Amended in Assembly August 18, 2014

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 Bill No. 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, to amend Section 10123.196 of the Insurance Code, and to amend Section 14132 of the Welfare and Institutions Code, 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 begin delete FDA approved end delete begin insert FDA-approved end insert 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.

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.

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 begin delete FDA approved end delete begin insert FDA-approved end insert 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 begin delete coverage, but would authorize cost-sharing for equivalent nonpreferred drugs, devices, or products unless, among other exceptions, the enrollee is a Medi-Cal beneficiary, end delete begin insert coverage, end insert 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.

The bill would retain the provision authorizing a religious employer to request a contract or policy without coverage of begin delete FDA approved end delete begin insert FDA-approved end insert 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.

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

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:

SECTION 1.  

The Legislature hereby finds and declares all of
the following:

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

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

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

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

SEC. 2.  

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

1367.25.  

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

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

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

(b) (1) A begin delete group or individual end delete health care service plan contract,
except for a specialized health care service plan contract, that is
issued, amended, renewed, or delivered on or after January 1, 2016,
shall provide coverage for all of the following begin insert services and
contraceptive methods end insert for women:

(A)  begin delete All FDA approved end delete begin insert Except as provided in subparagraphs
(B) and (C) of paragraph (2), all FDA-approved end insert contraceptive
drugs, devices, and begin insert other end insert products for women, including begin insert all
FDA-approved contraceptive end insert drugs, devices, and products available
begin delete over the counter, end delete begin insert over-the-counter, end insert as prescribed by the enrollee’s
provider.

(B) Voluntary sterilization procedures.

(C) Patient education and counseling on contraception.

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

(2) (A) Except for a grandfathered health plan, begin delete and subject to
subparagraph (B), end delete a health care service plan subject to this
subdivision shall not impose a deductible, coinsurance, copayment,
or any other cost-sharing requirement on the coverage provided
pursuant to this subdivision. begin insert Cost sharing shall not be imposed on
any Medi-Cal beneficiary. end insert

begin delete

(B) A health care service plan may cover a generic or preferred
drug, device, or product without cost sharing and impose cost
sharing for equivalent nonpreferred drugs, devices, or products,
except that cost sharing shall not be imposed on any Medi-Cal
beneficiary. However, if a generic or preferred version of a drug,
device, or product is not available, or is deemed medically
inadvisable by the enrollee’s provider, a health care service plan
shall provide coverage for the nonpreferred drug, device, or product
without cost sharing.

end delete begin insert

(B) Where the FDA has approved one or more therapeutic
equivalents of a contraceptive drug, device, or product, a health
care service plan is not required to cover all of those
therapeutically equivalent versions in accordance with this
subdivision, as long as at least one is covered without cost sharing
in accordance with this subdivision.

end insert begin insert

(C) If a covered therapeutic equivalent of a drug, device, or
product is not available, or is deemed medically inadvisable by
the enrollee’s provider, a health care service plan shall provide
coverage, subject to a plan’s utilization management procedures,
for the prescribed contraceptive drug, device, or product without
cost sharing. Any request by a contracting provider shall be
responded to by the health care service plan in compliance with
the Knox-Keene Health Care Service Plan Act of 1975, as set forth
in this chapter and, as applicable, with the plan’s Medi-Cal
managed care contract.

end insert

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

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

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

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

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

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

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

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

(D)  The entity is a nonprofit organization as described in
Section begin delete 6033(a)(2)(A)i or iii, end delete begin insert 6033(a)(3)(A)(i) or (iii) end insert of the Internal
Revenue Code of 1986, as amended.

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

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

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

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

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

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

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

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

SEC. 3.  

Section 10123.196 of the Insurance Code is amended
to read:

10123.196.  

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

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

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

(b) (1) A group or individual policy of disability insurance,
except for a specialized health insurance policy, that is issued,
amended, renewed, or delivered on or after January 1, 2016, shall
provide coverage for all of the following begin insert services and contraceptive
methods end insert for women:

(A)  begin delete All FDA approved end delete begin insert Except as provided in subparagraphs
(B) and (C) of paragraph (2), all FDA-approved end insert contraceptive
drugs, devices, and begin insert other end insert products for women, including begin insert all
FDA-approved contraceptive end insert drugs, devices, and products available
begin delete over the counter, end delete begin insert over-the-counter, end insert as prescribed by the insured’s
provider.

(B) Voluntary sterilization procedures.

(C) Patient education and counseling on contraception.

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

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

begin delete

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

end delete begin insert

(B) Where the FDA has approved one or more therapeutic
equivalents of a contraceptive drug, device, or product, a disability
insurer is not required to cover all of those therapeutically
equivalent versions in accordance with this subdivision, as long
as at least one is covered without cost sharing in accordance with
this subdivision.

end insert begin insert

(C) If a covered therapeutic equivalent of a drug, device, or
product is not available, or is deemed medically inadvisable by
the insured’s provider, a disability insurer shall provide coverage,
subject to an insurer’s utilization management procedures, for the
prescribed contraceptive drug, device, or product without cost
sharing. Any request by a contracting provider shall be responded
to by the disability insurer in compliance with Section 10123.191.

end insert

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

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

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

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

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

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

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

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

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

(D) The entity is a nonprofit organization pursuant to Section
begin delete 6033(a)(2)(A)(i) or (iii) end delete begin insert 6033(a)(3)(A)(i) or (iii) end insert of the Internal
Revenue Code of 1986, as amended.

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

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

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

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

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

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

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

SEC. 4.  

Section 14132 of the Welfare and Institutions Code is
amended to read:

14132.  

The following is the schedule of benefits under this
chapter:

(a) Outpatient services are covered as follows:

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

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

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

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

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

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

(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall
conform to the guidance issued by the federal Centers for Medicare
and Medicaid Services but shall not conflict with state statutes on
the characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety
Code. The department shall provide providers and beneficiaries
with as much flexibility in implementing these rules as allowed
by the federal government. The department shall notify and consult
with appropriate stakeholders in implementing, interpreting, or
making specific this paragraph.

(B) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may take the actions specified in subparagraph (A)
by means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.

(4) (A) (i) For the purposes of this paragraph, nonlegend has
the same meaning as defined in subdivision (a) of Section
14105.45.

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

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

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

(B) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may take the actions specified in subparagraph (A)
by means of a provider bulletin or notice, policy letter, or other
similar instruction without taking regulatory action.

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

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

(g) Blood and blood derivatives are covered.

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

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

(A) Periodontal treatment is not a benefit.

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

(C) Laboratory processed crowns are not a benefit.

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

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

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

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

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

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

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

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

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

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

(m) Durable medical equipment and medical supplies are
covered, subject to utilization controls. The utilization controls
shall allow the replacement of durable medical equipment and
medical supplies when necessary because of loss or destruction
due to circumstances beyond the beneficiary’s control. The
utilization controls shall allow authorization of durable medical
equipment needed to assist a disabled beneficiary in caring for a
child for whom the disabled beneficiary is a parent, stepparent,
foster parent, or legal guardian, subject to the availability of federal
financial participation. The department shall adopt emergency
regulations to define and establish criteria for assistive durable
medical equipment in accordance with the rulemaking 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).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1)  begin delete Level of care and cost of care end delete begin insert Level-of-care and cost-of-care end insert
evaluations.

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

(3) Physician fees for home visits.

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

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

(6) Medically related personal services.

(7) Home nursing education.

(8) Emergency maintenance repair.

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

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

(11) Emergency and nonemergency medical transportation.

(12) Medical supplies.

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

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

(15) Special drugs and medications.

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

(17) Therapy services.

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

(19) Modification of medical equipment for home use.

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

(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.

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

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

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

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

(v) Early and periodic screening, diagnosis, and treatment for
any individual under 21 years of age is covered, consistent with
the requirements of Subchapter XIX (commencing with Section
1396) of Chapter 7 of Title 42 of the United States Code.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(i) Psychosocial and medical aspects of contraception.

(ii) Sexuality.

(iii) Fertility.

(iv) Pregnancy.

(v) Parenthood.

(vi) Infertility.

(vii) Reproductive health care.

(viii) Preconception and nutrition counseling.

(ix) Prevention and treatment of sexually transmitted infection.

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

(xi) Possible contraceptive consequences and followup.

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

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

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

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

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

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

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

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

(4) 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 the amendments to this subdivision
made by the act that added this paragraph by means of all-county
letters, provider bulletins, or similar instructions, without taking
regulatory action.

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

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

SEC. 5.  

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