BILL NUMBER: AB 1803	INTRODUCED
	BILL TEXT


INTRODUCED BY   Assembly Member Mitchell

                        FEBRUARY 21, 2012

   An act to amend Section 14134 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 1803, as introduced, Mitchell. Medi-Cal: copayments.
   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 health care services.
The Medi-Cal program is, in part, governed and funded by federal
Medicaid Program provisions. Existing law requires Medi-Cal
beneficiaries to make set copayments for specified services and, upon
federal approval, existing law revises these copayment rates and
makes other related changes, as specified.
   This bill would make technical, nonsubstantive changes to these
provisions.
   Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.


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

  SECTION 1.  Section 14134 of the Welfare and Institutions Code, as
amended by Chapter 3 of the Statutes of 2011, is amended to read:
   14134.  (a) Except for any prescription, refill, visit, service,
device, or item for which the program's payment is ten dollars ($10)
or less, in which case no copayment shall be required, a recipient of
services under this chapter shall be required to make copayments not
to exceed the maximum permitted under federal regulations or federal
waivers as follows:
   (1) Copayment of five dollars ($5) shall be made for nonemergency
services received in an emergency room. For the purposes of this
section, "nonemergency services" means any services not required for
the alleviation of severe pain or the immediate diagnosis and
treatment of severe medical conditions which, if not immediately
diagnosed and treated, would lead to disability or death.
   (2) Copayment of one dollar ($1) shall be made for each drug
prescription or refill.
   (3) Copayment of one dollar ($1) shall be made for each visit for
services under subdivisions (a) and (h) of Section 14132.
   (4) The copayment amounts set forth in paragraphs (1), (2), and
(3) may be collected and retained or waived by the provider.
   (5) The department shall not reduce the reimbursement otherwise
due to providers as a result of the copayment. The copayment amounts
shall be in addition to any reimbursement otherwise due the provider
for services rendered under this program.
   (6) This section does not apply to emergency services, family
planning services, or to any services received by:
   (A) Any child in AFDC-Foster Care, as defined in Section 11400.
   (B) Any person who is an inpatient in a health facility, as
defined in Section 1250 of the Health and Safety Code.
   (C) Any person 18 years of age or under.
   (D) Any woman receiving perinatal care.
   (7) Paragraph (2) does not apply to any person 65 years of age or
over.
   (8) A provider of service shall not deny care or services to an
individual solely because of that person's inability to copay under
this section. An individual shall, however, remain liable to the
provider for any copayment amount owed.
   (9) The department shall seek any federal waivers necessary to
implement this section. The provisions for which appropriate federal
waivers cannot be obtained shall not be implemented, but provisions
for which waivers are either obtained or found to be unnecessary
shall be unaffected by the inability to obtain federal waivers for
the other provisions.
   (10) The director shall adopt any regulations necessary to
implement this section as emergency regulations in accordance with
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code. The adoption of the regulations
shall be deemed to be an emergency and necessary for the immediate
preservation of the public peace, health and safety, or general
welfare. The director shall transmit these emergency regulations
directly to the Secretary of State for filing and the regulations
shall become effective immediately upon filing. Upon completion of
the formal regulation adoption process and prior to the expiration of
the 120 day duration period of emergency regulations, the director
shall transmit directly to the Secretary of State for filing the
adopted regulations, the rulemaking file, and the certification of
compliance as required by subdivision (e) of Section 11346.1 of the
Government Code.
   (b) This section shall become inoperative on the implementation
date for copayments stated in the declaration executed by the
director pursuant to Section 14134  ,  as added by Section
101.5 of the act that added this subdivision, and is repealed on
January 1 of the following year.
  SEC. 2.  Section 14134 of the Welfare and Institutions Code, as
added by Chapter 3 of the Statutes of 2011, is amended to read:
   14134.  (a) The Legislature finds and declares all of the
following:
   (1) Costs within the Medi-Cal program continue to grow due to the
rising cost of providing health care throughout the state and also
due to increases in enrollment, which are more pronounced during
difficult economic times.
   (2) In order to minimize the need for drastically cutting
enrollment standards or benefits or imposing further reductions on
Medi-Cal providers during times of economic crisis, it is crucial to
find areas within the program where beneficiaries can share
responsibility for utilization of health care, whether they are
participating in the fee-for-service or the managed care model of
service delivery.
   (3) The establishment of cost-sharing obligations within the
Medi-Cal program is complex and is subject to close supervision by
the United States Department of Health and Human Services.
   (4) As the single state agency for Medicaid in California, the
State Department of Health Care Services has unique expertise that
can inform decisions that set or adjust cost-sharing responsibilities
for Medi-Cal beneficiaries receiving health care services.
   (b) Therefore, it is the intent of the Legislature for the
department to obtain federal approval to implement cost-sharing for
Medi-Cal beneficiaries and permit providers to require that
individuals meet their cost-sharing obligation prior to receiving
care or services.
   (c) A Medi-Cal beneficiary shall be required to make copayments as
described in this section. These copayments represent a contribution
toward the rate of payment made to providers of Medi-Cal services
and shall be as follows:
   (1) Copayment of up to fifty dollars ($50) shall be made for
nonemergency services received in an emergency room. For the purposes
of this section, "nonemergency services" means services not required
for the alleviation of severe pain or the immediate diagnosis and
treatment of unforeseen medical conditions that, if not immediately
diagnosed and treated, would lead to disability or death.
   (2) Copayment of up to fifty dollars ($50) shall be made for
emergency services received in an emergency room. For purposes of
this section, "emergency services" means services required for the
alleviation of severe pain or the immediate diagnosis and treatment
of unforeseen medical conditions that, if not immediately diagnosed
and treated, would lead to disability or death.
   (3) Copayment of up to one hundred dollars ($100) shall be made
for each hospital inpatient day, up to a maximum of two hundred
dollars ($200) per admission.
   (4) Copayment of up to three dollars ($3) shall be made for each
preferred drug prescription or refill. A copayment of up to five
dollars ($5) shall be made for each nonpreferred drug prescription or
refill. Except as provided in subdivision (g), "preferred drug"
shall have the same meaning as in Section 1916A of the Social
Security Act (42 U.S.C. Sec. 1396o-1).
   (5) Copayment of up to five dollars ($5) shall be made for each
visit for services under subdivision (a) of Section 14132 and for
dental services received on an outpatient basis provided as a
Medi-Cal benefit pursuant to this chapter or Chapter 8 (commencing
with Section 14200), as applicable.
   (6) This section does not apply to services provided pursuant to
subdivision (aa) of Section 14132.
   (d) The copayments established pursuant to subdivision (c) shall
be set by the department, at the maximum amount provided for in the
applicable paragraph, except that each copayment amount shall not
exceed the maximum amount allowable pursuant to the state plan
amendments or other federal approvals.
   (e) The copayment amounts set forth in subdivision (c) may be
collected and retained or waived by the provider. The department
shall deduct the amount of the copayment from the payment the
department makes to the provider whether retained, waived, or not
collected by the provider.
   (f) Notwithstanding any other  provision of  law,
and only to the extent allowed pursuant to federal law, a provider
of service has no obligation to provide services to a Medi-Cal
beneficiary who does not, at the point of service, pay the copayment
assessed pursuant to this section. If the provider provides services
without collecting the copayment, and has not waived the copayment,
the provider may hold the beneficiary liable for the copayment amount
owed.
   (g) (1) Notwithstanding any other  provision of 
law, except as described in paragraph (2), this section shall apply
to Medi-Cal beneficiaries enrolled in a health plan contracting with
the department pursuant to this chapter or Chapter 8 (commencing with
Section 14200), except for Senior Care Action Network or AIDS
Healthcare Foundation. To the extent permitted by federal law and
pursuant to any federal waivers or state plan adjustments obtained, a
managed care health plan may establish a lower copayment or no
copayment.
   (2) For the purpose of paragraph (4) of subdivision (c),
copayments assessed against a beneficiary who receives Medi-Cal
services through a health plan described in paragraph (1) shall be
based on the plan's designation of a drug as preferred or
nonpreferred.
   (3) To the extent provided by federal law, capitation payments
shall be calculated on an actuarial basis as if copayments described
in this section were collected.
   (h) This section shall be implemented only to the extent that
federal financial participation is available. The department shall
seek and obtain any federal waivers or state plan amendments
necessary to implement this section. The provisions for which
appropriate federal waivers or state plan amendments cannot be
obtained shall not be implemented, but provisions for which waivers
or state plan amendments are either obtained or found to be
unnecessary shall be unaffected by the inability to obtain federal
waivers or state plan amendments for the other provisions.
   (i) 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, interpret, or make specific this section by
means of all-county letters, all-plan letters, provider bulletins,
or similar instructions, without taking further regulatory actions.
   (j) (1) This section shall become operative on the date that the
act adding this section is effective, but shall not be implemented
until the date in the declaration executed by the director pursuant
to paragraph (2). In no event shall the director set an
implementation date prior to the date federal approval is received.
   (2) The director shall execute a declaration that states the date
that implementation of the copayments described in this section will
commence and shall post the declaration on the department's Internet
Web site and provide a copy of the declaration to the Chair of the
Joint Legislative Budget Committee, the Chief Clerk of the Assembly,
the Secretary of the Senate, the Office of the Legislative Counsel,
and the Secretary of State.