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SB-1287 Medi-Cal: medically necessary services.(2017-2018)

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Date Published: 04/16/2018 12:45 PM
SB1287:v97#DOCUMENT

Amended  IN  Senate  April 16, 2018
Amended  IN  Senate  March 22, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 1287


Introduced by Senator Hernandez

February 16, 2018


An act to amend Sections 14059.5 and 14132 14133.3 of the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


SB 1287, as amended, Hernandez. Medi-Cal: medically necessary 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, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for an individual under 21 years of age who is covered under the Medi-Cal program, program, subject to utilization controls, and consistent with federal requirements. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.
Existing federal law provides that EPSDT services include screening services; vision services; dental services; hearing services; and other necessary health care, diagnostic services, treatment, and other measures described in specified federal provisions to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the necessary services are covered under the state plan.
Under the Medi-Cal program, existing state law, a service is “medically necessary” if it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.
This bill would revise the Medi-Cal definition of “medically necessary” for purposes of an individual under 21 years of age to incorporate the existing description of necessary EPSDT services under federal law. The bill would clarify, within the schedule of benefits under the Medi-Cal program for an individual under 21 years of age, that EPSDT services include those medically necessary services. clarify the meaning of “medically necessary” with regard to prior authorization controls in the Medi-Cal program.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: NO   Local Program: NO  

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


SECTION 1.

 Section 14059.5 of the Welfare and Institutions Code is amended to read:

14059.5.
 (a) For individuals 21 years of age or older, a service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.
(b) For individuals under 21 years of age, a service is “medically necessary” or a “medical necessity” if it is a service provided pursuant to paragraph (2) of subdivision (v) of Section 14132. if the service is:
(1) An early and periodic screening, diagnosis, and treatment, as described in Section 1396d(r)(1) to (4), inclusive, of Title 42 of the United States Code. or
(2) Any other necessary health care, diagnostic services, treatment, and other measures, as 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 service identified under paragraph (1) of this subdivision, whether or not such services are covered under the state plan.

SEC. 2.

 Section 14133.3 of the Welfare and Institutions Code is amended to read:

14133.3.
 (a) The director shall require fully documented medical justification from providers that the requested services are medically necessary to prevent significant illness, to alleviate severe pain, to protect life, or to prevent significant disability, or a medical necessity, as defined in Section 14059.5, on all requests for prior authorization.
(b) For services not subject to prior authorization controls, offered by noncontract hospitals in closed health facility planning areas to beneficiaries who were experiencing life-threatening or emergency situations, but could not be stabilized sufficiently in order to facilitate being transported to contracting hospitals, the director shall additionally determine utilization controls that shall be applied to ensure that the health care services provided and the conditions treated, are medically necessary to prevent significant illness, alleviate severe pain, to protect life, or prevent significant disability. These utilization controls shall take into account those diseases, illnesses, or injuries that require preventive health services or treatment to prevent serious deterioration of health.
(c) Nothing in this section shall preclude payment for family planning services or early and periodic screening, diagnosis, and treatment services mandated by federal law.
(d) For the purposes of this section, a “noncontract hospital” means a hospital that has not contracted with the department for the provision of inpatient services pursuant to Article 2.6 (commencing with Section 14081).
(e) This section shall not be applied to mental health services as defined under Division 5 (commencing with Section 5000) or Section 14021, or any other mental health services funded by the Medi-Cal program.