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SB-437 Health care coverage: joint senior level working group.(2017-2018)

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Date Published: 04/07/2017 04:00 AM
SB437:v98#DOCUMENT

Amended  IN  Senate  April 06, 2017

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 437


Introduced by Senator Atkins

February 15, 2017


An act to amend Section 14132.01 of the Welfare and Institutions Code, relating to Medi-Cal. 1342.4 of the Health and Safety Code, and to amend Section 12923.5 of the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


SB 437, as amended, Atkins. Medi-Cal: clinics: drugs and supplies. Health care coverage: joint senior level working group.
Existing law requires the Department of Managed Health Care and the Department of Insurance to maintain a joint senior level working group to ensure clarity for health care consumers about who enforces their patient rights and consistency in the regulations for these departments. Existing law requires the joint working group to review and examine various processes in each department, including the examination of the grievance and consumer complaint processes that include, without limitation, outreach and standard complaints. Existing law requires the joint working group to report its findings to the Insurance Commissioner and the Director of the Department of Managed Health Care for review and approval.
This bill would also require the joint working group to review and examine timely access to care and network adequacy as part of its review of the grievance and consumer complaint processes, and to review and examine the state implementation of federal health care reforms, including any changes in federal law, or rules, regulations, or guidance issued under federal law.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law establishes the Family Planning, Access, Care, and Treatment (Family PACT) Program, administered by the Office of Family Planning, to provide comprehensive clinical family planning services to a person who has a family income at or below 200% of the federal poverty level and who is eligible to receive those services. Existing law requires reimbursement for drugs and supplies covered under the Medi-Cal program and the Family PACT Program by a licensed community clinic or free clinic, or an intermittent clinic, to be the lesser of the amount billed or the Medi-Cal reimbursement rate and caps reimbursement at the net cost of the drugs or products as provided to retail pharmacies under the Medi-Cal program. Existing law sets the costs for drugs and supplies covered under those programs at an aggregate amount equivalent to the sum of the actual acquisition cost of a drug or supply plus a clinic dispensing fee not to exceed $12 per billing unit, as specified. Existing law also sets the cost for a take-home drug that is dispensed for use by the patient within a specific timeframe of 5 or less days from the date medically indicated at the actual acquisition cost for that drug plus a clinic dispensing fee, not to exceed $17 per prescription.

This bill would make technical, nonsubstantive changes to this provision.

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

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


SECTION 1.

 Section 1342.4 of the Health and Safety Code is amended to read:

1342.4.
 (a)  The Department of Managed Health Care and the Department of Insurance shall maintain a joint senior level working group to ensure clarity for health care consumers about who enforces their patient rights and consistency in the regulations of these departments.
(b)  The joint working group shall undertake a review and examination of the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code as they apply to the Department of Managed Health Care and the Department of Insurance to ensure consistency in consumer protection.
(c)  The joint working group shall review and examine all of the following processes in each department:
(1)  Grievance The grievance and consumer complaint processes, including, but not limited to, outreach, standard complaints, including coverage and medical necessity complaints, timely access to care, network adequacy, independent medical review, and information developed for consumer use.
(2)  The processes used to ensure enforcement of the law, including, but not limited to, the medical survey and audit process in the Health and Safety Code and market conduct exams in the Insurance Code.
(3) The state implementation of federal health care reforms, including any changes in federal law, or rules, regulations, or guidance issued under federal law.

(3)

(4) The processes for regulating the timely payment of claims.
(d)  The joint working group shall report its findings to the Insurance Commissioner and the Director of the Department of Managed Health Care for review and approval. The commissioner and the director shall submit the approved final report under signature to the Legislature by January 1 of every year for five years.

SEC. 2.

 Section 12923.5 of the Insurance Code is amended to read:

12923.5.
 (a) The Department of Managed Health Care and the Department of Insurance shall maintain a joint senior level working group to ensure clarity for health care consumers about who enforces their patient rights and consistency in the regulations of these departments.
(b) The joint working group shall undertake a review and examination of the Health and Safety Code, the Insurance Code, and the Welfare and Institutions Code as they apply to the Department of Managed Health Care and the Department of Insurance to ensure consistency in consumer protection.
(c) The joint working group shall review and examine all of the following processes in each department:
(1) Grievance The grievance and consumer complaint processes, including, but not limited to, outreach, standard complaints, including coverage and medical necessity complaints, timely access to care, network adequacy, independent medical review, and information developed for consumer use.
(2) The processes used to ensure enforcement of the law, including, but not limited to, the medical survey and audit process in the Health and Safety Code and market conduct exams in the Insurance Code.
(3) The state implementation of federal health care reforms, including any changes in federal law, or rules, regulations, or guidance issued under federal law.

(3)

(4) The processes for regulating the timely payment of claims.
(d) The joint working group shall report its findings to the Insurance Commissioner and the Director of the Department of Managed Health Care for review and approval. The commissioner and the director shall submit the approved final report under signature to the Legislature by January 1 of every year for five years.

SECTION 1.Section 14132.01 of the Welfare and Institutions Code is amended to read:
14132.01.

(a)Notwithstanding any other law, a community clinic or free clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or an intermittent clinic operating pursuant to subdivision (h) of Section 1206 of the Health and Safety Code, that has a valid license pursuant to Article 13 (commencing with Section 4180) of Chapter 9 of Division 2 of the Business and Professions Code shall bill and be reimbursed, as described in this section, for drugs and supplies covered under the Medi-Cal program and Family PACT Program.

(b)(1)A clinic described in subdivision (a) shall bill the Medi-Cal program and Family PACT Program for drugs and supplies covered under those programs at the lesser of cost or the clinic’s usual charge made to the general public.

(2)For purposes of this section, “cost” means an aggregate amount equivalent to the sum of the actual acquisition cost of a drug or supply plus a clinic dispensing fee not to exceed twelve dollars ($12) per billing unit as identified in either the Family PACT Policies, Procedures, and Billing Instructions Manual, or the Medi-Cal Inpatient/Outpatient Provider Manual governing outpatient clinic billing for drugs and supplies, as applicable. For purposes of this section, “cost” for a take-home drug that is dispensed for use by the patient within a specific timeframe of five or less days from the date medically indicated means actual acquisition cost for that drug plus a clinic dispensing fee, not to exceed seventeen dollars ($17) per prescription. Reimbursement shall be at the lesser of the amount billed or the Medi-Cal reimbursement rate, and shall not exceed the net cost of these drugs or supplies when provided by retail pharmacies under the Medi-Cal program.

(c)A clinic described in subdivision (a) that furnishes services free of charge, or at a nominal charge, as defined in subsection (a) of Section 413.13 of Title 42 of the Code of Federal Regulations, or that can demonstrate to the department, upon request, that it serves primarily low-income patients, and its customary practice is to charge patients on the basis of their ability to pay, shall not be subject to reimbursement reductions based on its usual charge to the general public.

(d)Federally qualified health centers and rural health clinics that are clinics as described in subdivision (a) may bill and be reimbursed as described in this section, upon electing to be reimbursed for pharmaceutical goods and services on a fee-for-service basis, as permitted by subdivision (k) of Section 14132.100.

(e)A clinic that otherwise meets the qualifications set forth in subdivision (a), that is eligible to, but that has elected not to, utilize drugs purchased under the 340B Discount Drug Program for its Medi-Cal patients, shall provide notification to the Health Resources and Services Administration’s Office of Pharmacy Affairs that it is utilizing non-340B drugs for its Medi-Cal patients in the manner and to the extent required by federal law.