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

Senate BillNo. 1053


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,begin delete andend delete to amend Section 10123.196 of the Insurance Code,begin insert and to amend Section 14132 of the Welfare and Institutions Code,end insert relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 1053, as amended, 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.

begin insert

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.

end insert

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,begin delete except as specified. Theend deletebegin insert but would authorize cost-sharing for equivalent nonpreferred drugs, devices, or products unless, among other exceptions, the enrollee is a Medi-Cal beneficiary, 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.end insert

begin insert Theend insert 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.

begin insert

The bill would require utilization controls for family planning services for Medi-Cal managed care plans to be subject the cost-sharing requirements described above.

end insert

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.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

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

P3    1

SECTION 1.  

The Legislature hereby finds and declares all of
2the following:

3(a) California has a long history of expanding timely access to
4birth control to prevent unintended pregnancy.

5(b) The federal Patient Protection and Affordable Care Act
6includes a contraceptive coverage guarantee as part of a broader
7requirement for health insurance carriers and plans to cover key
8preventive care services without out-of-pocket costs for patients.

9(c) The Legislature intends to build on existing state and federal
10law to promote gender equity and women’s health and to ensure
11greater contraceptive coverage equity and timely access to all
12federal Food and Drug Administration approved methods of birth
13control for women covered by health care service plan contracts
14and health insurance policies in California.

15(d) Medical management techniques such as denials, step
16therapy, or prior authorization in public and private health care
17coverage can impede access to the most effective contraceptive
18methods.

P4    1

SEC. 2.  

Section 1367.25 of the Health and Safety Code is
2amended to read:

3

1367.25.  

(a)  A group health care service plan contract, except
4for a specialized health care service plan contract, that is issued,
5amended, renewed, or delivered on or after January 1, 2000,
6through December 31, 2015, inclusive, and an individual health
7care service plan contract that is amended, renewed, or delivered
8on or after January 1, 2000, through December 31, 2015, inclusive,
9except for a specialized health care service plan contract, shall
10provide coverage for the following, under general terms and
11conditions applicable to all benefits:

12(1)  A health care service plan contract that provides coverage
13for outpatient prescription drug benefits shall include coverage for
14a variety of federal Food and Drug Administration (FDA) approved
15prescription contraceptive methods designated by the plan. In the
16event the patient’s participating provider, acting within his or her
17scope of practice, determines that none of the methods designated
18by the plan is medically appropriate for the patient’s medical or
19personal history, the plan shall also provide coverage for another
20FDA approved, medically appropriate prescription contraceptive
21method prescribed by the patient’s provider.

22(2)  Benefits for an enrollee under this subdivision shall be the
23same for an enrollee’s covered spouse and covered nonspouse
24dependents.

25(b) (1) A group or individual health care service plan contract,
26except for a specialized health care service plan contract, that is
27issued, amended, renewed, or delivered on or after January 1, 2016,
28shall provide coverage for all of the following for women:

29(A) All FDA approved contraceptive drugs, devices, and
30products for women, including drugs, devices, and products
31available over the counter, as prescribed by the enrollee’s provider.

32(B) Voluntary sterilization procedures.

33(C) Patient education and counseling on contraception.

34(D) Followup services related to the drugs, devices, products,
35and procedures covered under this subdivision, including, but not
36limited to, management of side effects, counseling for continued
37adherence, and device removal.

38(2) (A) Except for a grandfathered health plan, and subject to
39subparagraph (B), a health care service plan subject to this
40subdivision shall not impose a deductible, coinsurance, copayment,
P5    1or any other cost-sharing requirement on the coverage provided
2pursuant to this subdivision.

3(B) A health care service plan may cover a generic or preferred
4drug, device, or product without cost sharing and impose cost
5sharing for equivalent nonpreferred drugs, devices, orbegin delete productsend delete
6begin insert products, except that cost sharing shall not be imposed on any
7Medi-Cal beneficiaryend insert
. However, if a generic or preferred version
8of a drug, device, or product is not available, or is deemed
9medically inadvisable by the enrollee’s provider, a health care
10service plan shall provide coverage for the nonpreferred drug,
11device, or product without cost sharing.

12(3) Except as otherwise authorized under this section, a health
13care service plan shall not impose any restrictions or delays on the
14coverage required under this subdivision.

15(4) Benefits for an enrollee under this subdivision shall be the
16same for an enrollee’s covered spouse and covered nonspouse
17dependents.

begin insert

18(5) For purposes of paragraphs (2) and (3) of this subdivision,
19“health care service plan” shall include Medi-Cal managed care
20plans that contract with the State Department of Health Care
21Services pursuant to Chapter 7 (commencing with Section 14000)
22and Chapter 8 (commencing with Section 14200) of Part 3 of
23Division 9 of the Welfare and Institutions Code.

end insert

24(c) Notwithstanding any other provision of this section, a
25religious employer may request a health care service plan contract
26without coverage for FDA approved contraceptive methods that
27are contrary to the religious employer’s religious tenets. If so
28requested, a health care service plan contract shall be provided
29without coverage for contraceptive methods.

30(1)  For purposes of this section, a “religious employer” is an
31entity for which each of the following is true:

32(A)  The inculcation of religious values is the purpose of the
33entity.

34(B)  The entity primarily employs persons who share the
35religious tenets of the entity.

36(C)  The entity serves primarily persons who share the religious
37tenets of the entity.

38(D)  The entity is a nonprofit organization as described in
39 Section 6033(a)(2)(A)i or iii, of the Internal Revenue Code of
401986, as amended.

P6    1(2)  Every religious employer that invokes the exemption
2provided under this section shall provide written notice to
3prospective enrollees prior to enrollment with the plan, listing the
4contraceptive health care services the employer refuses to cover
5for religious reasons.

6(d) Nothing in this section shall be construed to exclude
7coverage for contraceptive supplies as prescribed by a provider,
8acting within his or her scope of practice, for reasons other than
9contraceptive purposes, such as decreasing the risk of ovarian
10cancer or eliminating symptoms of menopause, or for contraception
11that is necessary to preserve the life or health of an enrollee.

12(e) Nothing in this section shall be construed to deny or restrict
13in any way the department’s authority to ensure plan compliance
14with this chapter when a plan provides coverage for contraceptive
15drugs, devices, and products.

16(f) Nothing in this section shall be construed to require an
17individual or group health care service plan contract to cover
18experimental or investigational treatments.

19(g) For purposes of this section, the following definitions apply:

20(1) “Grandfathered health plan” has the meaning set forth in
21Section 1251 of PPACA.

22(2) “PPACA” means the federal Patient Protection and
23Affordable Care Act (Public Law 111-148), as amended by the
24federal Health Care and Education Reconciliation Act of 2010
25(Public Law 111-152), and any rules, regulations, or guidance
26issued thereunder.

27(3) With respect to health care service plan contracts issued,
28amended, or renewed on or after January 1, 2016, “provider” means
29an individual who is certified or licensed pursuant to Division 2
30(commencing with Section 500) of the Business and Professions
31Code, or an initiative act referred to in that division, or Division
322.5 (commencing with Section 1797).

33

SEC. 3.  

Section 10123.196 of the Insurance Code is amended
34to read:

35

10123.196.  

(a) An individual or group policy of disability
36insurance issued, amended, renewed, or delivered on or after
37January 1, 2000, through December 31, 2015, inclusive, that
38provides coverage for hospital, medical, or surgical expenses, shall
39provide coverage for the following, under the same terms and
40conditions as applicable to all benefits:

P7    1(1) A disability insurance policy that provides coverage for
2outpatient prescription drug benefits shall include coverage for a
3variety of federal Food and Drug Administration (FDA) approved
4prescription contraceptive methods, as designated by the insurer.
5If an insured’s health care provider determines that none of the
6methods designated by the disability insurer is medically
7 appropriate for the insured’s medical or personal history, the insurer
8shall, in the alternative, provide coverage for some other FDA
9approved prescription contraceptive method prescribed by the
10patient’s health care provider.

11(2) Coverage with respect to an insured under this subdivision
12shall be identical for an insured’s covered spouse and covered
13nonspouse dependents.

14(b) (1) A group or individual policy of disability insurance,
15except for a specialized health insurance policy, that is issued,
16amended, renewed, or delivered on or after January 1, 2016, shall
17provide coverage for all of the following for women:

18(A) All FDA approved contraceptive drugs, devices, and
19products for women, including drugs, devices, and products
20available over the counter, as prescribed by the insured’s provider.

21(B) Voluntary sterilization procedures.

22(C) Patient education and counseling on contraception.

23(D) Followup services related to the drugs, devices, products,
24and procedures covered under this subdivision, including, but not
25limited to, management of side effects, counseling for continued
26adherence, and device removal.

27(2) (A) Except for a grandfathered health plan, and subject to
28subparagraph (B), a disability insurer subject to this subdivision
29shall not impose a deductible, coinsurance, copayment, or any
30other cost-sharing requirement on the coverage provided pursuant
31to this subdivision.

32(B) A disability insurer may cover a generic or preferred drug,
33 device, or product without cost sharing and impose cost sharing
34for an equivalent nonpreferred drug, device, or product. However,
35if a generic or preferred version of a drug, device, or product is
36not available, or is deemed medically inadvisable by the insured’s
37provider, a disability insurer shall provide coverage for the
38nonpreferred drug, device, or product without cost sharing.

P8    1(3) Except as otherwise authorized under this section, an insurer
2shall not impose any restrictions or delays on the coverage required
3under this subdivision.

4(4) Coverage with respect to an insured under this subdivision
5shall be identical for an insured’s covered spouse and covered
6nonspouse dependents.

7(c) Nothing in this section shall be construed to deny or restrict
8in any way any existing right or benefit provided under law or by
9 contract.

10(d) Nothing in this section shall be construed to require an
11individual or group disability insurance policy to cover
12experimental or investigational treatments.

13(e) Notwithstanding any other provision of this section, a
14religious employer may request a disability insurance policy
15without coverage for contraceptive methods that are contrary to
16the religious employer’s religious tenets. If so requested, a
17disability insurance policy shall be provided without coverage for
18contraceptive methods.

19(1) For purposes of this section, a “religious employer” is an
20entity for which each of the following is true:

21(A) The inculcation of religious values is the purpose of the
22entity.

23(B) The entity primarily employs persons who share the religious
24tenets of the entity.

25(C) The entity serves primarily persons who share the religious
26tenets of the entity.

27(D) The entity is a nonprofit organization pursuant to Section
286033(a)(2)(A)(i) or (iii) of the Internal Revenue Code of 1986, as
29amended.

30(2) Every religious employer that invokes the exemption
31provided under this section shall provide written notice to any
32prospective employee once an offer of employment has been made,
33and prior to that person commencing that employment, listing the
34contraceptive health care services the employer refuses to cover
35for religious reasons.

36(f) Nothing in this section shall be construed to exclude coverage
37for contraceptive supplies as prescribed by a provider, acting within
38his or her scope of practice, for reasons other than contraceptive
39purposes, such as decreasing the risk of ovarian cancer or
P9    1eliminating symptoms of menopause, or for contraception that is
2necessary to preserve the life or health of an insured.

3(g) This section shall only apply to disability insurance policies
4or contracts that are defined as health benefit plans pursuant to
5subdivision (a) of Section 10198.6, except that for accident only,
6specified disease, or hospital indemnity coverage, coverage for
7benefits under this section shall apply to the extent that the benefits
8are covered under the general terms and conditions that apply to
9all other benefits under the policy or contract. Nothing in this
10section shall be construed as imposing a new benefit mandate on
11accident only, specified disease, or hospital indemnity insurance.

12(h) For purposes of this section, the following definitions apply:

13(1) “Grandfathered health plan” has the meaning set forth in
14Section 1251 of PPACA.

15(2) “PPACA” means the federal Patient Protection and
16Affordable Care Act (Public Law 111-148), as amended by the
17federal Health Care and Education Reconciliation Act of 2010
18(Public Law 111-152), and any rules, regulations, or guidance
19issued thereunder.

20(3) With respect to policies of disability insurance issued,
21amended, or renewed on or after January 1, 2016, “health care
22provider” means an individual who is certified or licensed pursuant
23to Division 2 (commencing with Section 500) of the Business and
24Professions Code, or an initiative act referred to in that division,
25or Division 2.5 (commencing with Section 1797) of the Health
26and Safety Code.

27begin insert

begin insertSEC. 4.end insert  

end insert

begin insertSection 14132 of the end insertbegin insertWelfare and Institutions Codeend insertbegin insert is
28amended to read:end insert

29

14132.  

The following is the schedule of benefits under this
30chapter:

31(a) Outpatient services are covered as follows:

32Physician, hospital or clinic outpatient, surgical center,
33respiratory care, optometric, chiropractic, psychology, podiatric,
34occupational therapy, physical therapy, speech therapy, audiology,
35acupuncture to the extent federal matching funds are provided for
36acupuncture, and services of persons rendering treatment by prayer
37or healing by spiritual means in the practice of any church or
38religious denomination insofar as these can be encompassed by
39federal participation under an approved plan, subject to utilization
40controls.

P10   1(b) (1) Inpatient hospital services, including, but not limited
2to, physician and podiatric services, physical therapy and
3occupational therapy, are covered subject to utilization controls.

4(2) For Medi-Cal fee-for-service beneficiaries, emergency
5services and care that are necessary for the treatment of an
6emergency medical condition and medical care directly related to
7the emergency medical condition. This paragraph shall not be
8construed to change the obligation of Medi-Cal managed care
9plans to provide emergency services and care. For the purposes of
10this paragraph, “emergency services and care” and “emergency
11medical condition” shall have the same meanings as those terms
12are defined in Section 1317.1 of the Health and Safety Code.

13(c) Nursing facility services, subacute care services, and services
14provided by any category of intermediate care facility for the
15developmentally disabled, including podiatry, physician, nurse
16practitioner services, and prescribed drugs, as described in
17subdivision (d), are covered subject to utilization controls.
18Respiratory care, physical therapy, occupational therapy, speech
19therapy, and audiology services for patients in nursing facilities
20and any category of intermediate care facility for the
21developmentally disabled are covered subject to utilization controls.

22(d) (1) Purchase of prescribed drugs is covered subject to the
23Medi-Cal List of Contract Drugs and utilization controls.

24(2) Purchase of drugs used to treat erectile dysfunction or any
25off-label uses of those drugs are covered only to the extent that
26federal financial participation is available.

27(3) (A) To the extent required by federal law, the purchase of
28outpatient prescribed drugs, for which the prescription is executed
29by a prescriber in written, nonelectronic form on or after April 1,
302008, is covered only when executed on a tamper resistant
31prescription form. The implementation of this paragraph shall
32conform to the guidance issued by the federal Centers for Medicare
33and Medicaid Services but shall not conflict with state statutes on
34the characteristics of tamper resistant prescriptions for controlled
35substances, including Section 11162.1 of the Health and Safety
36Code. The department shall provide providers and beneficiaries
37with as much flexibility in implementing these rules as allowed
38by the federal government. The department shall notify and consult
39with appropriate stakeholders in implementing, interpreting, or
40making specific this paragraph.

P11   1(B) Notwithstanding Chapter 3.5 (commencing with Section
211340) of Part 1 of Division 3 of Title 2 of the Government Code,
3the department may take the actions specified in subparagraph (A)
4by means of a provider bulletin or notice, policy letter, or other
5similar instructions without taking regulatory action.

6(4) (A) (i) For the purposes of this paragraph, nonlegend has
7the same meaning as defined in subdivision (a) of Section
814105.45.

9(ii) Nonlegend acetaminophen-containing products, with the
10exception of children’s acetaminophen-containing products,
11selected by the department are not covered benefits.

12(iii) Nonlegend cough and cold products selected by the
13department are not covered benefits. This clause shall be
14implemented on the first day of the first calendar month following
1590 days after the effective date of the act that added this clause,
16or on the first day of the first calendar month following 60 days
17after the date the department secures all necessary federal approvals
18to implement this section, whichever is later.

19(iv) Beneficiaries under the Early and Periodic Screening,
20Diagnosis, and Treatment Program shall be exempt from clauses
21(ii) and (iii).

22(B) Notwithstanding Chapter 3.5 (commencing with Section
2311340) of Part 1 of Division 3 of Title 2 of the Government Code,
24the department may take the actions specified in subparagraph (A)
25by means of a provider bulletin or notice, policy letter, or other
26similar instruction without taking regulatory action.

27(e) Outpatient dialysis services and home hemodialysis services,
28including physician services, medical supplies, drugs and
29equipment required for dialysis, are covered, subject to utilization
30controls.

31(f) Anesthesiologist services when provided as part of an
32outpatient medical procedure, nurse anesthetist services when
33rendered in an inpatient or outpatient setting under conditions set
34forth by the director, outpatient laboratory services, and X-ray
35services are covered, subject to utilization controls. Nothing in
36this subdivision shall be construed to require prior authorization
37for anesthesiologist services provided as part of an outpatient
38medical procedure or for portable X-ray services in a nursing
39facility or any category of intermediate care facility for the
40developmentally disabled.

P12   1(g) Blood and blood derivatives are covered.

2(h) (1) Emergency and essential diagnostic and restorative
3dental services, except for orthodontic, fixed bridgework, and
4partial dentures that are not necessary for balance of a complete
5artificial denture, are covered, subject to utilization controls. The
6utilization controls shall allow emergency and essential diagnostic
7and restorative dental services and prostheses that are necessary
8to prevent a significant disability or to replace previously furnished
9prostheses which are lost or destroyed due to circumstances beyond
10the beneficiary’s control. Notwithstanding the foregoing, the
11director may by regulation provide for certain fixed artificial
12dentures necessary for obtaining employment or for medical
13conditions that preclude the use of removable dental prostheses,
14and for orthodontic services in cleft palate deformities administered
15by the department’s California Children Services Program.

16(2) For persons 21 years of age or older, the services specified
17in paragraph (1) shall be provided subject to the following
18conditions:

19(A) Periodontal treatment is not a benefit.

20(B) Endodontic therapy is not a benefit except for vital
21pulpotomy.

22(C) Laboratory processed crowns are not a benefit.

23(D) Removable prosthetics shall be a benefit only for patients
24as a requirement for employment.

25(E) The director may, by regulation, provide for the provision
26of fixed artificial dentures that are necessary for medical conditions
27that preclude the use of removable dental prostheses.

28(F) Notwithstanding the conditions specified in subparagraphs
29(A) to (E), inclusive, the department may approve services for
30persons with special medical disorders subject to utilization review.

31(3) Paragraph (2) shall become inoperative July 1, 1995.

32(i) Medical transportation is covered, subject to utilization
33controls.

34(j) Home health care services are covered, subject to utilization
35controls.

36(k) Prosthetic and orthotic devices and eyeglasses are covered,
37subject to utilization controls. Utilization controls shall allow
38replacement of prosthetic and orthotic devices and eyeglasses
39necessary because of loss or destruction due to circumstances
40beyond the beneficiary’s control. Frame styles for eyeglasses
P13   1replaced pursuant to this subdivision shall not change more than
2once every two years, unless the department so directs.

3Orthopedic and conventional shoes are covered when provided
4by a prosthetic and orthotic supplier on the prescription of a
5physician and when at least one of the shoes will be attached to a
6prosthesis or brace, subject to utilization controls. Modification
7of stock conventional or orthopedic shoes when medically
8indicated, is covered subject to utilization controls. When there is
9a clearly established medical need that cannot be satisfied by the
10modification of stock conventional or orthopedic shoes,
11custom-made orthopedic shoes are covered, subject to utilization
12controls.

13Therapeutic shoes and inserts are covered when provided to
14beneficiaries with a diagnosis of diabetes, subject to utilization
15controls, to the extent that federal financial participation is
16available.

17(l) Hearing aids are covered, subject to utilization controls.
18Utilization controls shall allow replacement of hearing aids
19necessary because of loss or destruction due to circumstances
20beyond the beneficiary’s control.

21(m) Durable medical equipment and medical supplies are
22covered, subject to utilization controls. The utilization controls
23shall allow the replacement of durable medical equipment and
24medical supplies when necessary because of loss or destruction
25due to circumstances beyond the beneficiary’s control. The
26utilization controls shall allow authorization of durable medical
27equipment needed to assist a disabled beneficiary in caring for a
28child for whom the disabled beneficiary is a parent, stepparent,
29foster parent, or legal guardian, subject to the availability of federal
30financial participation. The department shall adopt emergency
31regulations to define and establish criteria for assistive durable
32medical equipment in accordance with the rulemaking provisions
33of the Administrative Procedure Act (Chapter 3.5 (commencing
34with Section 11340) of Part 1 of Division 3 of Title 2 of the
35Government Code).

36(n) Family planning services are covered, subject to utilization
37 controls.begin insert end insertbegin insertHowever, for Medi-Cal managed care plans, utilization
38controls shall be subject to paragraphs (2) and (3) of subdivision
39(b) of Section 1367.25 of the Health and Safety Code.end insert

P14   1(o) Inpatient intensive rehabilitation hospital services, including
2respiratory rehabilitation services, in a general acute care hospital
3are covered, subject to utilization controls, when either of the
4following criteria are met:

5(1) A patient with a permanent disability or severe impairment
6requires an inpatient intensive rehabilitation hospital program as
7described in Section 14064 to develop function beyond the limited
8amount that would occur in the normal course of recovery.

9(2) A patient with a chronic or progressive disease requires an
10inpatient intensive rehabilitation hospital program as described in
11Section 14064 to maintain the patient’s present functional level as
12long as possible.

13(p) (1) Adult day health care is covered in accordance with
14Chapter 8.7 (commencing with Section 14520).

15(2) Commencing 30 days after the effective date of the act that
16added this paragraph, and notwithstanding the number of days
17previously approved through a treatment authorization request,
18adult day health care is covered for a maximum of three days per
19week.

20(3) As provided in accordance with paragraph (4), adult day
21health care is covered for a maximum of five days per week.

22(4) As of the date that the director makes the declaration
23described in subdivision (g) of Section 14525.1, paragraph (2)
24shall become inoperative and paragraph (3) shall become operative.

25(q) (1) Application of fluoride, or other appropriate fluoride
26treatment as defined by the department, and other prophylaxis
27treatment for children 17 years of age and under are covered.

28(2) All dental hygiene services provided by a registered dental
29hygienist, registered dental hygienist in extended functions, and
30registered dental hygienist in alternative practice licensed pursuant
31to Sections 1753, 1917, 1918, and 1922 of the Business and
32Professions Code may be covered as long as they are within the
33scope of Denti-Cal benefits and they are necessary services
34provided by a registered dental hygienist, registered dental
35hygienist in extended functions, or registered dental hygienist in
36alternative practice.

37(r) (1) Paramedic services performed by a city, county, or
38special district, or pursuant to a contract with a city, county, or
39special district, and pursuant to a program established under Article
403 (commencing with Section 1480) of Chapter 2.5 of Division 2
P15   1of the Health and Safety Code by a paramedic certified pursuant
2to that article, and consisting of defibrillation and those services
3specified in subdivision (3) of Section 1482 of the article.

4(2) All providers enrolled under this subdivision shall satisfy
5all applicable statutory and regulatory requirements for becoming
6a Medi-Cal provider.

7(3) This subdivision shall be implemented only to the extent
8funding is available under Section 14106.6.

9(s) In-home medical care services are covered when medically
10appropriate and subject to utilization controls, for beneficiaries
11who would otherwise require care for an extended period of time
12in an acute care hospital at a cost higher than in-home medical
13care services. The director shall have the authority under this
14section to contract with organizations qualified to provide in-home
15medical care services to those persons. These services may be
16provided to patients placed in shared or congregate living
17arrangements, if a home setting is not medically appropriate or
18available to the beneficiary. As used in this section, “in-home
19medical care service” includes utility bills directly attributable to
20continuous, 24-hour operation of life-sustaining medical equipment,
21to the extent that federal financial participation is available.

22As used in this subdivision, in-home medical care services
23 include, but are not limited to:

24(1) Level of care and cost of care evaluations.

25(2) Expenses, directly attributable to home care activities, for
26materials.

27(3) Physician fees for home visits.

28(4) Expenses directly attributable to home care activities for
29shelter and modification to shelter.

30(5) Expenses directly attributable to additional costs of special
31diets, including tube feeding.

32(6) Medically related personal services.

33(7) Home nursing education.

34(8) Emergency maintenance repair.

35(9) Home health agency personnel benefits which permit
36coverage of care during periods when regular personnel are on
37vacation or using sick leave.

38(10) All services needed to maintain antiseptic conditions at
39stoma or shunt sites on the body.

40(11) Emergency and nonemergency medical transportation.

P16   1(12) Medical supplies.

2(13) Medical equipment, including, but not limited to, scales,
3gurneys, and equipment racks suitable for paralyzed patients.

4(14) Utility use directly attributable to the requirements of home
5care activities which are in addition to normal utility use.

6(15) Special drugs and medications.

7(16) Home health agency supervision of visiting staff which is
8medically necessary, but not included in the home health agency
9rate.

10(17) Therapy services.

11(18) Household appliances and household utensil costs directly
12attributable to home care activities.

13(19) Modification of medical equipment for home use.

14(20) Training and orientation for use of life-support systems,
15including, but not limited to, support of respiratory functions.

16(21) Respiratory care practitioner services as defined in Sections
173702 and 3703 of the Business and Professions Code, subject to
18prescription by a physician and surgeon.

19Beneficiaries receiving in-home medical care services are entitled
20to the full range of services within the Medi-Cal scope of benefits
21as defined by this section, subject to medical necessity and
22applicable utilization control. Services provided pursuant to this
23subdivision, which are not otherwise included in the Medi-Cal
24schedule of benefits, shall be available only to the extent that
25federal financial participation for these services is available in
26accordance with a home- and community-based services waiver.

27(t) Home- and community-based services approved by the
28United States Department of Health and Human Services are
29covered to the extent that federal financial participation is available
30for those services under the state plan or waivers granted in
31accordance with Section 1315 or 1396n of Title 42 of the United
32States Code. The director may seek waivers for any or all home-
33 and community-based services approvable under Section 1315 or
341396n of Title 42 of the United States Code. Coverage for those
35services shall be limited by the terms, conditions, and duration of
36the federal waivers.

37(u) Comprehensive perinatal services, as provided through an
38agreement with a health care provider designated in Section
3914134.5 and meeting the standards developed by the department
40pursuant to Section 14134.5, subject to utilization controls.

P17   1The department shall seek any federal waivers necessary to
2implement the provisions of this subdivision. The provisions for
3which appropriate federal waivers cannot be obtained shall not be
4implemented. Provisions for which waivers are obtained or for
5which waivers are not required shall be implemented
6notwithstanding any inability to obtain federal waivers for the
7other provisions. No provision of this subdivision shall be
8implemented unless matching funds from Subchapter XIX
9(commencing with Section 1396) of Chapter 7 of Title 42 of the
10United States Code are available.

11(v) Early and periodic screening, diagnosis, and treatment for
12any individual under 21 years of age is covered, consistent with
13the requirements of Subchapter XIX (commencing with Section
141396) of Chapter 7 of Title 42 of the United States Code.

15(w) Hospice service which is Medicare-certified hospice service
16is covered, subject to utilization controls. Coverage shall be
17available only to the extent that no additional net program costs
18are incurred.

19(x) When a claim for treatment provided to a beneficiary
20includes both services which are authorized and reimbursable
21under this chapter, and services which are not reimbursable under
22this chapter, that portion of the claim for the treatment and services
23authorized and reimbursable under this chapter shall be payable.

24(y) Home- and community-based services approved by the
25United States Department of Health and Human Services for
26beneficiaries with a diagnosis of AIDS or ARC, who require
27intermediate care or a higher level of care.

28Services provided pursuant to a waiver obtained from the
29Secretary of the United States Department of Health and Human
30Services pursuant to this subdivision, and which are not otherwise
31included in the Medi-Cal schedule of benefits, shall be available
32only to the extent that federal financial participation for these
33services is available in accordance with the waiver, and subject to
34the terms, conditions, and duration of the waiver. These services
35shall be provided to individual beneficiaries in accordance with
36the client’s needs as identified in the plan of care, and subject to
37medical necessity and applicable utilization control.

38The director may under this section contract with organizations
39qualified to provide, directly or by subcontract, services provided
40for in this subdivision to eligible beneficiaries. Contracts or
P18   1agreements entered into pursuant to this division shall not be
2subject to the Public Contract Code.

3(z) Respiratory care when provided in organized health care
4systems as defined in Section 3701 of the Business and Professions
5Code, and as an in-home medical service as outlined in subdivision
6(s).

7(aa) (1) There is hereby established in the department, a
8program to provide comprehensive clinical family planning
9services to any person who has a family income at or below 200
10percent of the federal poverty level, as revised annually, and who
11is eligible to receive these services pursuant to the waiver identified
12in paragraph (2). This program shall be known as the Family
13Planning, Access, Care, and Treatment (Family PACT) Program.

14(2) The department shall seek a waiver in accordance with
15Section 1315 of Title 42 of the United States Code, or a state plan
16amendment adopted in accordance with Section
171396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code,
18which was added to Section 1396a of Title 42 of the United States
19Code by Section 2303(a)(2) of the federal Patient Protection and
20Affordable Care Act (PPACA) (Public Law 111-148), for a
21program to provide comprehensive clinical family planning
22services as described in paragraph (8). Under the waiver, the
23program shall be operated only in accordance with the waiver and
24the statutes and regulations in paragraph (4) and subject to the
25terms, conditions, and duration of the waiver. Under the state plan
26amendment, which shall replace the waiver and shall be known as
27the Family PACT successor state plan amendment, the program
28shall be operated only in accordance with this subdivision and the
29statutes and regulations in paragraph (4). The state shall use the
30standards and processes imposed by the state on January 1, 2007,
31including the application of an eligibility discount factor to the
32extent required by the federal Centers for Medicare and Medicaid
33Services, for purposes of determining eligibility as permitted under
34Section 1396a(a)(10)(A)(ii)(XXI) of Title 42 of the United States
35Code. To the extent that federal financial participation is available,
36the program shall continue to conduct education, outreach,
37enrollment, service delivery, and evaluation services as specified
38under the waiver. The services shall be provided under the program
39only if the waiver and, when applicable, the successor state plan
40amendment are approved by the federal Centers for Medicare and
P19   1Medicaid Services and only to the extent that federal financial
2participation is available for the services. Nothing in this section
3shall prohibit the department from seeking the Family PACT
4successor state plan amendment during the operation of the waiver.

5(3) Solely for the purposes of the waiver or Family PACT
6successor state plan amendment and notwithstanding any other
7provision of law, the collection and use of an individual’s social
8security number shall be necessary only to the extent required by
9federal law.

10(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005,
11and 24013, and any regulations adopted under these statutes shall
12apply to the program provided for under this subdivision. No other
13provision of law under the Medi-Cal program or the State-Only
14Family Planning Program shall apply to the program provided for
15under this subdivision.

16(5) Notwithstanding Chapter 3.5 (commencing with Section
1711340) of Part 1 of Division 3 of Title 2 of the Government Code,
18the department may implement, without taking regulatory action,
19the provisions of the waiver after its approval by the federal Health
20Care Financing Administration and the provisions of this section
21by means of an all-county letter or similar instruction to providers.
22Thereafter, the department shall adopt regulations to implement
23this section and the approved waiver in accordance with the
24requirements of Chapter 3.5 (commencing with Section 11340) of
25Part 1 of Division 3 of Title 2 of the Government Code. Beginning
26six months after the effective date of the act adding this
27subdivision, the department shall provide a status report to the
28Legislature on a semiannual basis until regulations have been
29adopted.

30(6) In the event that the Department of Finance determines that
31the program operated under the authority of the waiver described
32in paragraph (2) or the Family PACT successor state plan
33amendment is no longer cost effective, this subdivision shall
34become inoperative on the first day of the first month following
35the issuance of a 30-day notification of that determination in
36writing by the Department of Finance to the chairperson in each
37house that considers appropriations, the chairpersons of the
38committees, and the appropriate subcommittees in each house that
39considers the State Budget, and the Chairperson of the Joint
40Legislative Budget Committee.

P20   1(7) If this subdivision ceases to be operative, all persons who
2have received or are eligible to receive comprehensive clinical
3family planning services pursuant to the waiver described in
4paragraph (2) shall receive family planning services under the
5Medi-Cal program pursuant to subdivision (n) if they are otherwise
6eligible for Medi-Cal with no share of cost, or shall receive
7comprehensive clinical family planning services under the program
8established in Division 24 (commencing with Section 24000) either
9if they are eligible for Medi-Cal with a share of cost or if they are
10otherwise eligible under Section 24003.

11(8) For purposes of this subdivision, “comprehensive clinical
12family planning services” means the process of establishing
13objectives for the number and spacing of children, and selecting
14the means by which those objectives may be achieved. These
15means include a broad range of acceptable and effective methods
16and services to limit or enhance fertility, including contraceptive
17methods, federal Food and Drug Administration approved
18contraceptive drugs, devices, and supplies, natural family planning,
19abstinence methods, and basic, limited fertility management.
20Comprehensive clinical family planning services include, but are
21not limited to, preconception counseling, maternal and fetal health
22counseling, general reproductive health care, including diagnosis
23and treatment of infections and conditions, including cancer, that
24threaten reproductive capability, medical family planning treatment
25and procedures, including supplies and followup, and
26informational, counseling, and educational services.
27Comprehensive clinical family planning services shall not include
28abortion, pregnancy testing solely for the purposes of referral for
29abortion or services ancillary to abortions, or pregnancy care that
30is not incident to the diagnosis of pregnancy. Comprehensive
31clinical family planning services shall be subject to utilization
32control and include all of the following:

33(A) Family planning related services and male and female
34sterilization. Family planning services for men and women shall
35include emergency services and services for complications directly
36related to the contraceptive method, federal Food and Drug
37Administration approved contraceptive drugs, devices, and
38supplies, and followup, consultation, and referral services, as
39indicated, which may require treatment authorization requests.

P21   1(B) All United States Department of Agriculture, federal Food
2and Drug Administration approved contraceptive drugs, devices,
3and supplies that are in keeping with current standards of practice
4and from which the individual may choose.

5(C) Culturally and linguistically appropriate health education
6and counseling services, including informed consent, that include
7all of the following:

8(i) Psychosocial and medical aspects of contraception.

9(ii) Sexuality.

10(iii) Fertility.

11(iv) Pregnancy.

12(v) Parenthood.

13(vi) Infertility.

14(vii) Reproductive health care.

15(viii) Preconception and nutrition counseling.

16(ix) Prevention and treatment of sexually transmitted infection.

17(x) Use of contraceptive methods, federal Food and Drug
18Administration approved contraceptive drugs, devices, and
19supplies.

20(xi) Possible contraceptive consequences and followup.

21(xii) Interpersonal communication and negotiation of
22relationships to assist individuals and couples in effective
23contraceptive method use and planning families.

24(D) A comprehensive health history, updated at the next periodic
25visit (between 11 and 24 months after initial examination) that
26includes a complete obstetrical history, gynecological history,
27contraceptive history, personal medical history, health risk factors,
28and family health history, including genetic or hereditary
29conditions.

30(E) A complete physical examination on initial and subsequent
31periodic visits.

32(F) Services, drugs, devices, and supplies deemed by the federal
33Centers for Medicare and Medicaid Services to be appropriate for
34inclusion in the program.

35(9) In order to maximize the availability of federal financial
36participation under this subdivision, the director shall have the
37discretion to implement the Family PACT successor state plan
38amendment retroactively to July 1, 2010.

P22   1(ab) (1) Purchase of prescribed enteral nutrition products is
2covered, subject to the Medi-Cal list of enteral nutrition products
3and utilization controls.

4(2) Purchase of enteral nutrition products is limited to those
5products to be administered through a feeding tube, including, but
6not limited to, a gastric, nasogastric, or jejunostomy tube.
7Beneficiaries under the Early and Periodic Screening, Diagnosis,
8and Treatment Program shall be exempt from this paragraph.

9(3) Notwithstanding paragraph (2), the department may deem
10an enteral nutrition product, not administered through a feeding
11tube, including, but not limited to, a gastric, nasogastric, or
12jejunostomy tube, a benefit for patients with diagnoses, including,
13but not limited to, malabsorption and inborn errors of metabolism,
14if the product has been shown to be neither investigational nor
15experimental when used as part of a therapeutic regimen to prevent
16serious disability or death.

17(4) Notwithstanding Chapter 3.5 (commencing with Section
1811340) of Part 1 of Division 3 of Title 2 of the Government Code,
19the department may implement the amendments to this subdivision
20made by the act that added this paragraph by means of all-county
21letters, provider bulletins, or similar instructions, without taking
22regulatory action.

23(5) The amendments made to this subdivision by the act that
24added this paragraph shall be implemented June 1, 2011, or on the
25first day of the first calendar month following 60 days after the
26date the department secures all necessary federal approvals to
27implement this section, whichever is later.

28(ac) Diabetic testing supplies are covered when provided by a
29pharmacy, subject to utilization controls.

30

begin deleteSEC. 4.end delete
31begin insertSEC. 5.end insert  

No reimbursement is required by this act pursuant to
32Section 6 of Article XIII B of the California Constitution because
33the only costs that may be incurred by a local agency or school
34district will be incurred because this act creates a new crime or
35infraction, eliminates a crime or infraction, or changes the penalty
36for a crime or infraction, within the meaning of Section 17556 of
37the Government Code, or changes the definition of a crime within
P23   1the meaning of Section 6 of Article XIII B of the California
2Constitution.



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