BILL ANALYSIS Ó
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
AB 1114 (Eggman) - Medi-Cal: pharmacist services
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|Version: August 15, 2016 |Policy Vote: Health 7-0 |
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|Urgency: Yes |Mandate: No |
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|Hearing Date: August 23, 2016 |Consultant: Brendan McCarthy |
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This bill meets the criteria for referral to the Suspense File.
Bill
Summary: AB 1114 would require pharmacist services to be a
covered benefit in the Medi-Cal program, with specified
requirements.
Fiscal
Impact:
One-time costs of $400,000 to $600,000 to make changes to the
system for processing Medi-Cal payments to allow pharmacist
services to be reimbursed at the rate level specified in the
bill (25% General Fund and 75% federal funds).
Unknown cost savings due to a shift from services being
provided by physicians to those services being provided by
pharmacists (General Fund and federal funds). Under the bill,
Medi-Cal beneficiaries would be able to access certain
services from a pharmacist without the need to see a physician
to get a prescription. The bill requires pharmacists to be
reimbursed at 85% of the rate paid to physicians. The extent
of the cost savings from shifting from physician services to
pharmacist services is unknown.
AB 1114 (Eggman) Page 1 of
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Likely overall cost savings to the Medi-Cal program due to
increased utilization of certain drugs prescribed and
dispensed by pharmacists (General Fund and federal funds).
Under the bill, it is likely that there will be increased
utilization of certain drugs, because it will be easier for
some Medi-Cal beneficiaries to access those drugs directly
from pharmacist without the need for a physician visit. Under
current law, the drugs that can be provided by a pharmacist in
this manner include smoking cessation drugs, contraceptives,
naloxone (a drug that prevents opioid overdoses), and
immunizations. These types of drugs have been shown to result
in overall health care cost savings, so it is likely that any
overall increase in their utilization by Medi-Cal
beneficiaries is likely to reduce long-term Medi-Cal spending.
Background: Under state and federal law, the Department of Health Care
Services operates the Medi-Cal program, which provides health
care coverage to low income individuals, families, and children.
Medi-Cal provides coverage to childless adults and parents with
household income up to 138% of the federal poverty level and to
children with household income up to 266% of the federal poverty
level. The federal government provides matching funds that vary
from 50% to 90% of expenditures depending on the category of
beneficiary.
Under current law, Medi-Cal reimburses pharmacists for drugs
dispensed (including both the cost of the drug and the
administrative costs of dispensing drugs). Medi-Cal does not
reimburse pharmacists for medical evaluations, consultations
with patients or prescribing drugs to patients.
Current law allows pharmacists who meet specified requirements
to prescribe certain drugs directly, without the need for a
prescription from a physician (or other practitioner such as a
nurse practitioner). Under these laws, a pharmacist can
prescribe and dispense contraceptives, smoking cessation drugs,
and naloxone (a drug used to prevent opioid overdoses) and other
drugs or services. The implementing regulations for those laws
have recently been adopted, allowing certain pharmacists to
begin prescribing those drugs.
AB 1114 (Eggman) Page 2 of
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Proposed Law:
AB 1114 would require pharmacist services to be a covered
benefit in the Medi-Cal program, with specified requirements.
Specific provisions of the bill would:
Establish pharmacist services as a Medi-Cal benefit, subject
to federal approval;
Require the Department of Health Care Services to develop a
list of pharmacist services that are reimbursable under the
Medi-Cal program;
Require the Department to establish a fee schedule for
pharmacist services, with reimbursement rates set at 85% of
physician services;
Require covered pharmacist services to only include services
provided consistent with the laws governing the scope of
practice of pharmacists;
Require covered pharmacist services to be subject to
department protocols and utilization controls;
Require a pharmacist to be enrolled as a Medi-Cal provider
prior to rendering a pharmacist service;
Require the Department to seek any necessary federal
approvals;
Authorize the Department to implement the bill without
adopting regulations, but also require the Department to adopt
regulations by July 1, 2021.
This bill is an urgency measure.
Related legislation: AB 2084 (Wood) would have provided Medi-Cal
coverage for comprehensive medication management. AB 2084 was
held on the Assembly Appropriations Committee's suspense file.
Staff comments: This bill previously addressed enrollment and
eligibility requirements for Covered California and the Medi-Cal
program.
As drafted, the requirements of the bill would only directly
impact the fee-for-service Medi-Cal program. However, because
Medi-Cal managed care plans are required by law to provide
equivalent benefits to the fee-for-service benefits, the bill
will indirectly require Medi-Cal managed care plans to provide
coverage for equivalent services. Because all of the services
addressed by the bill are already Medi-Cal benefits, Medi-Cal
AB 1114 (Eggman) Page 3 of
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managed care plans would likely have some latitude to offer
those benefits through pharmacists or continue to provide them
through their contracted physicians.
Committee
amendments: Staff recommends the bill be amended to specify
which services shall be eligible for coverage by Medi-Cal as
pharmacist services - specifically, furnishing contraceptives,
providing tobacco cessation counseling and furnishing nicotine
replacement therapy, furnishing naloxone, administering
immunizations, and furnishing travel medications.
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