Bill Text: CA AB68 | 2015-2016 | Regular Session | Amended

California Assembly Bill 68 (Prior Session Legislation)

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

Bill Title: Medi-Cal.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Vetoed) 2016-01-15 - Consideration of Governor's veto stricken from file. [AB68 Detail]

Download: California-2015-AB68-Amended.html

BILL NUMBER: AB 68	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  MARCH 26, 2015

INTRODUCED BY   Assembly Member Waldron

                        DECEMBER 18, 2014

   An act to  amend Section 14000 of   add
Section 14133.06 to  the Welfare and Institutions Code, relating
to Medi-Cal.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 68, as amended, Waldron. Medi-Cal.
   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.  Covered benefits under the
Medi-Cal program include the purchase of prescribed drugs, subject to
the Medi-Cal List of Contract Drugs and utilization controls. 
 Existing law provides that it is the intent of the
Legislature to provide, to the extent practicable, for health care
for those aged and other persons who lack sufficient annual income to
meet the costs of health care, and whose other assets are so limited
that their application toward the costs of care would jeopardize the
person's or family's future minimum self-maintenance and security.
 
   This bill, which would be known as the Patient Access to
Prescribed Epilepsy Treatments Act, would require, to the extent
permitted by federal law, that any drug in the seizure or epilepsy
therapeutic drug class would be a covered benefit under the Medi-Cal
program. The bill would require a Medi-Cal managed care plan to
provide coverage for these drugs, regardless of whether the drug is
on the plan's formulary, if the treating provider demonstrates that,
in his or her reasonable, professional judgment, the drug is
medically necessary and consistent with specified federal rules and
regulations. If the managed care plan elects not to cover a drug
described in the bill, the drug would be deemed a noncapitated
benefit not reimbursed by the managed care plan, which would be
available on a fee-for-service basis, and the plan's contracted rate
would be reduced to reflect the cost to the state of providing the
benefit to the patient, as specified. This bill would declare the
intent of the Legislature that a prescriber's reasonable,
professional judgment prevail in prescribing the drugs described in
the bill to Medi-Cal patients.  
   This bill would make technical, nonsubstantive changes to those
provisions.
   Vote: majority. Appropriation: no. Fiscal committee:  no
  yes  . State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

   SECTION 1.    This act shall be known, and may be
cited, as the Patient Access to Prescribed Epilepsy Treatments Act.

   SEC. 2.   Section 14133.06 is added to the  
Welfare and Institutions Code   , to read:  
   14133.06.  (a) It is the intent of the Legislature in enacting
this section that a prescriber's reasonable, professional judgment
prevail in prescribing to Medi-Cal patients any drug in the
therapeutic drug class that includes drugs approved by the federal
Food and Drug Administration for use in the treatment of seizures or
epilepsy, but are not on Medi-Cal managed care plan formularies, or
are subject to prior authorization requirements.
   (b) To the extent permitted by federal law, if any drug in the
seizure or epilepsy therapeutic drug class described in subdivision
(a) is prescribed by a Medi-Cal beneficiary's treating provider, that
drug shall be a covered benefit under this chapter.
   (c) Except as provided in subdivision (d), and notwithstanding the
establishment of a statewide outpatient drug formulary, a Medi-Cal
managed care plan shall provide coverage for a drug in the seizures
and epilepsy therapeutic class, as described in subdivision (a),
regardless of whether the drug is on the plan's formulary, if the
treating provider demonstrates, consistent with federal law that, in
his or her reasonable, professional judgment, the drug is medically
necessary and consistent with the federal Food and Drug
Administration's labeling and use rules and regulations, as supported
in at least one of the official compendia identified in Section 1927
(g)(1)(B)(i) of the federal Social Security Act (42 U.S.C. Sec.
1396r-8(g)(1)(B)(i)).
   (d) (1) If a Medi-Cal managed care plan elects not to cover a
seizure or epilepsy drug described in subdivision (b), the drug shall
be deemed a noncapitated benefit not reimbursed by the managed care
plan, and shall be available on a fee-for-service basis. The treating
provider shall follow fee-for-service billing instructions for
reimbursement under these circumstances.
   (2) If a drug is deemed a noncapitated benefit not reimbursed by a
Medi-Cal managed care plan, as described in paragraph (1), the plan'
s contracted rate shall be reduced to reflect the cost of providing
the benefit to the patient on a fee-for-service basis.  

  SECTION 1.    Section 14000 of the Welfare and
Institutions Code is amended to read:
   14000.  The purpose of this chapter is to afford to qualifying
individuals health care and related remedial or preventive services,
including related social services that are necessary for those
receiving health care under this chapter.
   The intent of the Legislature is to provide, to the extent
practicable, through the provisions of this chapter, for health care
for those aged and other individuals, including family members, who
lack sufficient annual income to meet the costs of health care and
whose other assets are so limited that their application toward the
costs of that care would jeopardize the individual's or family's
future minimum self-maintenance and security. It is intended that
whenever possible and feasible:
   (a) The means employed shall allow, to the extent practicable, an
eligible individual to secure health care in the same manner employed
by the public generally, and without discrimination or segregation
based purely on his or her economic disability. The means employed
shall include an emphasis on efforts to arrange and encourage access
to health care through enrollment in organized, managed care plans of
the type available to the general public.
   (b) The benefits available under this chapter shall not duplicate
those provided under other federal or state laws or under other
contractual or legal entitlements of the individual or individuals
receiving them.
   (c) In the administration of this chapter and in establishing the
means to be used to provide access to health care to individuals
eligible under this chapter, the department shall emphasize and take
advantage of both the efficient organization and ready accessibility
and availability of health care facilities and resources through
enrollment in managed health care plans and new and innovative
fee-for-service managed health care plan approaches to the delivery
of health care services.