SB 447, as introduced, Allen. Medi-Cal: clinics: drugs and supplies.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions.
The Medi-Cal program, pursuant to a federal waiver, administers a program known as the Family Planning, Access, Care, and Treatment (Family PACT) Program, to provide comprehensive clinical family planning services to any person who has a family income at or below 200% of the federal poverty level and who is eligible to receive those services pursuant to the waiver. Existing law requires reimbursement for drugs and supplies covered under the Medi-Cal program and Family PACT Program by a licensed community clinic or free clinic, or an intermittent clinic, to be the lesser of the amount billed or the Medi-Cal reimbursement rate and caps reimbursement at the net cost of the drugs or products as provided to retail pharmacies under the Medi-Cal program. Existing law sets the costs for drugs and supplies covered under those programs at an aggregate amount equivalent to the sum of the actual acquisition cost of a drug or supply plus a clinic dispensing fee not to exceed $12 per billing unit, as specified. Existing law also sets the cost for a take-home drug that is dispensed for use by the patient within a specific timeframe of 5 or less days from the date medically indicated at the actual acquisition cost for that drug plus a clinic dispensing fee, not to exceed $17 per prescription.
This bill would revise this reimbursement formula, and would instead require the clinic dispensing fee to be the difference between the actual acquisition cost of a drug or supply, to be calculated not less than annually, and the Medi-Cal reimbursement rate. The bill would remove the cap on reimbursement that is based on the net cost of drugs or supplies when provided by retail pharmacies under the Medi-Cal program.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 14132.01 of the Welfare and Institutions
2Code is amended to read:
(a) Notwithstanding any otherbegin delete provision ofend delete law, a
4community clinic or free clinic licensed pursuant to subdivision
5(a) of Section 1204 of the Health and Safety Code or an intermittent
6clinic operating pursuant to subdivision (h) of Section 1206 of the
7Health and Safety Code, that has a valid license pursuant to Article
813 (commencing with Section 4180) of Chapter 9 of Division 2
9of the Business and Professions Code shall bill and be reimbursed,
10as described in this section, for drugs and supplies covered under
11the Medi-Cal program and Family PACT Waiver Program.
12(b) (1) A clinic described in subdivision (a) shall bill
the
13Medi-Cal program and Family PACT Waiver Program for drugs
14and supplies covered under those programs at the lesser of cost or
15the clinic’s usual charge made to the general public.
16(2) For purposes of this section, “cost” means an aggregate
17amount equivalent to the sum of the actual acquisition cost of a
18drug or supply plus a clinic dispensingbegin delete fee not to exceed twelve
19dollars ($12) per billing unit as identified in either the Family
20PACT Policies, Procedures, and Billing Instructions Manual, or
21the Medi-Cal Inpatient/Outpatient Provider Manual governing
22outpatient clinic billing for drugs and supplies, as applicable. For
23purposes of this section, “cost” for a take-home drug that is
24dispensed for use by the patient within a specific timeframe of five
25or less days from the
date medically indicated means actual
26acquisition cost for that drug plus a clinic dispensing fee, not to
P3 1exceed seventeen dollars ($17) per prescription. Reimbursement
2shall be at the lesser of the amount billed or the Medi-Cal
3reimbursement rate, and shall not exceed the net cost of these drugs
4or supplies when provided by retail pharmacies under the Medi-Cal
5program.end delete
6be calculated not less than annually. The clinic dispensing fee
7shall be the difference between the actual acquisition cost of a
8drug or supply and the Medi-Cal reimbursement rate.end insert
9(c) Reimbursement shall be at the lesser of the amount billed
10or the Medi-Cal reimbursement rate.
11(c)
end delete
12begin insert(d)end insert A clinic described in subdivision (a) that furnishes services
13free of charge, or at a nominal charge, as defined in subsection (a)
14of Section 413.13 of Title 42 of the Code of Federal Regulations,
15or that can demonstrate to the department, upon request, that it
16serves primarily low-income patients, and its customary practice
17is to charge patients on the basis of their ability to pay, shall not
18be subject to reimbursement reductions based on its usual charge
19to the general public.
20(d)
end delete
21begin insert(e)end insert Federally
qualified health centers and rural health clinics
22that are clinics as described in subdivision (a) may bill and be
23reimbursed as described in this section, upon electing to be
24reimbursed for pharmaceutical goods and services on a
25fee-for-service basis, as permitted by subdivision (k) of Section
2614132.100.
27(e)
end delete
28begin insert(f)end insert A clinic that otherwise meets the qualifications set forth in
29subdivision (a), that is eligible to, but that has elected not to, utilize
30drugs purchased under the 340B Discount Drug Program for its
31Medi-Cal patients, shall provide notification to the Health
32Resources and Services Administration’s Office of Pharmacy
33Affairs that it is utilizing non-340B drugs for its
Medi-Cal patients
34in the manner and to the extent required by federal law.
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