Amended in Assembly March 28, 2014

California Legislature—2013–14 Regular Session

Assembly Bill No. 1814

Introduced by Assembly Member Waldron

February 18, 2014

begin delete An act to amend Section 14000 of the Welfare and Institutions Code, relating to Medi-Cal. end delete begin insert An act to add Section 14133.06 to the Welfare and Institutions Code, relating to Medi-Cal. end insert

LEGISLATIVE COUNSEL’S DIGEST

AB 1814, as amended, Waldron. begin delete Medi-Cal. end delete begin insert Prescriber Prevails Act. end insert

begin insert

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law specifies the benefits provided pursuant to the program, including the purchase of prescribed drugs which are covered subject to utilization controls. Utilization controls include a requirement that the treatment provider obtain prior authorization for providing medical treatment, as specified.

end insert begin insert

This bill would, to the extent permitted by federal law, provide that drugs in specified therapeutic drug classes that are prescribed by a Medi-Cal beneficiary’s treating provider are covered Medi-Cal benefits. The bill would require, except as specified, that a Medi-Cal managed care plan cover the drug upon demonstration by the provider that the drug is medically necessary and consistent with federal rules and regulations for labeling and use, as specified.

end insert begin delete

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides that it is the intent of the Legislature to provide, to the extent practicable, for health care for those aged and other persons who lack sufficient annual income to meet the costs of health care, and whose other assets are so limited that their application toward the costs of care would jeopardize the person’s or family’s future minimum self-maintenance and security.

end delete begin delete

This bill would make technical, nonsubstantive changes to these provisions.

end delete

Vote: majority. Appropriation: no. Fiscal committee:  begin delete no end delete begin insert yes end insert . State-mandated local program: no.

The people of the State of California do enact as follows:

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert This act shall be known, and may be cited as, the
Prescriber Prevails Act. end insert

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 14133.06 is added to the end insert begin insert Welfare and
Institutions Code end insert begin insert , to read: end insert

begin insert

begin insert 14133.06. end insert   

(a) It is the intent of the Legislature in enacting this
section that a prescriber’s reasonable, professional judgment
prevails for the therapeutic drug classes specified in subdivision
(b) that are not on managed care plan formularies or have prior
authorization requirements.

(b) To the extent permitted by federal law, if a drug in any of
the following therapeutic drug classes is prescribed by a Medi-Cal
beneficiary’s treating provider, that drug shall be covered under
the Medi-Cal program:

(1) Antiretroviral drugs for HIV/AIDS.

(2) Drugs used to treat hepatitis C.

(3) Antipsychotics.

(4) Antirejection drugs.

(5) Drugs used to treat seizures or epilepsy.

(c) Except as provided in subdivision (d), and notwithstanding
the establishment of a statewide outpatient drug formulary, a
Medi-Cal managed care plan shall cover a drug specified in
subdivision (b), regardless of whether the drug is on the plan’s
formulary, if, upon demonstration by the provider that the drug,
in his or her reasonable, professional judgment, is medically
necessary and consistent with the federal Food and Drug
Administration’s labeling and use rules and regulations, as
supported in at least one of the official compendia, as defined in
Section 1927(g)(1)(B)(i) of the federal Social Security Act (42
U.S.C. Sec. 1396r-8(g)(1)(B)(i)).

(1) Medi-Cal managed care plans shall continue to develop
formularies and may also administer prior authorization programs
for the drugs specified in subdivision (b). Providers prescribing
those drugs may be required to provide the plans with requested
information or clinical documentation to support prior
authorization requests. The plans may continue to provide a
temporary three-day supply of medication when medically
necessary.

(2) Consistent with federal law, if a Medi-Cal managed care
plan is unable to complete a prior authorization due to missing
information or because the prescriber’s reasonable, professional
judgment has not been adequately demonstrated, as required under
this subdivision, the plan shall issue a notice of action to the
provider and the beneficiary. The plan shall include in the notice
of action a description of the information that is required from the
provider or the beneficiary in order for the plan to complete the
authorization, and the beneficiary’s rights regarding appeal and
fair hearing options.

(d) (1) If a Medi-Cal managed care plan chooses not to cover
the drugs described in subdivision (b), the drugs shall be carved
out of that plan and covered on a fee-for-service basis.

(2) If a drug is carved out of a Medi-Cal managed care plan as
described in paragraph (1), the plan’s contracted rate shall be
reduced accordingly.

end insert

begin delete

SECTION 1.  

Section 14000 of the Welfare and Institutions
Code is amended to read:

14000.  

The purpose of this chapter is to afford to qualifying
individuals health care and related remedial or preventive services,
including related social services that are necessary for those
receiving health care under this chapter.

The intent of the Legislature is to provide, to the extent
practicable, through the provisions of this chapter, for health care
for those aged and other individuals, including family members
who lack sufficient annual income to meet the costs of health care,
and whose other assets are so limited that their application toward
the costs of health care would jeopardize the individual’s or
family’s future minimum self-maintenance and security. It is
intended that whenever possible and feasible:

(a) The means employed shall allow, to the extent practicable,
an eligible individual to secure health care in the same manner
employed by the public generally, and without discrimination or
segregation based purely on his or her economic disability. The
means employed shall include an emphasis on efforts to arrange
and encourage access to health care through enrollment in
organized, managed care plans of the type available to the general
public.

(b) The benefits available under this chapter shall not duplicate
those provided under other federal or state laws or under other
contractual or legal entitlements of the individual or individuals
receiving them.

(c) In the administration of this chapter and in establishing the
means to be used to provide access to health care to individuals
eligible under this chapter, the department shall emphasize and
take advantage of both the efficient organization and ready
accessibility and availability of health care facilities and resources
through enrollment in managed health care plans and new and
innovative fee-for-service managed health care plan approaches
to the delivery of health care services.

end delete