Amended in Assembly March 26, 2015

California Legislature—2015–16 Regular Session

Assembly BillNo. 68


Introduced by Assembly Member Waldron

December 18, 2014


An act tobegin delete amend Section 14000 ofend deletebegin insert add Section 14133.06 toend insert the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

AB 68, as amended, Waldron. Medi-Cal.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.begin insert Covered benefits under the Medi-Cal program include the purchase of prescribed drugs, subject to the Medi-Cal List of Contract Drugs and utilization controls.end insertbegin delete Existing law provides that it is the intent of the Legislature to provide, to the extent practicable, for health care for those aged and other persons who lack sufficient annual income to meet the costs of health care, and whose other assets are so limited that their application toward the costs of care would jeopardize the person’s or family’s future minimum self-maintenance and security.end delete

begin insert

This bill, which would be known as the Patient Access to Prescribed Epilepsy Treatments Act, would require, to the extent permitted by federal law, that any drug in the seizure or epilepsy therapeutic drug class would be a covered benefit under the Medi-Cal program. The bill would require a Medi-Cal managed care plan to provide coverage for these drugs, regardless of whether the drug is on the plan’s formulary, if the treating provider demonstrates that, in his or her reasonable, professional judgment, the drug is medically necessary and consistent with specified federal rules and regulations. If the managed care plan elects not to cover a drug described in the bill, the drug would be deemed a noncapitated benefit not reimbursed by the managed care plan, which would be available on a fee-for-service basis, and the plan’s contracted rate would be reduced to reflect the cost to the state of providing the benefit to the patient, as specified. This bill would declare the intent of the Legislature that a prescriber’s reasonable, professional judgment prevail in prescribing the drugs described in the bill to Medi-Cal patients.

end insert
begin delete

This bill would make technical, nonsubstantive changes to those provisions.

end delete

Vote: majority. Appropriation: no. Fiscal committee: begin deleteno end deletebegin insertyesend insert. State-mandated local program: no.

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

P2    1begin insert

begin insertSECTION 1.end insert  

end insert

begin insertThis act shall be known, and may be cited, as the
2Patient Access to Prescribed Epilepsy Treatments Act.end insert

3begin insert

begin insertSEC. 2.end insert  

end insert

begin insertSection 14133.06 is added to the end insertbegin insertWelfare and
4Institutions Code
end insert
begin insert, to read:end insert

begin insert
5

begin insert14133.06.end insert  

(a) It is the intent of the Legislature in enacting this
6section that a prescriber’s reasonable, professional judgment
7prevail in prescribing to Medi-Cal patients any drug in the
8therapeutic drug class that includes drugs approved by the federal
9Food and Drug Administration for use in the treatment of seizures
10or epilepsy, but are not on Medi-Cal managed care plan
11formularies, or are subject to prior authorization requirements.

12(b) To the extent permitted by federal law, if any drug in the
13seizure or epilepsy therapeutic drug class described in subdivision
14(a) is prescribed by a Medi-Cal beneficiary’s treating provider,
15that drug shall be a covered benefit under this chapter.

16(c) Except as provided in subdivision (d), and notwithstanding
17the establishment of a statewide outpatient drug formulary, a
18Medi-Cal managed care plan shall provide coverage for a drug
19in the seizures and epilepsy therapeutic class, as described in
20subdivision (a), regardless of whether the drug is on the plan’s
21formulary, if the treating provider demonstrates, consistent with
22federal law that, in his or her reasonable, professional judgment,
P3    1the drug is medically necessary and consistent with the federal
2Food and Drug Administration’s labeling and use rules and
3regulations, as supported in at least one of the official compendia
4identified in Section 1927(g)(1)(B)(i) of the federal Social Security
5Act (42 U.S.C. Sec. 1396r-8(g)(1)(B)(i)).

6(d) (1) If a Medi-Cal managed care plan elects not to cover a
7seizure or epilepsy drug described in subdivision (b), the drug
8shall be deemed a noncapitated benefit not reimbursed by the
9managed care plan, and shall be available on a fee-for-service
10basis. The treating provider shall follow fee-for-service billing
11instructions for reimbursement under these circumstances.

12(2) If a drug is deemed a noncapitated benefit not reimbursed
13by a Medi-Cal managed care plan, as described in paragraph (1),
14the plan’s contracted rate shall be reduced to reflect the cost of
15providing the benefit to the patient on a fee-for-service basis.

end insert
begin delete
16

SECTION 1.  

Section 14000 of the Welfare and Institutions
17Code
is amended to read:

18

14000.  

The purpose of this chapter is to afford to qualifying
19individuals health care and related remedial or preventive services,
20including related social services that are necessary for those
21receiving health care under this chapter.

22The intent of the Legislature is to provide, to the extent
23practicable, through the provisions of this chapter, for health care
24for those aged and other individuals, including family members,
25who lack sufficient annual income to meet the costs of health care
26and whose other assets are so limited that their application toward
27the costs of that care would jeopardize the individual’s or family’s
28future minimum self-maintenance and security. It is intended that
29 whenever possible and feasible:

30(a) The means employed shall allow, to the extent practicable,
31an eligible individual to secure health care in the same manner
32employed by the public generally, and without discrimination or
33segregation based purely on his or her economic disability. The
34means employed shall include an emphasis on efforts to arrange
35and encourage access to health care through enrollment in
36organized, managed care plans of the type available to the general
37public.

38(b) The benefits available under this chapter shall not duplicate
39those provided under other federal or state laws or under other
P4    1contractual or legal entitlements of the individual or individuals
2receiving them.

3(c) In the administration of this chapter and in establishing the
4means to be used to provide access to health care to individuals
5eligible under this chapter, the department shall emphasize and
6take advantage of both the efficient organization and ready
7accessibility and availability of health care facilities and resources
8through enrollment in managed health care plans and new and
9innovative fee-for-service managed health care plan approaches
10to the delivery of health care services.

end delete


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