BILL NUMBER: AB 741 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 15, 2015
INTRODUCED BY Assembly Member Williams
FEBRUARY 25, 2015
An act to amend Section 1502 of the Health and Safety Code,
and to amend Section 14132 of the Welfare and Institutions
Code, relating to Medi-Cal. mental health.
LEGISLATIVE COUNSEL'S DIGEST
AB 741, as amended, Williams. Medi-Cal: comprehensive
Comprehensive mental health crisis services.
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 provides for a schedule of
benefits under the Medi-Cal program, which includes early and
periodic screening, diagnosis, and treatment for any individual under
21 years of age.
This bill would add to the schedule of benefits comprehensive
mental health crisis services, including crisis intervention, crisis
stabilization, crisis residential treatment, rehabilitative mental
health services, and mobile crisis support teams, to the extent that
federal financial participation is available and any necessary
federal approvals have been obtained.
Existing law, the California Community Care Facilities Act,
provides for the licensing and regulation of community care
facilities, as defined, by the State Department of Social Services.
Existing law includes within the definition of community care
facility, a social rehabilitation facility, which is a residential
facility that provides social rehabilitation services in a group
setting to adults recovering from mental illness. A violation of the
act is a misdemeanor.
This bill would expand the definition of a social rehabilitation
facility to include a residential facility that provides social
rehabilitation services in a group setting to children, adolescents,
or adults recovering from mental illness or in a mental health
crisis. By expanding the types of facilities that are regulated as a
community care facility, this bill would expand the scope of an
existing crime, thus creating a state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no yes .
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the
following:
(a) There is an urgent need to provide more crisis care
alternatives to hospitals for individuals
children and youth experiencing mental health crises.
(b) The problems are especially acute for children and youth
who may have to wait for days for a hospital bed and who may be
transported, without a parent, to the nearest facility hundreds of
miles away.
(c) In 2012, the California Hospital Association reported that
two-thirds of the people taken to a hospital for a psychiatric
emergency did not meet the criteria for that level of care but the
care they needed was not available.
(d) The type of care that is needed includes crisis
stabilization, stabilization and crisis
residential treatment, mobile crisis support teams, and
in-home crisis care treatment for children.
(e) This level of care is part of the full continuum of care
considered medically necessary for many children with serious
emotional disturbances and adults with severe mental
illnesses. disturbances.
(f) In 2013, the Legislature enacted Senate Bill 82
(Chapter the Investment in Mental Health Wellness Act
(Senate Bill 82, Chapter 34 of the Statutes of 2013) to provide
one-time funding to counties to expand the availability of
these mental health crisis care facilities.
However, very few of these facilities can accommodate children.
services, including short-term crisis residential
treatment services. However, there is currently no state licensing
category for short-term crisis residential programs for children. As
a result, counties wanting to expand local capacity to meet the needs
of children and youth for crisis residential treatment services were
ineligible for this competitive grant program.
(g) There is currently no state licensing category for crisis
residential programs for children. Federal Medicaid provisions
require, however, that services be equal in amount, duration, and
scope for all individuals within each eligibility category. It is
essential that children receive the same range of services as adults
with mental health conditions.
(g) Federal Medicaid provisions allow for federal matching funds
for mental health services delivered to Medi-Cal beneficiaries under
21 years of age in psychiatric residential treatment facilities,
including short-term crisis residential treatment programs. However,
because there is currently no state licensing category for crisis
residential treatment programs for children, California is unable to
benefit from these otherwise available federal financial resources.
(h) In most private health plans this level of care
communities, inpatient crisis treatment is
completely unavailable for children and adults
youth even though it may be medically necessary.
(i) Crisis residential care is an essential level of
care for the rehabilitation of individuals with serious
emotional disturbances and severe mental illnesses,
treatment of children and youth with serious emotional disturbances
in a mental health crisis, and it often serves as an
alternative to hospitalization.
(j) It is imperative that public and private
health care coverage include these services as a covered benefit.
SEC. 2. Section 1502 of the Health and
Safety Code is amended to read:
1502. As used in this chapter:
(a) "Community care facility" means any facility, place, or
building that is maintained and operated to provide nonmedical
residential care, day treatment, adult day care, or foster family
agency services for children, adults, or children and adults,
including, but not limited to, the physically handicapped, mentally
impaired, incompetent persons, and abused or neglected children, and
includes the following:
(1) "Residential facility" means any family home, group care
facility, or similar facility determined by the director, for 24-hour
nonmedical care of persons in need of personal services,
supervision, or assistance essential for sustaining the activities of
daily living or for the protection of the individual.
(2) "Adult day program" means any community-based facility or
program that provides care to persons 18 years of age or older in
need of personal services, supervision, or assistance essential for
sustaining the activities of daily living or for the protection of
these individuals on less than a 24-hour basis.
(3) "Therapeutic day services facility" means any facility that
provides nonmedical care, counseling, educational or vocational
support, or social rehabilitation services on less than a 24-hour
basis to persons under 18 years of age who would otherwise be placed
in foster care or who are returning to families from foster care.
Program standards for these facilities shall be developed by the
department, pursuant to Section 1530, in consultation with
therapeutic day services and foster care providers.
(4) "Foster family agency" means any organization engaged in the
recruiting, certifying, and training of, and providing professional
support to, foster parents, or in finding homes or other places for
placement of children for temporary or permanent care who require
that level of care as an alternative to a group home. Private foster
family agencies shall be organized and operated on a nonprofit basis.
(5) "Foster family home" means any residential facility providing
24-hour care for six or fewer foster children that is owned, leased,
or rented and is the residence of the foster parent or parents,
including their family, in whose care the foster children have been
placed. The placement may be by a public or private child placement
agency or by a court order, or by voluntary placement by a parent,
parents, or guardian. It also means a foster family home described in
Section 1505.2.
(6) "Small family home" means any residential facility, in the
licensee's family residence, that provides 24-hour care for six or
fewer foster children who have mental disorders or developmental or
physical disabilities and who require special care and supervision as
a result of their disabilities. A small family home may accept
children with special health care needs, pursuant to subdivision (a)
of Section 17710 of the Welfare and Institutions Code. In addition to
placing children with special health care needs, the department may
approve placement of children without special health care needs, up
to the licensed capacity.
(7) "Social rehabilitation facility" means any residential
facility that provides social rehabilitation services for no longer
than 18 months in a group setting to adults
individuals, including children, adolescents, and adults,
recovering from mental illness or in a mental health crisis
who temporarily need assistance, guidance, or counseling.
Program components shall be subject to program standards pursuant to
Article 1 (commencing with Section 5670) of Chapter 2.5 of Part 2 of
Division 5 of the Welfare and Institutions Code.
(8) "Community treatment facility" means any residential facility
that provides mental health treatment services to children in a group
setting and that has the capacity to provide secure containment.
Program components shall be subject to program standards developed
and enforced by the State Department of Health Care Services pursuant
to Section 4094 of the Welfare and Institutions Code.
Nothing in this section shall be construed to prohibit or
discourage placement of persons who have mental or physical
disabilities into any category of community care facility that meets
the needs of the individual placed, if the placement is consistent
with the licensing regulations of the department.
(9) "Full-service adoption agency" means any licensed entity
engaged in the business of providing adoption services, that does all
of the following:
(A) Assumes care, custody, and control of a child through
relinquishment of the child to the agency or involuntary termination
of parental rights to the child.
(B) Assesses the birth parents, prospective adoptive parents, or
child.
(C) Places children for adoption.
(D) Supervises adoptive placements.
Private full-service adoption agencies shall be organized and
operated on a nonprofit basis. As a condition of licensure to provide
intercountry adoption services, a full-service adoption agency shall
be accredited and in good standing according to Part 96 of Title 22
of the Code of Federal Regulations, or supervised by an accredited
primary provider, or acting as an exempted provider, in compliance
with Subpart F (commencing with Section 96.29) of Part 96 of Title 22
of the Code of Federal Regulations.
(10) "Noncustodial adoption agency" means any licensed entity
engaged in the business of providing adoption services, that does all
of the following:
(A) Assesses the prospective adoptive parents.
(B) Cooperatively matches children freed for adoption, who are
under the care, custody, and control of a licensed adoption agency,
for adoption, with assessed and approved adoptive applicants.
(C) Cooperatively supervises adoptive placements with a
full-service adoptive agency, but does not disrupt a placement or
remove a child from a placement.
Private noncustodial adoption agencies shall be organized and
operated on a nonprofit basis. As a condition of licensure to provide
intercountry adoption services, a noncustodial adoption agency shall
be accredited and in good standing according to Part 96 of Title 22
of the Code of Federal Regulations, or supervised by an accredited
primary provider, or acting as an exempted provider, in compliance
with Subpart F (commencing with Section 96.29) of Part 96 of Title 22
of the Code of Federal Regulations.
(11) "Transitional shelter care facility" means any group care
facility that provides for 24-hour nonmedical care of persons in need
of personal services, supervision, or assistance essential for
sustaining the activities of daily living or for the protection of
the individual. Program components shall be subject to program
standards developed by the State Department of Social Services
pursuant to Section 1502.3.
(12) "Transitional housing placement provider" means an
organization licensed by the department pursuant to Section 1559.110
and Section 16522.1 of the Welfare and Institutions Code to provide
transitional housing to foster children at least 16 years of age and
not more than 18 years of age, and nonminor dependents, as defined in
subdivision (v) of Section 11400 of the Welfare and Institutions
Code, to promote their transition to adulthood. A transitional
housing placement provider shall be privately operated and organized
on a nonprofit basis.
(13) "Group home" means a residential facility that provides
24-hour care and supervision to children, delivered at least in part
by staff employed by the licensee in a structured environment. The
care and supervision provided by a group home shall be nonmedical,
except as otherwise permitted by law.
(14) "Runaway and homeless youth shelter" means a group home
licensed by the department to operate a program pursuant to Section
1502.35 to provide voluntary, short-term, shelter and personal
services to runaway youth or homeless youth, as defined in paragraph
(2) of subdivision (a) of Section 1502.35.
(15) "Enhanced behavioral supports home" means a facility
certified by the State Department of Developmental Services pursuant
to Article 3.6 (commencing with Section 4684.80) of Chapter 6 of
Division 4.5 of the Welfare and Institutions Code, and licensed by
the State Department of Social Services as an adult residential
facility or a group home that provides 24-hour nonmedical care to
individuals with developmental disabilities who require enhanced
behavioral supports, staffing, and supervision in a homelike setting.
An enhanced behavioral supports home shall have a maximum capacity
of four consumers, shall conform to Section 441.530(a)(1) of Title 42
of the Code of Federal Regulations, and shall be eligible for
federal Medicaid home- and community-based services funding.
(16) "Community crisis home" means a facility certified by the
State Department of Developmental Services pursuant to Article 8
(commencing with Section 4698) of Chapter 6 of Division 4.5 of the
Welfare and Institutions Code, and licensed by the State Department
of Social Services pursuant to Article 9.7 (commencing with Section
1567.80), as an adult residential facility, providing 24-hour
nonmedical care to individuals with developmental disabilities
receiving regional center service, in need of crisis intervention
services, and who would otherwise be at risk of admission to the
acute crisis center at Fairview Developmental Center, Sonoma
Developmental Center, an acute general hospital, acute psychiatric
hospital, an institution for mental disease, as described in Part 5
(commencing with Section 5900) of Division 5 of the Welfare and
Institutions Code, or an out-of-state placement. A community crisis
home shall have a maximum capacity of eight consumers, as defined in
subdivision (a) of Section 1567.80, shall conform to Section 441.530
(a)(1) of Title 42 of the Code of Federal Regulations, and shall be
eligible for federal Medicaid home- and community-based services
funding.
(17) "Crisis nursery" means a facility licensed by the department
to operate a program pursuant to Section 1516 to provide short-term
care and supervision for children under six years of age who are
voluntarily placed for temporary care by a parent or legal guardian
due to a family crisis or stressful situation.
(b) "Department" or "state department" means the State Department
of Social Services.
(c) "Director" means the Director of Social Services.
SEC. 2. SEC. 3. Section 14132 of the
Welfare and Institutions Code is amended to read:
14132. The following is the schedule of benefits under this
chapter:
(a) Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
(b) (1) Inpatient hospital services, including, but not limited
to, physician and podiatric services, physical therapy
therapy, and occupational therapy, are covered
subject to utilization controls.
(2) For Medi-Cal fee-for-service beneficiaries, emergency services
and care that are necessary for the treatment of an emergency
medical condition and medical care directly related to the emergency
medical condition. This paragraph shall not be construed to change
the obligation of Medi-Cal managed care plans to provide emergency
services and care. For the purposes of this paragraph, "emergency
services and care" and "emergency medical condition" shall have the
same meanings as those terms are defined in Section 1317.1 of the
Health and Safety Code.
(c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.
(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers for Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
(4) (A) (i) For the purposes of this paragraph, nonlegend has the
same meaning as defined in subdivision (a) of Section 14105.45.
(ii) Nonlegend acetaminophen-containing products, with the
exception of children's acetaminophen-containing products, selected
by the department are not covered benefits.
(iii) Nonlegend cough and cold products selected by the department
are not covered benefits. This clause shall be implemented on the
first day of the first calendar month following 90 days after the
effective date of the act that added this clause, or on the first day
of the first calendar month following 60 days after the date the
department secures all necessary federal approvals to implement this
section, whichever is later.
(iv) Beneficiaries under the Early and Periodic Screening,
Diagnosis, and Treatment Program shall be exempt from clauses (ii)
and (iii).
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instruction instruction,
without taking regulatory action.
(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs
drugs, and equipment required for dialysis, are
covered, subject to utilization controls.
(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
(g) Blood and blood derivatives are covered.
(h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
(A) Periodontal treatment is not a benefit.
(B) Endodontic therapy is not a benefit except for vital
pulpotomy.
(C) Laboratory processed crowns are not a benefit.
(D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
(E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
(F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
(3) Paragraph (2) shall become inoperative July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
(m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
(n) Family planning services are covered, subject to utilization
controls. However, for Medi-Cal managed care plans, any utilization
controls shall be subject to Section 1367.25 of the Health and Safety
Code.
(o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).
(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request, adult
day health care is covered for a maximum of three days per week.
(3) As provided in accordance with paragraph (4), adult day health
care is covered for a maximum of five days per week.
(4) As of the date that the director makes the declaration
described in subdivision (g) of Section 14525.1, paragraph (2) shall
become inoperative and paragraph (3) shall become operative.
(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, and other prophylaxis
treatment for children 17 years of age and under are covered.
(2) All dental hygiene services provided by a registered dental
hygienist, registered dental hygienist in extended functions, and
registered dental hygienist in alternative practice licensed pursuant
to Sections 1753, 1917, 1918, and 1922 of the Business and
Professions Code may be covered as long as they are within the scope
of Denti-Cal benefits and they are necessary services provided by a
registered dental hygienist, registered dental hygienist in extended
functions, or registered dental hygienist in alternative practice.
(r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under former
Article 3 (commencing with Section 1480) of Chapter 2.5 of
Division 2 of the Health and Safety Code by a paramedic certified
pursuant to that article, and consisting of defibrillation and those
services specified in subdivision (3) of former Section
1482 of the article.
(2) All providers enrolled under this subdivision shall
satisfy all applicable statutory and regulatory requirements for
becoming a Medi-Cal provider.
(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
As used in this subdivision, in-home medical care services
include, but are not limited to:
(1) Level-of-care and cost-of-care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which
that permit coverage of care during periods when regular
personnel are on vacation or using sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which that are in
addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff
which that is medically necessary, but not
included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
(t) Home- and community-based services approved by the United
States Department of Health and Human Services are covered to the
extent that federal financial participation is available for those
services under the state plan or waivers granted in accordance with
Section 1315 or 1396n of Title 42 of the United States Code. The
director may seek waivers for any or all home- and community-based
services approvable under Section 1315 or 1396n of Title 42 of the
United States Code. Coverage for those services shall be limited by
the terms, conditions, and duration of the federal waivers.
(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
(v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
(w) Hospice service which that is
Medicare-certified hospice service is covered, subject to utilization
controls. Coverage shall be available only to the extent that no
additional net program costs are incurred.
(x) When a claim for treatment provided to a beneficiary includes
both services which that are authorized
and reimbursable under this chapter, and services which
that are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
(y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
Services provided pursuant to a waiver obtained from the Secretary
of the United States Department of Health and Human Services
pursuant to this subdivision, and which are not otherwise included in
the Medi-Cal schedule of benefits, shall be available only to the
extent that federal financial participation for these services is
available in accordance with the waiver, and subject to the terms,
conditions, and duration of the waiver. These services shall be
provided to individual beneficiaries in accordance with the client's
needs as identified in the plan of care, and subject to medical
necessity and applicable utilization control.
The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
(aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Program.
(2) The department shall seek a waiver in accordance with Section
1315 of Title 42 of the United States Code, or a state plan amendment
adopted in accordance with Section 1396a(a)(10)(A)(ii)(XXI) of Title
42 of the United States Code, which was added to Section 1396a of
Title 42 of the United States Code by Section 2303(a)(2) of the
federal Patient Protection and Affordable Care Act (PPACA) (Public
Law 111-148), for a program to provide comprehensive clinical family
planning services as described in paragraph (8). Under the waiver,
the program shall be operated only in accordance with the waiver and
the statutes and regulations in paragraph (4) and subject to the
terms, conditions, and duration of the waiver. Under the state plan
amendment, which shall replace the waiver and shall be known as the
Family PACT successor state plan amendment, the program shall be
operated only in accordance with this subdivision and the statutes
and regulations in paragraph (4). The state shall use the standards
and processes imposed by the state on January 1, 2007, including the
application of an eligibility discount factor to the extent required
by the federal Centers for Medicare and Medicaid Services, for
purposes of determining eligibility as permitted under Section 1396a
(a)(10)(A)(ii)(XXI) of Title 42 of the United States Code. To the
extent that federal financial participation is available, the program
shall continue to conduct education, outreach, enrollment, service
delivery, and evaluation services as specified under the waiver. The
services shall be provided under the program only if the waiver and,
when applicable, the successor state plan amendment are approved by
the federal Centers for Medicare and Medicaid Services and only to
the extent that federal financial participation is available for the
services. Nothing in this section shall prohibit the department from
seeking the Family PACT successor state plan amendment during the
operation of the waiver.
(3) Solely for the purposes of the waiver or Family PACT successor
state plan amendment and notwithstanding any other
provision of law, the collection and use of an individual's
social security number shall be necessary only to the extent
required by federal law.
(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
(5) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, without taking regulatory action, the
provisions of the waiver after its approval by the federal
Health Care Financing Administration Centers for
Medicare and Medicaid Services and the provisions of this
section by means of an all-county letter or similar instruction to
providers. Thereafter, the department shall adopt regulations to
implement this section and the approved waiver in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of Part
1 of Division 3 of Title 2 of the Government Code. Beginning six
months after the effective date of the act adding this subdivision,
the department shall provide a status report to the Legislature on a
semiannual basis until regulations have been adopted.
(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) or the Family PACT successor state plan amendment is no
longer cost effective, this subdivision shall become inoperative on
the first day of the first month following the issuance of a 30-day
notification of that determination in writing by the Department of
Finance to the chairperson in each house that considers
appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
(8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
(B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
(C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
(i) Psychosocial and medical aspects of contraception.
(ii) Sexuality.
(iii) Fertility.
(iv) Pregnancy.
(v) Parenthood.
(vi) Infertility.
(vii) Reproductive health care.
(viii) Preconception and nutrition counseling.
(ix) Prevention and treatment of sexually transmitted infection.
(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
(xi) Possible contraceptive consequences and followup.
(xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
(E) A complete physical examination on initial and subsequent
periodic visits.
(F) Services, drugs, devices, and supplies deemed by the federal
Centers for Medicare and Medicaid Services to be appropriate for
inclusion in the program.
(9) In order to maximize the availability of federal financial
participation under this subdivision, the director shall have the
discretion to implement the Family PACT successor state plan
amendment retroactively to July 1, 2010.
(ab) (1) Purchase of prescribed enteral nutrition products is
covered, subject to the Medi-Cal list of enteral nutrition products
and utilization controls.
(2) Purchase of enteral nutrition products is limited to those
products to be administered through a feeding tube, including, but
not limited to, a gastric, nasogastric, or jejunostomy tube.
Beneficiaries under the Early and Periodic Screening, Diagnosis, and
Treatment Program shall be exempt from this paragraph.
(3) Notwithstanding paragraph (2), the department may deem an
enteral nutrition product, not administered through a feeding tube,
including, but not limited to, a gastric, nasogastric, or jejunostomy
tube, a benefit for patients with diagnoses, including, but not
limited to, malabsorption and inborn errors of metabolism, if the
product has been shown to be neither investigational nor experimental
when used as part of a therapeutic regimen to prevent serious
disability or death.
(4) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement the amendments to this subdivision made by
the act that added this paragraph by means of all-county letters,
provider bulletins, or similar instructions, without taking
regulatory action.
(5) The amendments made to this subdivision by the act that added
this paragraph shall be implemented June 1, 2011, or on the first day
of the first calendar month following 60 days after the date the
department secures all necessary federal approvals to implement this
section, whichever is later.
(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.
(ad) (1) Comprehensive mental health crisis services, including
crisis intervention, crisis stabilization, crisis residential
treatment, rehabilitative mental health services, and mobile crisis
support teams, are covered.
(2) The department shall seek approval of any necessary state plan
amendments to implement this subdivision. This subdivision shall be
implemented only to the extent that federal financial participation
is available and any necessary federal approvals have been obtained.
SEC. 4. No reimbursement is required by this act
pursuant to Section 6 of Article XIII B of the California
Constitution because the only costs that may be incurred by a local
agency or school district will be incurred because this act creates a
new crime or infraction, eliminates a crime or infraction, or
changes the penalty for a crime or infraction, within the meaning of
Section 17556 of the Government Code, or changes the definition of a
crime within the meaning of Section 6 of Article XIII B of the
California Constitution.