plan and that states with higher rates of whites enrolled in their Medicaid programs have higher CGM use than states with higher rates of Black enrollees. Finally, they point out that during the COVID-19 pandemic, approximately 40% of the COVID-19 deaths occurred among people with diabetes.
SUPPORT AND OPPOSITION:
Support: American Diabetes Association (ADA) (sponsor)
Biocom California
California Academy of Family Physicians
California Black Health Network
California Chapter of the American College of Cardiology
California Chronic Care Coalition
California Health+ Advocates
California Life Sciences
Children's Specialty Care Coalition
County Health Executives Association of California
Diabetes Patient Advocacy Coalition
Western Center on Law & Poverty
Oppose: None received.
-- END --
ASSEMBLY THIRD READING
ATR Bill Id:AB 365
Author:(Aguiar-Curry)
As Amended Ver:March 15, 2023
Majority vote
SUMMARY
Includes in the Medi-Cal schedule of benefits continuous glucose monitors (CGMs) and related supplies.
Major Provisions
COMMENTS
- Diabetes Prevalence and Disparities. Diabetes is a chronic disease with short and long-term health effects that prevent the proper production of and/or response to insulin, a hormone that facilitates the transfer of glucose into cells to provide energy. The risk of diabetes increases significantly with age, with prevalence rates of diabetes highest among older adults over 65. Research shows racial and ethnic minorities, individuals with lower education levels, and individuals with a family income below 200% of the federal poverty level also experience higher prevalence rates than non-Hispanic white individuals and individuals with higher education levels and higher incomes. According to the California Department of Public Health (DPH), the prevalence of prediabetes and diabetes among California adults has significantly increased since 2013. Data show strong geographic patterns in California, with inland and southern California counties generally experiencing higher prevalence rates. In 2017, DPH reported the prevalence of Type 2 diabetes ranged from 3.8% to 13.6% across California's counties, with the highest age-adjusted prevalence of Type 2 diabetes in San Bernardino County. At the neighborhood level, differences in diabetes prevalence by census tract correspond with socioeconomic status.
- Medi-Cal Coverage of CGMs. CGMs are wearable devices that continuously monitor glucose levels to help individuals manage their diabetes. Like many specific devices, supplies, and services, CGMs are not specifically listed in state law as a Medi-Cal benefit. With certain exceptions, state law establishes broad categories of benefits that are covered subject to utilization controls. The Department of Health Care Services (DHCS) describes details of covered benefits, and establishes and updates utilization controls, through promulgation of coverage policy as specified in various Medi-Cal provider manuals.
AB 128 (Ting), Chapter 21, Statutes of 2021, the Budget Act of 2021, included coverage of CGM for Medi-Cal beneficiaries with Type 1 diabetes over age 21 meeting specific criteria, beginning January 2022. Coverage was included via a policy change in the DHCS Medi-Cal estimate, but CGMs were not specifically enumerated as a benefit in statute. However, state law enacted through SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, the Health trailer bill to the budget, recognizes CGMs as a covered benefit in that it specifically exempts CGMs from payment reductions that apply to other benefits and services. The November 2022 Medi-Cal Local Assistance Estimate estimates full-year total costs of $15 million for the provision of CGMs for beneficiaries with Type 1 diabetes meeting specific criteria.
Medi-Cal reimburses for CGMs under Medi-Cal Rx, the state Medi-Cal prescription drug coverage program, with an approved prior authorization request. Medi-Cal Rx coverage policy defines a number of specific criteria that must be met in order to qualify for coverage of a CGM. These criteria include, among other requirements, having a Type 1 insulin-dependent diabetes diagnosis and being on an insulin treatment plan that requires multiple (three or more) daily injections of insulin or a needing continuous infusion of insulin.
- Medical Necessity. Medi-Cal benefits are covered when medically necessary. According to DHCS provider manual describing coverage for durable medical equipment (DME), the Medi-Cal definition of medical necessity for those 21 and over limits health care services to those necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Prescribed DME items may be covered as medically necessary only to preserve bodily functions essential to activities of daily living or to prevent significant physical disability. In addition, authorization for DME is limited to the lowest cost item that meets a patient's medical needs.
Medical necessity for children under 21 uses a different standard under the federal Early and Periodic Screening, Diagnosis and Treatment requirement, which requires coverage of any benefit or service that can be covered under Medicaid that are necessary to correct or ameliorate a child's health condition. Because of this different medical necessity standard, CGM coverage for children is broader than that for adults.
- Rebates. According to the November 2022 Medi-Cal Local Assistance Estimate, DHCS has entered into rebate agreements with manufacturers of the CGM components. This bill would authorize DHCS to do so.
- Medicare Coverage. Medicare has recently updated coverage parameters for CGMs. Effective July 18, 2021, the requirement for frequent self-monitoring of blood glucose over four times per day was removed as prerequisite for coverage. In addition, a new Medicare Local Coverage Determination (LCD) related to CGMs is set to go into effect on April 16, 2023. According to the Centers for Medicare & Medicaid Services, an item or service may be covered at the discretion of Medicare contractors based on an LCD. This LCD updates and simplifies initial CGM coverage criteria to two basic requirements, generally: a) the beneficiary has diabetes; and, b) The beneficiary's treating practitioner has concluded that the beneficiary (or the beneficiary's caregiver) has sufficient training using the particular device prescribed.
According to the Author
With a large and increasing number of people with diabetes, CGMs can prevent and delay diabetes-associated morbidity and death. The author asserts current criteria for Medi-Cal coverage of CGMs unnecessarily restrict access to CGMs to people with certain types of diabetes, and does not follow any current standard of care for the treatment of diabetes. This bill is intended to ensure coverage is based on current clinical guidelines and improve access to CGMs for Medi-Cal beneficiaries. This bill is sponsored by the American Diabetes Association.
Arguments in Support
Supporters emphasize this bill will improve access to CGM systems in the Medi-Cal program, which is an important health equity issue, given people of color make up the majority of the Medi-Cal population. Supporters note a national American Diabetes Association study shows states with higher rates of white Americans enrolled in Medicaid have higher CGM use than states with higher rates of Black Americans, and that Hispanic individuals are less likely to get a CGM if they are covered by Medicaid than a commercial health insurance plan. Biocom California notes CGMs have become a standard of care in the treatment of diabetes.
Arguments in Opposition
There is no known opposition.
FISCAL COMMENTS
According to the Assembly Appropriations Committee:
Unknown costs to DHCS, possibly low- to mid-tens of millions of dollars (General Fund (GF) and federal funds (FF)). These costs would likely be offset, at least in part, by reduced health care costs associated with better control of diabetes. According to the November 2022 Medi-Cal Local Assistance Estimate, utilization of CGMs leads to improvement in diabetes management, fewer emergency room visits and hospitalizations, and reduced complications, which may include stroke, kidney disease, amputations, and blindness.
The November 2022 Medi-Cal Local Assistance Estimate estimates full-year total costs of $15 million ($5.6 million GF, $9.4 million FF) for the provision of CGMs for beneficiaries with Type 1 diabetes meeting specific criteria. The Medi-Cal estimate appears to incorporate an annual savings of approximately $300 per beneficiary for self-monitoring of blood glucose when transitioning to GCMs. There are approximately ten Type II diabetics for every Type I, but type II diabetes is much less likely to be treated with insulin. If the expansion of eligibility to beneficiaries with Type II diabetes triples the number who would receive CGMs through Medi-Cal, the cost of CGMs could also approximately triple.
VOTES
ASM HEALTH: 14-0-1
YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber
ABS, ABST OR NV: Wendy Carrillo
ASM APPROPRIATIONS: 15-0-1
YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega
ABS, ABST OR NV: Robert Rivas
UPDATED
VERSION: March 15, 2023
CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0000637
Date of Hearing: April 19, 2023
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Chris Holden, Chair
ABPCA Bill Id:AB 365
Author:(Aguiar-Curry) – As Amended Ver:March 15, 2023
Policy Committee: | Health | Vote: | 14 - 0 |
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Urgency: No State Mandated Local Program: No Reimbursable: No
SUMMARY:
This bill includes continuous glucose monitors (CGMs) and related supplies in the Medi-Cal schedule of benefits, as specified, and requires by July 1, 2024, the Department of Health Care Services (DHCS) to consider current clinical guidelines and coverage policies of other payers and update coverage policies for CGMs, as specified. This bill also authorizes DHCS to require the manufacturer of a CGM to enter into a rebate agreement.
FISCAL EFFECT:
Unknown costs to DHCS, possibly low- to mid-tens of millions of dollars (General Fund (GF) and federal funds (FF)). These costs would likely be offset, at least in part, by reduced health care costs associated with better control of diabetes. According to the November 2022 Medi-Cal Local Assistance Estimate, utilization of CGMs leads to improvement in diabetes management, fewer emergency room visits and hospitalizations, and reduced complications, which may include stroke, kidney disease, amputations, and blindness.
The November 2022 Medi-Cal Local Assistance Estimate estimates full-year total costs of $15 million ($5.6 million GF, $9.4 million FF) for the provision of CGMs for beneficiaries with Type 1 diabetes meeting specific criteria. The Medi-Cal estimate appears to incorporate an annual savings of approximately $300 per beneficiary for self-monitoring of blood glucose when transitioning to GCMs. There are approximately ten Type II diabetics for every Type I, but type II diabetes is much less likely to be treated with insulin. If the expansion of eligibility to beneficiaries with Type II diabetes triples the number who would receive CGMs through Medi-Cal, the cost of CGMs could also approximately triple.
COMMENTS:
- Purpose. According to the author:
3 million Californians, which is around one in seven adults, have diabetes (…Centers for Disease Control and Prevention’s 2022 California Diabetes Profile). Among US states, California has the highest level of new cases of diabetes annually. Additionally, the number of persons with diabetes in California has increased 32% in ten years. With this increase in diabetes, Continuous Glucose Monitors (CGM) provide significant, potentially life changing benefits for diabetes management and in turn for avoidance or delay of serious co-morbidities, hospitalizations and even death. Current Medi-Cal coverage of CGMs criteria by the Department of Health Care Services unnecessarily restrict access to CGMs to people with certain types of diabetes, and does not follow any current standard of care for the treatment of diabetes. This bill requires that Medi-Cal base their coverage criteria for CGMS on medical standards of care for the treatment of diabetes to ensure that all prescribed uses of CGMs are rightfully covered by Medi-Cal.
- Background.
- Medi-Cal Coverage of CGMs. CGMs are wearable devices that continuously monitor glucose levels to help individuals manage their diabetes. CGMs became a covered Medi-Cal benefit for beneficiaries 21 years and older on January 1, 2022. Medi-Cal reimburses for CGMs under Medi-Cal Rx, the Medi-Cal prescription drug coverage program, with an approved prior authorization request. Medi-Cal Rx coverage policy defines specific criteria for coverage of a CGM, including, among other requirements, having Type 1 insulin-dependent diabetes and having an insulin treatment plan that requires three or more injections per day or continuous infusion of insulin.
This bill would require Medi-Cal to additionally cover GCMs for Type 2 diabetes. Although the majority (90-95%) of diabetics have Type 2 diabetes, most Type II diabetics are not insulin-dependent. - Medical Necessity. Medi-Cal benefits are covered when medically necessary. According to the DHCS provider manual describing coverage for durable medical equipment (DME), the Medi-Cal definition of medical necessity for those 21 years and over limits health care services to those necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Prescribed DME items may be covered as medically necessary only to preserve bodily functions essential to activities of daily living or to prevent significant physical disability. Authorization for DME is limited to the lowest cost item that meets a patient’s medical needs. The standard of medical necessity is broader for children and is defined as necessary to correct or ameliorate a child’s health condition.
- Rebates. According to the November 2022 Medi-Cal Local Assistance Estimate, DHCS has entered into rebate agreements with manufacturers of the CGM components.
- Medi-Cal Coverage of CGMs. CGMs are wearable devices that continuously monitor glucose levels to help individuals manage their diabetes. CGMs became a covered Medi-Cal benefit for beneficiaries 21 years and older on January 1, 2022. Medi-Cal reimburses for CGMs under Medi-Cal Rx, the Medi-Cal prescription drug coverage program, with an approved prior authorization request. Medi-Cal Rx coverage policy defines specific criteria for coverage of a CGM, including, among other requirements, having Type 1 insulin-dependent diabetes and having an insulin treatment plan that requires three or more injections per day or continuous infusion of insulin.
- Prior Legislation. AB 128 (Ting), Chapter 21, Statutes of 2021, the Budget Act of 2021, included coverage of CGM for Medi-Cal beneficiaries with Type 1 diabetes over age 21 meeting specific criteria, beginning January 2022. DHCS specified this coverage was included via a policy change in the Medi-Cal estimate, but CGMs were not specifically enumerated as a benefit in statute.
Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081
Date of Hearing: March 21, 2023
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
ABPCA Bill Id:AB 365
Author:(Aguiar-Curry) – As Amended Ver:March 15, 2023
SUBJECT: Medi-Cal: diabetes management.
SUMMARY: Includes in the Medi-Cal schedule of benefits continuous glucose monitors (CGMs) and related supplies. Specifically, this bill:
- Specifies CGMs and related supplies required for use with those monitors are covered for the treatment of diabetes when medically necessary, subject to utilization controls.
- Requires by July 1, 2024, the Department of Health Care Services (DHCS) to review, and update, as appropriate, coverage policies for CGMs, and requires, for this purpose, DHCS to consider current evidence-based clinical guidelines and coverage policies of other payers.
- Authorizes DHCS to require the manufacturer of a CGM to enter into a rebate agreement with the department.
- Requires 1) through 3), above, to be implemented only to the extent that federal financial participation is available and any necessary federal approvals have been obtained.
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, including durable medical equipment (DME) and medical supplies, subject to utilization controls, and coverage of diabetic test supplies when provided by a pharmacy. [WIC §14132]
- Exempts from 10% payment reductions fee-for-service (FFS) rates for certain services, facilities, and payments, including CGMs and related supplies and accessories. [WIC §14105.192]
FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, with a large and increasing number of people with diabetes, CGMs can prevent and delay diabetes-associated morbidity and death. The author asserts current criteria for Medi-Cal coverage of CGMs unnecessarily restrict access to CGMs to people with certain types of diabetes, and does not follow any current standard of care for the treatment of diabetes. This bill is intended to ensure coverage is based on current clinical guidelines and improve access to CGMs for Medi-Cal beneficiaries. This bill is sponsored by the American Diabetes Association.
- BACKGROUND.
- Diabetes Prevalence and Disparities. Diabetes is a chronic disease with short and long-term health effects that prevent the proper production of and/or response to insulin, a hormone that facilitates the transfer of glucose into cells to provide energy. The risk of diabetes increases significantly with age, with prevalence rates of diabetes highest among older adults over 65. Research shows racial and ethnic minorities, individuals with lower education levels, and individuals with a family income below 200% of the federal poverty level also experience higher prevalence rates than non-Hispanic white individuals and individuals with higher education levels and higher incomes. According to the California Department of Public Health (DPH), the prevalence of prediabetes and diabetes among California adults has significantly increased since 2013. Data show strong geographic patterns in California, with inland and southern California counties generally experiencing higher prevalence rates. In 2017, DPH reported the prevalence of type 2 diabetes ranged from 3.8% to 13.6% across California’s counties, with the highest age-adjusted prevalence of type 2 diabetes in San Bernardino County. At the neighborhood level, differences in diabetes prevalence by census tract correspond with socioeconomic status.
- Medi-Cal Coverage of CGMs. CGMs are wearable devices that continuously monitor glucose levels to help individuals manage their diabetes. Like many specific devices, supplies, and services, CGMs are not specifically listed in state law as a Medi-Cal benefit. With certain exceptions, state law establishes broad categories of benefits that are covered subject to utilization controls. DHCS describes details of covered benefits, and establishes and updates utilization controls, through promulgation of coverage policy as specified in various Medi-Cal provider manuals.
AB 128 (Ting), Chapter 21, Statutes of 2021, the Budget Act of 2021, included coverage of CGM for Medi-Cal beneficiaries with Type 1 diabetes over age 21 meeting specific criteria, beginning January 2022. Coverage was included via a policy change in the DHCS Medi-Cal estimate, but CGMs were not specifically enumerated as a benefit in statute. However, state law enacted through SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, the Health trailer bill to the budget, recognizes CGMs as a covered benefit in that it specifically exempts CGMs from payment reductions that apply to other benefits and services. The November 2022 Medi-Cal Local Assistance Estimate estimates full-year total costs of $15 million for the provision of CGMs for beneficiaries with Type 1 diabetes meeting specific criteria.
Medi-Cal reimburses for CGMs under Medi-Cal Rx, the state Medi-Cal prescription drug coverage program, with an approved prior authorization request. Medi-Cal Rx coverage policy defines a number of specific criteria that must be met in order to qualify for coverage of a CGM. These criteria include, among other requirements, having a Type 1 insulin-dependent diabetes diagnosis and being on an insulin treatment plan that requires multiple (three or more) daily injections of insulin or a needing continuous infusion of insulin. - Medical Necessity. Medi-Cal benefits are covered when medically necessary. According to DHCS provider manual describing coverage for DME, the Medi-Cal definition of medical necessity for those 21 and over limits health care services to those necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Prescribed DME items may be covered as medically necessary only to preserve bodily functions essential to activities of daily living or to prevent significant physical disability. In addition, authorization for DME is limited to the lowest cost item that meets a patient’s medical needs.
Medical necessity for children under 21 uses a different standard under the federal Early and Periodic Screening, Diagnosis and Treatment requirement, which requires coverage of any benefit or service that can be covered under Medicaid that are necessary to correct or ameliorate a child’s health condition. Because of this different medical necessity standard, CGM coverage for children is broader than that for adults. - Rebates. According to the November 2022 Medi-Cal Local Assistance Estimate, DHCS has entered into rebate agreements with manufacturers of the CGM components. This bill would authorize DHCS to do so.
- Medicare Coverage. Medicare has recently updated coverage parameters for CGMs. Effective July 18, 2021, the requirement for frequent self-monitoring of blood glucose over four times per day was removed as prerequisite for coverage. In addition, a new Medicare Local Coverage Determination (LCD) related to CGMs is set to go into effect on April 16, 2023. According to the Centers for Medicare & Medicaid Services, an item or service may be covered at the discretion of Medicare contractors based on an LCD. This LCD updates and simplifies initial CGM coverage criteria to two basic requirements, generally: i) the beneficiary has diabetes; and, ii) The beneficiary’s treating practitioner has concluded that the beneficiary (or the beneficiary’s caregiver) has sufficient training using the particular device prescribed.
- SUPPORT. Supporters emphasize this bill will improve access to CGM systems in the Medi-Cal program, which is an important health equity issue, given people of color make up the majority of the Medi-Cal population. Supporters note a national American Diabetes Association study shows states with higher rates of white Americans enrolled in Medicaid have higher CGM use than states with higher rates of Black Americans, and that Hispanic individuals are less likely to get a CGM if they are covered by Medicaid than a commercial health insurance plan. Biocom California notes CGMs have become a standard of care in the treatment of diabetes
- PREVIOUS LEGISLATION.
- AB 447 (Gray) of 2017 would have added CGMs and related supplies to the Medi-Cal schedule of benefits, for the treatment of diabetes when medically necessary, subject to utilization controls. AB 447 was vetoed by Governor Brown, who stated, “These bills expand benefits in the Medi-Cal program, one for asthma preventative services and one for continuous glucose monitor medical devices. The Department of Health Care Services, however, has considerable administrative authority to make changes to benefits based upon new medical evidence and clinical guidelines. Therefore, these statutory changes are unnecessary.”
- AB 128, the Budget Act of 2021, included funding for CGMs in the Medi-Cal program.
- SB 184, the Health trailer bill, exempted CGMs and related supplies and accessories, from ten percent rate reductions in Medi-Cal fee-for-service (FFS) rates.
REGISTERED SUPPORT / OPPOSITION:
Support
American Diabetes Association (sponsor)
Biocom California
California Life Sciences
California Dialysis Council
Diabetes Patient Advocacy Coalition
Opposition
None on file.
Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097
Bill Author
Bill Co-Author(s):