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AB-1892 Medi-Cal: orthotic and prosthetic appliances.(2021-2022)



Current Version: 04/07/22 - Amended Assembly

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AB1892:v97#DOCUMENT

Amended  IN  Assembly  April 07, 2022
Amended  IN  Assembly  March 23, 2022

CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Assembly Bill
No. 1892

Introduced by Assembly Member Flora
(Coauthors: Assembly Members Fong, Gray, and Villapudua)

February 09, 2022

An act to amend Section 14105.21 of the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 1892, as amended, Flora. Medi-Cal: orthotic and prosthetic appliances.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, 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.
Existing law requires the department to establish a list of covered services and maximum allowable reimbursement rates for prosthetic and orthotic appliances and requires that the list be published in provider manuals. Existing law prohibits reimbursement for prosthetic and orthotic appliances from exceeding 80% of the lowest maximum allowance for California established by the federal Medicare Program for the same or similar services.
This bill would instead require reimbursement for these appliances to be set at least at 80% of the lowest maximum allowance for California established by the federal Medicare Program, and would require that reimbursement to be adjusted annually, as specified.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   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 California Orthotic and Prosthetic Patient Access and Fairness Act.

SEC. 2.

 The Legislature finds and declares all of the following:
(a) Certified orthotists and prosthetists are medical professionals who have specialized training to assess the mobility and functional needs of patients and apply orthotic and prosthetic appliances, as prescribed by an appropriately licensed health care provider.
(b) Orthotic and prosthetic appliances are worn by the patient to assist or replace the functioning of a natural part of the human body.
(c) Most orthotic and prosthetic users must wear an appliance on a daily basis, and these users rely on their prosthetic limb or orthotic brace to optimize their ability to participate in activities of daily living, including seemingly simple tasks such as walking within their own home, cooking, running errands, and getting to medical appointments.
(d) Lack of access to orthotic and prosthetic professionals, or the incorrect use of these types of appliances because of inadequate access, education, and support, increases the prevalence of chronic and life-threatening health problems.
(e) For patients who require long-term use of their appliances, there is required maintenance and continued interaction with their orthotic and prosthetic provider to ensure the appliance is appropriately fitting and functioning. The care needed is not simply a one-time encounter, but many encounters over a long period of time.
(f) Medi-Cal beneficiaries are sometimes left with no choice but to utilize used or obsolete technology, rely on crutches or a wheelchair as their only source of mobility, or continue using ill-fitting appliances that could lead to safety concerns.
(g) The cost of health care materials, labor, equipment, and utilities needed to fabricate and dispense these products has increased substantially. In many cases, the current Medi-Cal rates are below the actual cost of making and fitting the appliance. As such, Medi-Cal is no longer accepted by an increasing number of orthotic and prosthetic practitioners throughout California.
(h) Without a long-overdue increase to Medi-Cal reimbursement rates for prosthetic and orthotic appliances, socially vulnerable patients, many of whom are amputees, will continue to have challenges accessing orthotic and prosthetic care and will suffer from ongoing mobility and independence challenges.

SEC. 3.

 Section 14105.21 of the Welfare and Institutions Code is amended to read:

14105.21.
 (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.
(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.
(c) The department shall establish a list of covered services and maximum allowable reimbursement rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.
(d) Reimbursement for prosthetic and orthotic appliances, as described in Section 51161 of Title 22 of the California Code of Regulations, shall be at least 80 percent of the lowest maximum allowance for California established by the federal Medicare Program for the same or similar services and shall be adjusted annually to conform to any relevant changes in the Medicare Program.
(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.
(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.