SB 447, as amended, 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 reimbursementbegin delete formula,end deletebegin insert formula for those drugs subject to a
rebate under specified federal law,end insert 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 other law, a community
4clinic or free clinic licensed pursuant to subdivision (a) of Section
51204 of the Health and Safety Code or an intermittent clinic
6operating pursuant to subdivision (h) of Section 1206 of the Health
7and Safety Code, that has a valid license pursuant to Article 13
8(commencing with Section 4180) of Chapter 9 of Division 2 of
9the 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) begin deleteA end deletebegin insertWith
respect to those drugs that are subject to a rebate
13under Section 1396r-8 of Title 42 of the United States Code, a end insert
14clinic described in subdivision (a) shall bill the Medi-Cal program
15and Family PACT Waiver Program for drugs and supplies covered
16under those programs at the lesser of cost or the clinic’s usual
17charge made to the general public.
18(2) For purposes of this section, “cost” means an aggregate
19amount equivalent to the sum of the actual acquisition cost of a
20drug or supply plus a clinic dispensing fee. The actual acquisition
21cost of a drug or supply shall be calculated not less than annually.
22The clinic dispensing fee shall be the difference between the actual
P3 1acquisition cost of a drug or supply and the Medi-Cal
2reimbursement rate.
3(c) Reimbursement shall be
at the lesser of the amount billed
4or the Medi-Cal reimbursement rate.
5(d) A clinic described in subdivision (a) that furnishes services
6free of charge, or at a nominal charge, as defined in subsection (a)
7of Section 413.13 of Title 42 of the Code of Federal Regulations,
8or that can demonstrate to the department, upon request, that it
9serves primarily low-income patients, and its customary practice
10is to charge patients on the basis of their ability to pay, shall not
11be subject to reimbursement reductions based on its usual charge
12to the general public.
13(e) Federally qualified health centers and rural health clinics
14that are clinics as described in subdivision (a) may bill and be
15reimbursed as described in this section, upon electing to be
16reimbursed for pharmaceutical goods and
servicesbegin insert delivered
17through their dispensariesend insert on a fee-for-service basis, as permitted
18by subdivision (k) of Section 14132.100.
19(f) A clinic that otherwise meets the qualifications set forth in
20subdivision (a), that is eligible to, but that has elected not to, utilize
21drugs purchased under the 340B Discount Drug Program for its
22Medi-Cal patients, shall provide notification to the Health
23Resources and Services Administration’s Office of Pharmacy
24Affairs that it is utilizing non-340B drugs for its Medi-Cal patients
25in the manner and to the extent required by federal law.
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