Bill Text: CA SB1053 | 2013-2014 | Regular Session | Enrolled
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Health care coverage: contraceptives.
Spectrum: Partisan Bill (Democrat 10-0)
Status: (Passed) 2014-09-25 - Chaptered by Secretary of State. Chapter 576, Statutes of 2014. [SB1053 Detail]
Download: California-2013-SB1053-Enrolled.html
Bill Title: Health care coverage: contraceptives.
Spectrum: Partisan Bill (Democrat 10-0)
Status: (Passed) 2014-09-25 - Chaptered by Secretary of State. Chapter 576, Statutes of 2014. [SB1053 Detail]
Download: California-2013-SB1053-Enrolled.html
BILL NUMBER: SB 1053 ENROLLED
BILL TEXT
PASSED THE SENATE AUGUST 21, 2014
PASSED THE ASSEMBLY AUGUST 20, 2014
AMENDED IN ASSEMBLY AUGUST 18, 2014
AMENDED IN ASSEMBLY JULY 2, 2014
AMENDED IN ASSEMBLY JUNE 18, 2014
AMENDED IN SENATE MAY 28, 2014
AMENDED IN SENATE APRIL 22, 2014
AMENDED IN SENATE APRIL 9, 2014
INTRODUCED BY Senator Mitchell
(Coauthors: Senators DeSaulnier, Evans, and Wolk)
(Coauthors: Assembly Members Ammiano, Garcia, Mullin, Skinner,
Ting, and Wieckowski)
FEBRUARY 18, 2014
An act to amend Section 1367.25 of the Health and Safety Code, to
amend Section 10123.196 of the Insurance Code, and to amend Section
14132 of the Welfare and Institutions Code, relating to health care
coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 1053, Mitchell. Health care coverage: contraceptives.
Existing law, the federal Patient Protection and Affordable Care
Act (PPACA), enacts various reforms to the health insurance market.
Among other things, PPACA requires a nongrandfathered group health
plan and a health insurance issuer offering group or individual
insurance coverage to provide coverage, without imposing cost-sharing
requirements, for certain preventive services, including those
preventive care and screenings for women provided in specified
guidelines. PPACA requires those plans and issuers to provide
coverage without cost sharing for all federal Food and Drug
Administration approved contraceptive methods, sterilization
procedures, and patient education and counseling for all women with
reproductive capacity, as prescribed by a provider, except as
specified.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care and makes a willful
violation of the act a crime. Existing law also provides for the
regulation of health insurers by the Department of Insurance.
Existing law requires a health care service plan contract or health
insurance policy that provides coverage for outpatient prescription
drug benefits to provide coverage for a variety of federal Food and
Drug Administration (FDA) approved prescription contraceptive methods
designated by the plan or insurer, except as specified. Existing law
authorizes a religious employer, as defined, to request a contract
or policy without coverage of FDA-approved contraceptive methods that
are contrary to the employer's religious tenets and, if so
requested, requires a contract or policy to be provided without that
coverage. Existing law requires an individual or small group health
care service plan contract or health insurance policy issued,
amended, or renewed on or after January 1, 2014, to cover essential
health benefits, which are defined to include the health benefits
covered by particular benchmark plans.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive specified health care
services, including family planning services, subject to certain
utilization controls. The Medi-Cal program is, in part, governed and
funded by federal Medicaid Program provisions. Under existing law,
one of the methods by which Medi-Cal services are provided is
pursuant to contracts with various types of managed care plans.
This bill would require a health care service plan contract or
health insurance policy issued, amended, or renewed on or after
January 1, 2016, to provide coverage for women for all prescribed and
FDA-approved female contraceptive drugs, devices, and products, as
well as voluntary sterilization procedures, contraceptive education
and counseling, and related followup services. The bill would
prohibit a nongrandfathered plan contract or health insurance policy
from imposing any cost-sharing requirements or other restrictions or
delays with respect to this coverage, as specified. The bill would
include Medi-Cal managed plans, as specified, in the definition of a
health care service plan for purposes of these provisions.
The bill would retain the provision authorizing a religious
employer to request a contract or policy without coverage of
FDA-approved contraceptive methods that are contrary to the employer'
s religious tenets. Because a willful violation of the bill's
requirements by a health care service plan would be a crime, the bill
would impose a state-mandated local program.
The bill would require utilization controls for family planning
services for Medi-Cal managed care plans to be subject to the
cost-sharing requirements described above.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature hereby finds and declares all of the
following:
(a) California has a long history of expanding timely access to
birth control to prevent unintended pregnancy.
(b) The federal Patient Protection and Affordable Care Act
includes a contraceptive coverage guarantee as part of a broader
requirement for health insurance carriers and plans to cover key
preventive care services without out-of-pocket costs for patients.
(c) The Legislature intends to build on existing state and federal
law to promote gender equity and women's health and to ensure
greater contraceptive coverage equity and timely access to all
federal Food and Drug Administration approved methods of birth
control for women covered by health care service plan contracts and
health insurance policies in California.
(d) Medical management techniques such as denials, step therapy,
or prior authorization in public and private health care coverage can
impede access to the most effective contraceptive methods.
SEC. 2. Section 1367.25 of the Health and Safety Code is amended
to read:
1367.25. (a) A group health care service plan contract, except
for a specialized health care service plan contract, that is issued,
amended, renewed, or delivered on or after January 1, 2000, through
December 31, 2015, inclusive, and an individual health care service
plan contract that is amended, renewed, or delivered on or after
January 1, 2000, through December 31, 2015, inclusive, except for a
specialized health care service plan contract, shall provide coverage
for the following, under general terms and conditions applicable to
all benefits:
(1) A health care service plan contract that provides coverage
for outpatient prescription drug benefits shall include coverage for
a variety of federal Food and Drug Administration (FDA) approved
prescription contraceptive methods designated by the plan. In the
event the patient's participating provider, acting within his or her
scope of practice, determines that none of the methods designated by
the plan is medically appropriate for the patient's medical or
personal history, the plan shall also provide coverage for another
FDA approved, medically appropriate prescription contraceptive method
prescribed by the patient's provider.
(2) Benefits for an enrollee under this subdivision shall be the
same for an enrollee's covered spouse and covered nonspouse
dependents.
(b) (1) A health care service plan contract, except for a
specialized health care service plan contract, that is issued,
amended, renewed, or delivered on or after January 1, 2016, shall
provide coverage for all of the following services and contraceptive
methods for women:
(A) Except as provided in subparagraphs (B) and (C) of paragraph
(2), all FDA-approved contraceptive drugs, devices, and other
products for women, including all FDA-approved contraceptive drugs,
devices, and products available over the counter, as prescribed by
the enrollee's provider.
(B) Voluntary sterilization procedures.
(C) Patient education and counseling on contraception.
(D) Followup services related to the drugs, devices, products, and
procedures covered under this subdivision, including, but not
limited to, management of side effects, counseling for continued
adherence, and device insertion and removal.
(2) (A) Except for a grandfathered health plan, a health care
service plan subject to this subdivision shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided pursuant to this subdivision.
Cost sharing shall not be imposed on any Medi-Cal beneficiary.
(B) Where the FDA has approved one or more therapeutic equivalents
of a contraceptive drug, device, or product, a health care service
plan is not required to cover all of those therapeutically equivalent
versions in accordance with this subdivision, as long as at least
one is covered without cost sharing in accordance with this
subdivision.
(C) If a covered therapeutic equivalent of a drug, device, or
product is not available, or is deemed medically inadvisable by the
enrollee's provider, a health care service plan shall provide
coverage, subject to a plan's utilization management procedures, for
the prescribed contraceptive drug, device, or product without cost
sharing. Any request by a contracting provider shall be responded to
by the health care service plan in compliance with the Knox-Keene
Health Care Service Plan Act of 1975, as set forth in this chapter
and, as applicable, with the plan's Medi-Cal managed care contract.
(3) Except as otherwise authorized under this section, a health
care service plan shall not impose any restrictions or delays on the
coverage required under this subdivision.
(4) Benefits for an enrollee under this subdivision shall be the
same for an enrollee's covered spouse and covered nonspouse
dependents.
(5) For purposes of paragraphs (2) and (3) of this subdivision,
"health care service plan" shall include Medi-Cal managed care plans
that contract with the State Department of Health Care Services
pursuant to Chapter 7 (commencing with Section 14000) and Chapter 8
(commencing with Section 14200) of Part 3 of Division 9 of the
Welfare and Institutions Code.
(c) Notwithstanding any other provision of this section, a
religious employer may request a health care service plan contract
without coverage for FDA approved contraceptive methods that are
contrary to the religious employer's religious tenets. If so
requested, a health care service plan contract shall be provided
without coverage for contraceptive methods.
(1) For purposes of this section, a "religious employer" is an
entity for which each of the following is true:
(A) The inculcation of religious values is the purpose of the
entity.
(B) The entity primarily employs persons who share the religious
tenets of the entity.
(C) The entity serves primarily persons who share the religious
tenets of the entity.
(D) The entity is a nonprofit organization as described in
Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of
1986, as amended.
(2) Every religious employer that invokes the exemption provided
under this section shall provide written notice to prospective
enrollees prior to enrollment with the plan, listing the
contraceptive health care services the employer refuses to cover for
religious reasons.
(d) Nothing in this section shall be construed to exclude coverage
for contraceptive supplies as prescribed by a provider, acting
within his or her scope of practice, for reasons other than
contraceptive purposes, such as decreasing the risk of ovarian cancer
or eliminating symptoms of menopause, or for contraception that is
necessary to preserve the life or health of an enrollee.
(e) Nothing in this section shall be construed to deny or restrict
in any way the department's authority to ensure plan compliance with
this chapter when a plan provides coverage for contraceptive drugs,
devices, and products.
(f) Nothing in this section shall be construed to require an
individual or group health care service plan contract to cover
experimental or investigational treatments.
(g) For purposes of this section, the following definitions apply:
(1) "Grandfathered health plan" has the meaning set forth in
Section 1251 of PPACA.
(2) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152), and
any rules, regulations, or guidance issued thereunder.
(3) With respect to health care service plan contracts issued,
amended, or renewed on or after January 1, 2016, "provider" means an
individual who is certified or licensed pursuant to Division 2
(commencing with Section 500) of the Business and Professions Code,
or an initiative act referred to in that division, or Division 2.5
(commencing with Section 1797) of this code.
SEC. 3. Section 10123.196 of the Insurance Code is amended to
read:
10123.196. (a) An individual or group policy of disability
insurance issued, amended, renewed, or delivered on or after January
1, 2000, through December 31, 2015, inclusive, that provides coverage
for hospital, medical, or surgical expenses, shall provide coverage
for the following, under the same terms and conditions as applicable
to all benefits:
(1) A disability insurance policy that provides coverage for
outpatient prescription drug benefits shall include coverage for a
variety of federal Food and Drug Administration (FDA) approved
prescription contraceptive methods, as designated by the insurer. If
an insured's health care provider determines that none of the methods
designated by the disability insurer is medically appropriate for
the insured's medical or personal history, the insurer shall, in the
alternative, provide coverage for some other FDA approved
prescription contraceptive method prescribed by the patient's health
care provider.
(2) Coverage with respect to an insured under this subdivision
shall be identical for an insured's covered spouse and covered
nonspouse dependents.
(b) (1) A group or individual policy of disability insurance,
except for a specialized health insurance policy, that is issued,
amended, renewed, or delivered on or after January 1, 2016, shall
provide coverage for all of the following services and contraceptive
methods for women:
(A) Except as provided in subparagraphs (B) and (C) of paragraph
(2), all FDA-approved contraceptive drugs, devices, and other
products for women, including all FDA-approved contraceptive drugs,
devices, and products available over the counter, as prescribed by
the insured's provider.
(B) Voluntary sterilization procedures.
(C) Patient education and counseling on contraception.
(D) Followup services related to the drugs, devices, products, and
procedures covered under this subdivision, including, but not
limited to, management of side effects, counseling for continued
adherence, and device insertion and removal.
(2) (A) Except for a grandfathered health plan, a disability
insurer subject to this subdivision shall not impose a deductible,
coinsurance, copayment, or any other cost-sharing requirement on the
coverage provided pursuant to this subdivision.
(B) Where the FDA has approved one or more therapeutic equivalents
of a contraceptive drug, device, or product, a disability insurer is
not required to cover all of those therapeutically equivalent
versions in accordance with this subdivision, as long as at least one
is covered without cost sharing in accordance with this subdivision.
(C) If a covered therapeutic equivalent of a drug, device, or
product is not available, or is deemed medically inadvisable by the
insured's provider, a disability insurer shall provide coverage,
subject to an insurer's utilization management procedures, for the
prescribed contraceptive drug, device, or product without cost
sharing. Any request by a contracting provider shall be responded to
by the disability insurer in compliance with Section 10123.191.
(3) Except as otherwise authorized under this section, an insurer
shall not impose any restrictions or delays on the coverage required
under this subdivision.
(4) Coverage with respect to an insured under this subdivision
shall be identical for an insured's covered spouse and covered
nonspouse dependents.
(c) Nothing in this section shall be construed to deny or restrict
in any way any existing right or benefit provided under law or by
contract.
(d) Nothing in this section shall be construed to require an
individual or group disability insurance policy to cover experimental
or investigational treatments.
(e) Notwithstanding any other provision of this section, a
religious employer may request a disability insurance policy without
coverage for contraceptive methods that are contrary to the religious
employer's religious tenets. If so requested, a disability insurance
policy shall be provided without coverage for contraceptive methods.
(1) For purposes of this section, a "religious employer" is an
entity for which each of the following is true:
(A) The inculcation of religious values is the purpose of the
entity.
(B) The entity primarily employs persons who share the religious
tenets of the entity.
(C) The entity serves primarily persons who share the religious
tenets of the entity.
(D) The entity is a nonprofit organization pursuant to Section
6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as
amended.
(2) Every religious employer that invokes the exemption provided
under this section shall provide written notice to any prospective
employee once an offer of employment has been made, and prior to that
person commencing that employment, listing the contraceptive health
care services the employer refuses to cover for religious reasons.
(f) Nothing in this section shall be construed to exclude coverage
for contraceptive supplies as prescribed by a provider, acting
within his or her scope of practice, for reasons other than
contraceptive purposes, such as decreasing the risk of ovarian cancer
or eliminating symptoms of menopause, or for contraception that is
necessary to preserve the life or health of an insured.
(g) This section shall only apply to disability insurance policies
or contracts that are defined as health benefit plans pursuant to
subdivision (a) of Section 10198.6, except that for accident only,
specified disease, or hospital indemnity coverage, coverage for
benefits under this section shall apply to the extent that the
benefits are covered under the general terms and conditions that
apply to all other benefits under the policy or contract. Nothing in
this section shall be construed as imposing a new benefit mandate on
accident only, specified disease, or hospital indemnity insurance.
(h) For purposes of this section, the following definitions apply:
(1) "Grandfathered health plan" has the meaning set forth in
Section 1251 of PPACA.
(2) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152), and
any rules, regulations, or guidance issued thereunder.
(3) With respect to policies of disability insurance issued,
amended, or renewed on or after January 1, 2016, "health care
provider" means an individual who is certified or licensed pursuant
to Division 2 (commencing with Section 500) of the Business and
Professions Code, or an initiative act referred to in that division,
or Division 2.5 (commencing with Section 1797) of the Health and
Safety Code.
SEC. 4. 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 Medi-Cal fee-for-service beneficiaries, 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 shall not be construed to 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" shall 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 the
developmentally disabled 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, with the
exception of children's acetaminophen-containing products, selected
by the department are not covered benefits.
(iii) Nonlegend cough and cold products selected by the department
are not covered benefits. This clause shall be implemented on the
first day of the first calendar month following 90 days after the
effective date of the act that added this clause, 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.
(iv) Beneficiaries under the Early and Periodic Screening,
Diagnosis, and Treatment Program shall be exempt from clauses (ii)
and (iii).
(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. Nothing in
this subdivision shall be construed to 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 which are lost or destroyed due to circumstances beyond
the beneficiary's 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
department's California Children 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 July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) 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 beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
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. When 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.
Therapeutic shoes and inserts are covered when provided to
beneficiaries 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 beneficiary's 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 beneficiary's 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, any 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 patient's 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 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 Section 1482 of the article.
(2) All providers 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) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
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
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "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.
As used in this subdivision, in-home medical care services
include, but are not limited to:
(1) Level-of-care and cost-of-care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) 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.
Beneficiaries receiving in-home medical care services are 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 which 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 which are authorized and reimbursable under this
chapter, and services which 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 beneficiaries with
a diagnosis of AIDS or ARC, who require 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 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 the waiver, and subject to the terms,
conditions, and duration of the waiver. These services shall be
provided to individual beneficiaries in accordance with the client's
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 eligible beneficiaries. 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. Nothing in this section shall 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 provision of law,
the collection and use of an individual's 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
provision of 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 Health
Care Financing Administration 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) In the event that 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.
(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.
Beneficiaries under the Early and Periodic Screening, Diagnosis, 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.
SEC. 5. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.
