BILL NUMBER: SB 447 INTRODUCED
BILL TEXT
INTRODUCED BY Senator Allen
FEBRUARY 25, 2015
An act to amend Section 14132.01 of the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
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 1. Section 14132.01 of the Welfare and Institutions Code
is amended to read:
14132.01. (a) Notwithstanding any other provision of
law, a community clinic or free clinic licensed pursuant to
subdivision (a) of Section 1204 of the Health and Safety Code or an
intermittent clinic operating pursuant to subdivision (h) of Section
1206 of the Health and Safety Code, that has a valid license pursuant
to Article 13 (commencing with Section 4180) of Chapter 9 of
Division 2 of the Business and Professions Code shall bill and be
reimbursed, as described in this section, for drugs and supplies
covered under the Medi-Cal program and Family PACT Waiver Program.
(b) (1) A clinic described in subdivision (a) shall bill the
Medi-Cal program and Family PACT Waiver Program for drugs and
supplies covered under those programs at the lesser of cost or the
clinic's usual charge made to the general public.
(2) For purposes of this section, "cost" means 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 twelve
dollars ($12) per billing unit as identified in either the Family
PACT Policies, Procedures, and Billing Instructions Manual, or the
Medi-Cal Inpatient/Outpatient Provider Manual governing outpatient
clinic billing for drugs and supplies, as applicable. For purposes of
this section, "cost" for a take-home drug that is dispensed for use
by the patient within a specific timeframe of five or less days from
the date medically indicated means actual acquisition cost for that
drug plus a clinic dispensing fee, not to exceed seventeen dollars
($17) per prescription. Reimbursement shall be at the lesser of the
amount billed or the Medi-Cal reimbursement rate, and shall not
exceed the net cost of these drugs or supplies when provided by
retail pharmacies under the Medi-Cal program. fee. The
actual acquisition cost of a drug or supply shall be calculated not
less than annually. The clinic dispensing fee shall be the difference
between the actual acquisition cost of a drug or supply and the
Medi-Cal reimbursement rate.
(c) Reimbursement shall be at the lesser of the amount billed or
the Medi-Cal reimbursement rate.
(c)
(d) A clinic described in subdivision (a) that
furnishes services free of charge, or at a nominal charge, as defined
in subsection (a) of Section 413.13 of Title 42 of the Code of
Federal Regulations, or that can demonstrate to the department, upon
request, that it serves primarily low-income patients, and its
customary practice is to charge patients on the basis of their
ability to pay, shall not be subject to reimbursement reductions
based on its usual charge to the general public.
(d)
(e) Federally qualified health centers and rural health
clinics that are clinics as described in subdivision (a) may bill
and be reimbursed as described in this section, upon electing to be
reimbursed for pharmaceutical goods and services on a fee-for-service
basis, as permitted by subdivision (k) of Section 14132.100.
(e)
(f) A clinic that otherwise meets the qualifications
set forth in subdivision (a), that is eligible to, but that has
elected not to, utilize drugs purchased under the 340B Discount Drug
Program for its Medi-Cal patients, shall provide notification to the
Health Resources and Services Administration's Office of Pharmacy
Affairs that it is utilizing non-340B drugs for its Medi-Cal patients
in the manner and to the extent required by federal law.