Bill Text: CA AB2340 | 2023-2024 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Medi-Cal: EPSDT services: informational materials.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2024-05-09 - Read second time. Ordered to Consent Calendar. [AB2340 Detail]

Download: California-2023-AB2340-Introduced.html

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CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill

No. 2340

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Introduced by Assembly Member Bonta

February 12, 2024

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An act to add Article 4.12 (commencing with Section 14149.95) to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

AB 2340, as introduced, Bonta. Medi-Cal: EPSDT services.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive medically necessary health care services, through fee-for-service or managed care delivery systems. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, early and periodic screening, diagnostic, and treatment (EPSDT) services are covered under Medi-Cal for an individual under 21 years of age in accordance with certain federal provisions.

Under existing law, for an individual under 21 years of age, a service is medically necessary if the service meets the standards set forth in one of those federal EPSDT provisions, including the correction or amelioration of defects and physical and mental illnesses and conditions discovered by the screening services, whether or not those services are covered under the state plan. Existing law sets forth other provisions on medical necessity standards for covered benefits provided in a Medi-Cal behavioral health delivery system.

This bill would prohibit limits on EPSDT services when those services are medically necessary. The bill would require a Medi-Cal managed care plan to cover all medically necessary EPSDT services, unless otherwise carved out of the contract between the managed care plan and the department, regardless of whether those services are covered under the Medi-Cal State Plan.

The bill would establish definitions for “EPSDT services” and “medically necessary” by making references to the above-described provisions. The bill would specify that EPSDT services also include all age-specific assessments and services listed under the most current periodicity schedule by the American Academy of Pediatrics (AAP) and Bright Futures, and any other medically necessary assessments and services that exceed those listed by AAP and Bright Futures.

The bill would require the department and its contractors to accurately reflect these provisions in any model evidence-of-coverage documents, beneficiary handbooks, and related material.

Digest Key

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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Bill Text

The people of the State of California do enact as follows:

SECTION 1.

 Article 4.12 (commencing with Section 14149.95) is added to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to read:

Article  4.12. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services

14149.95.

 (a) For Medi-Cal beneficiaries under 21 years of age, early and periodic screening, diagnostic, and treatment (EPSDT) services are covered benefits under the Medi-Cal program when medically necessary, as defined in subdivision (e).

(b) Limits, including, but not limited to, caps on the number of covered visits, on EPSDT services shall not be imposed when those services are medically necessary.

(c) A Medi-Cal managed care plan shall meet both of the following conditions with regard to EPSDT services:

(1) The managed care plan shall provide and cover all medically necessary EPSDT services, unless otherwise carved out of the contract between the managed care plan and the department, regardless of whether those services are covered under the Medi-Cal State Plan.

(2) The managed care plan shall not impose limits on medically necessary EPSDT services, in accordance with subdivision (b).

(d) The department and its contractors shall accurately reflect the provisions of this section in any model evidence-of-coverage documents, beneficiary handbooks, and related material.

(e) For purposes of this section, the following definitions apply:

(1) “EPSDT services” means services covered under subdivision (v) of Section 14132 and that meet the standards set forth in Section 1396d(r) of Title 42 of the United States Code.

(A) In addition to the screening, vision, dental, and hearing services described in Section 1396d(r)(1)-(4) of Title 42 of the United States Code, EPSDT services include such other necessary health care, diagnostic services, treatment, and other measures described in Section 1396d(a) of Title 42 of the United States Code to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not those services are covered under the Medi-Cal State plan, in accordance with Section 1396d(r)(5) of Title 42 of the United States Code.

(B) EPSDT services also include all age-specific assessments and services listed under the most current periodicity schedule by the American Academy of Pediatrics (AAP) and Bright Futures, and any other medically necessary assessments and services that exceed those listed by AAP and Bright Futures.

(2) A service is “medically necessary” if it meets the applicable medical necessity standards set forth in Sections 14059.5 and 14184.402.