BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1114
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|AUTHOR: |Eggman |
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|VERSION: |August 15, 2016 |
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|HEARING DATE: |August 22, | | |
| |2016 | | |
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|CONSULTANT: |Scott Bain |
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PURSANT TO SENATE RULE 29.10
SUBJECT : Medi-Cal: pharmacist services
SUMMARY : Requires pharmacist services to be a benefit under the Medi-Cal
program, requires the Department of Health Care Services (DHCS)
to develop a list of pharmacist services that are reimbursable
to an enrolled Medi-Cal pharmacy provider, and requires DHCS to
establish a fee schedule for the list of pharmacist services to
be 85% of the fee schedule for physician services under the
Medi-Cal program.
Existing law:
1)Establishes the Medi-Cal program, which is administered by
DHCS, under which qualified low-income individuals receive
health care services, including certain prescription drugs.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes outpatient prescription drugs, subject to
utilization controls and the Medi-Cal list of contract drugs.
Requires reimbursement to Medi-Cal pharmacy providers for
drugs, as prescribed, and authorizes the department to
establish a new reimbursement methodology based on average
acquisition cost, as defined.
3)Requires, under the Pharmacy Law, pharmacists to be licensed
and regulated by the California State Board of Pharmacy in the
Department of Consumer Affairs. Establishes, under the
Pharmacy Law, the functions pharmacists are authorized to
perform, including administering drugs and biological products
that have been ordered by a prescriber, furnishing
self-administered hormonal contraceptives, nicotine
AB 1114 (Bonilla) Page 2 of ?
replacement products, prescription medications not requiring a
diagnosis that are recommended for international travelers,
and naloxone hydrochloride.
This bill:
1)Requires pharmacist services to be a benefit under the
Medi-Cal program, subject to approval by the federal Centers
for Medicare and Medicaid Services.
2)Requires DHCS to develop a list of pharmacist services
that are reimbursable to an enrolled Medi-Cal pharmacy
provider.
3)Requires DHCS to establish a fee schedule for the list of
pharmacist services, and requires the rate of
reimbursement for pharmacist services to be 85% of the fee
schedule for physician services under the Medi-Cal
program.
4)Limits covered pharmacist services provided to a Medi-Cal
beneficiary to include only those services provided by a
pharmacist consistent with the laws governing his or her
scope of practice.
5)Requires covered pharmacist services to be subject to DHCS
protocols and utilization controls.
6)Requires a pharmacist to be enrolled as an ordering,
referring, and prescribing provider under the Medi-Cal program
prior to rendering a pharmacist service that is submitted by a
Medi-Cal pharmacy provider for reimbursement.
7)Requires the DHCS director to seek any necessary federal
approvals to implement this bill. Implements this bill only
when necessary federal approvals are obtained, and only to
the extent that federal financial participation is
available.
8)Permits DHCS to implement, interpret, or make specific this
bill, and any applicable federal waivers and state plan
amendments, by means of all-county letters, plan letters, plan
or provider bulletins, or similar instructions, without taking
regulatory action.
AB 1114 (Bonilla) Page 3 of ?
9)Requires DHCS, by July 1, 2021, to adopt regulations in
accordance with the requirements of the Administrative
Procedure Act. Requires DHCS, commencing July 1, 2017, to
provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
10)Contains an urgency clause that will make this bill effective
upon enactment.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, according to the
author, regulations finalized in 2016 allow California
pharmacists to provide hormonal contraceptives, the opioid
overdose drug naloxone, and nicotine replacing products for
smoking cessation directly to patients. This bill will improve
access to these vital health services by authorizing DHCS to
establish a system for pharmacists to provide services in the
Medi-Cal program.
2)Background. This previous version of this bill dealt with
forms and notices issued through CalHEERS, the Covered
California eligibility and enrollment system. The August 15,
2016 deleted the previous contents and inserted the
above-described language.
The Pharmacy Law provides for the licensing and regulation of
pharmacists by the California State Board of Pharmacy in the
Department of Consumer Affairs. The law specifies the scope of
practice pharmacists are authorized to perform, including to
administer, orally or topically, drugs and biologicals
pursuant to a prescriber's order, and to administer
immunizations pursuant to a protocol with a prescriber.
Pharmacists may also furnish emergency contraception drug
therapy pursuant to standardized procedures if they have
completed a training program.
SB 493 (Hernandez, Chapter 469, Statutes of 2013) and AB 1535
(Bloom, Chapter 326, Statutes of 2014), expanded the scope of
practice of pharmacists. Among other provisions, SB 493
authorizes pharmacists to furnish self-administered hormonal
contraceptives, nicotine replacement products, and
prescription medications not requiring a diagnosis that are
AB 1114 (Bonilla) Page 4 of ?
recommended for international travelers, as specified.
Additionally, SB 493 authorized pharmacists to order and
interpret tests for the purpose of monitoring and managing the
efficacy and toxicity of drug therapies, and to independently
initiate and administer routine vaccinations, as specified. AB
1535 authorized a pharmacist to furnish naloxone hydrochloride
in accordance with standardized procedures or protocols
developed and approved by both Pharmacy Board and the Medical
Board of California, in consultation with specified entities.
Board of Pharmacy regulations implementing these bills took
effect in 2016.
Medi-Cal reimbursement to pharmacies currently consists of two
components: (a) a professional dispensing fee and (b) payment
for the drug dispensed (referred to as "drug ingredient
costs"). The dispensing fee is currently $7.25 per
prescription and $8 per prescription for drugs dispensed to
beneficiaries in skilled nursing and intermediate care
facilities. The purpose of this bill is to require Medi-Cal to
establish a separate reimbursement structure for pharmacist
services.
DHCS has provided technical assistance on the language in this
bill. As drafted, DHCS indicates this bill would only apply to
fee-for-service (FFS), as the change is being made to the
provisions of the Welfare and Institutions Code specific to
the Medi-Cal FFS benefit, and describes Medi-Cal direct
reimbursement to FFS pharmacy providers. DHCS' criteria for an
item to be added as a pharmacist-reimbursable service is the
service must already a Medi-Cal benefit (currently paid as a
medical service and the billing codes would remain the same),
and the service must be within the pharmacist's scope of
practice.
DHCS indicates the proposed pharmacist services currently
include the medical evaluation and consultation (and
prescription, if appropriate) for hormonal contraception,
smoking cessation, and the opioid antagonist naloxone. DHCS
will identify the list of pharmacist services in a provider
bulletin and all-plan letter (if applicable), then follow up
with updated regulations.
DHCS indicates if a pharmacist counsels the patient under
their expanded scope of practice and prescribes a medication
under their current scope of practice, and then dispenses the
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prescribed drug, these would be two billable services. Under
this bill, the pharmacy would be reimbursed for a medical
service provided by a pharmacist. DHCS indicates this service
is separate and distinct from the dispensing of the drug, for
which they also would be reimbursed for the drug ingredient
cost, plus the $7.25 dispensing fee.
3)Related legislation. AB 2084 (Wood) would have provided
Medi-Cal coverage for comprehensive medication management, is
defined as the process of care that ensures each beneficiary's
medications are appropriate, safe, and effective, and are
being used as intended. AB 2084 also defines beneficiaries,
goals, and related requirements, and requires DHCS to study
the effectiveness and costs. AB 2084 was held on the Assembly
Appropriations Committee suspense file.
4)Support. The California Pharmacists Association (CPhA) writes
in support that this bill would establish a system for
pharmacists to provide services in the Medi-Cal program. CPhA
argues this bill will expand access to a number of important
preventative health care services for Medi-Cal beneficiaries.
CPhA argues regulations finalized this year provide
pharmacists with new authority, including furnishing hormonal
contraceptives, certain tobacco cessation drugs, recommended
travel medicines, and the opioid overdose drug naloxone
directly to patients. These authorities allow pharmacists to
provide patients with direct access to important health care
services. CPhA argues this bill ensures that Medi-Cal patients
can benefit from the direct access to these health care
services envisioned by the Legislature. Under existing law,
pharmacists are not eligible "providers" in Medi-Cal and their
services cannot be reimbursed. Pharmacies are reimbursed for
drugs and a limited dispensing fee to cover the cost of
dispensing. Federal rules do not allow a dispensing fee to
cover the costs associated with these new pharmacist services.
This bill allows pharmacies to bill for services provided by
pharmacists to Medi-Cal patients. Pharmacies would be
reimbursed at 85% of the physician reimbursement rate,
offering increased access to patients and savings to the
state. As the state looks to manage the cost, quality of
care, and access challenges posed by the over 12 million
Californians enrolled in the Medi-Cal program, CPhA concludes
the state needs to concentrate its efforts on smart solutions
such as this bill.
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SUPPORT AND OPPOSITION :
Support: California Pharmacists Association
California Retailers Association
National Association of Chain Drug Stores
Rite Aid Pharmacies
Oppose: None received
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