| Last Version Text |
<?xml version="1.0" ?>
<ns0:MeasureDoc xmlns:html="http://www.w3.org/1999/xhtml" xmlns:ns0="http://lc.ca.gov/legalservices/schemas/caml.1#" xmlns:ns3="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" version="1.0" xsi:schemaLocation="http://lc.ca.gov/legalservices/schemas/caml.1# xca.1.xsd">
<ns0:Description>
<ns0:Id>20250AB__035095AMD</ns0:Id>
<ns0:VersionNum>95</ns0:VersionNum>
<ns0:History>
<ns0:Action>
<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2025-01-29</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2025-04-24</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2025-05-23</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_SENATE</ns0:ActionText>
<ns0:ActionDate>2025-07-07</ns0:ActionDate>
</ns0:Action>
<ns0:Action>
<ns0:ActionText>AMENDED_SENATE</ns0:ActionText>
<ns0:ActionDate>2025-09-05</ns0:ActionDate>
</ns0:Action>
</ns0:History>
<ns0:LegislativeInfo>
<ns0:SessionYear>2025</ns0:SessionYear>
<ns0:SessionNum>0</ns0:SessionNum>
<ns0:MeasureType>AB</ns0:MeasureType>
<ns0:MeasureNum>350</ns0:MeasureNum>
<ns0:MeasureState>AMD</ns0:MeasureState>
</ns0:LegislativeInfo>
<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Bonta</ns0:AuthorText>
<ns0:AuthorText authorType="COAUTHOR_ORIGINATING">(Coauthor: Assembly Member Jackson)</ns0:AuthorText>
<ns0:AuthorText authorType="COAUTHOR_OPPOSITE">(Coauthor: Senator Rubio)</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
<ns0:Contribution>LEAD_AUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Bonta</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Jackson</ns0:Name>
</ns0:Legislator>
<ns0:Legislator>
<ns0:Contribution>COAUTHOR</ns0:Contribution>
<ns0:House>SENATE</ns0:House>
<ns0:Name>Rubio</ns0:Name>
</ns0:Legislator>
</ns0:Authors>
<ns0:Title>An act to add Section 1367.73 to the Health and Safety Code, to add Section 10120.45 to the Insurance Code, and to amend Section 14132 of the Welfare and Institutions Code, relating to health care coverage. </ns0:Title>
<ns0:RelatingClause>health care coverage</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>Health care coverage: fluoride treatments. </ns0:Subject>
</ns0:GeneralSubject>
<ns0:DigestText>
<html:p>Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act’s requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law sets forth specified coverage requirements for health care service plan contracts and health insurance policies.</html:p>
<html:p>Existing law requires an individual or small group health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2017, to include, at a minimum, coverage for essential health benefits pursuant to the federal Patient Protection and Affordable Care Act. Existing
law requires an essential health benefit to be provided only to the extent that federal law does not require the state to defray the costs of the benefit.</html:p>
<html:p>This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2026, that provides coverage for the application of fluoride varnish as a pediatric oral care benefit to provide coverage without cost sharing for the application of fluoride varnish as medically necessary regardless of whether the service is billed as a dental benefit or as a medical benefit. If this coverage requirement creates an obligation for the state to defray costs for an individual, the bill would not require coverage unless there is an appropriation for this purpose, as specified. Because a willful violation of this provision by a health care service plan would be a crime, the bill would impose a state-mandated local program.</html:p>
<html:p>Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which health care services are provided to low-income individuals. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes a schedule of benefits under the Medi-Cal program and provides for various services, including certain dental services, that are rendered by Medi-Cal enrolled providers. Under existing law, silver diamine fluoride treatments are a covered benefit for eligible children 0 to 6 years of age, inclusive, as specified, and application of fluoride or other appropriate fluoride treatment is covered for children 17 years of age and under.</html:p>
<html:p>This bill would make the application of fluoride or other appropriate fluoride treatment, as defined by the department, a covered benefit under the Medi-Cal program for children under 21 years of age. The bill would require the State Department of Health Care Services to establish and promulgate a policy on or before January 1, 2027, that specifies this covered benefit includes the application of fluoride varnish, as
specified, and that allows reimbursement in certain circumstances.</html:p>
<html:p>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.</html:p>
<html:p>This bill would provide that no reimbursement is required by this act for a specified reason.</html:p>
</ns0:DigestText>
<ns0:DigestKey>
<ns0:VoteRequired>MAJORITY</ns0:VoteRequired>
<ns0:Appropriation>NO</ns0:Appropriation>
<ns0:FiscalCommittee>YES</ns0:FiscalCommittee>
<ns0:LocalProgram>YES</ns0:LocalProgram>
</ns0:DigestKey>
<ns0:MeasureIndicators>
<ns0:ImmediateEffect>NO</ns0:ImmediateEffect>
<ns0:ImmediateEffectFlags>
<ns0:Urgency>NO</ns0:Urgency>
<ns0:TaxLevy>NO</ns0:TaxLevy>
<ns0:Election>NO</ns0:Election>
<ns0:UsualCurrentExpenses>NO</ns0:UsualCurrentExpenses>
<ns0:BudgetBill>NO</ns0:BudgetBill>
<ns0:Prop25TrailerBill>NO</ns0:Prop25TrailerBill>
</ns0:ImmediateEffectFlags>
</ns0:MeasureIndicators>
</ns0:Description>
<ns0:Bill id="bill">
<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
<ns0:BillSection id="id_3523A20A-7734-451D-BADF-D0BC4D6EF6B7">
<ns0:Num>SECTION 1.</ns0:Num>
<ns0:Content>
<html:p>The Legislature finds and declares all of the following:</html:p>
<html:p>
(a)
<html:span class="EnSpace"/>
In 2021, the State Department of Public Health (DPH) reported that California’s third graders have a substantially higher proportion of tooth decay compared to the national median of 53 percent. Children from communities of color and Spanish-speaking households are more likely to experience tooth decay.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
Topical
fluoride varnish is a simple, effective, and low-cost intervention that is painted on the top and sides of each tooth with a small brush in less than two minutes. According to the American Academy of Pediatrics, fluoride varnish can help prevent tooth decay, slow it down, or stop it from getting worse. Fluoride varnish is safe and used by dentists and doctors all over the world to help prevent tooth decay in children. It must be reapplied at regular intervals to be fully effective. The American Dental Association recommends the application of fluoride varnish twice annually for all children.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
Although progress has been made to improve utilization, many children enrolled in Medi-Cal are not receiving regular dental services. Application of fluoride varnish outside dental settings offers an additional pathway for children to access this critical intervention. State Department of Health Care Services (DHCS) data published in May 2025 shows only
51.03 percent of children receiving dental services through the Medi-Cal Dental Fee-for-Service delivery system received at least one dental service in the 2024 calendar year. In the Counties of Los Angeles and Sacramento, fewer than one-half of all children receiving dental services through the Medi-Cal Dental Managed Care delivery system received at least one dental service in the 2024 calendar year.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
DHCS has specifically identified the application of fluoride varnish to children 0 to 20, inclusive, years of age as an area for quality improvement within Medi-Cal. As part of the Managed Care Accountability Set, a set of performance metrics that DHCS selects for annual reporting by Medi-Cal managed care health plans, the state measures the percentage of children who had at least two applications of fluoride varnish in a single year as one of several key quality metrics. The Topical Fluoride for Children (TFL-CH) metric counts application of
fluoride varnish in the dental and medical setting combined, for children 0 to 20, inclusive, years of age. As of April 2025, data shows most plans are below the Minimum Performance Level of 19.3 percent, meaning not even one in five Medi-Cal enrolled children is receiving fluoride varnish twice per year, as recommended, even when considering services provided in the dental setting and medical setting, combined.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
The application of fluoride varnish must be covered by states as medically necessary for all children under 21 years of age enrolled in Medi-Cal, pursuant to federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medicaid requirements. According to the federal Centers for Medicare and Medicaid Services:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Under EPSDT, states are required to provide any additional services that are coverable under the federal Medicaid program and found to be medically
necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A determination of whether a service is medically necessary for an individual child must be made on a case-by-case basis, taking into account the particular needs of the child.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
States may train primary care providers and pay them for oral health services, including fluoride varnish application.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
Incorporating oral health into children’s primary care visits is a best-practice strategy.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
It is about 10 times more expensive to provide inpatient dental care for caries-related conditions than to provide preventive care.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
Consistent
with EPSDT, “Medi-Cal for Kids and Teens,” a brochure published by DHCS describing EPSDT services, states that care covered by Medi-Cal for Kids and Teens includes all other needed services, as a child’s provider determines.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
Current Medi-Cal policy printed in the Medi-Cal Provider Manual allows for the reimbursement of fluoride varnish in a primary care setting only for children zero to five, inclusive, years of age.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
California law allows any person within a public health setting or a public health program created or administered by a federal, state, or local governmental entity to apply topical fluoride according to the prescription and protocol issued and established by a physician or dentist. This means that fluoride varnish can be applied by nonlicensed staff and lay workers that are overseen by a physician or dentist, including administrative staff, volunteers,
community health workers, and other school- and community-based personnel.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Current Medi-Cal reimbursement policy requires a qualified health professional to apply topical fluoride varnish.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
School-based fluoride varnish delivery programs are recommended as an evidence-based intervention by the Community Preventive Services Task Force, a federal entity created by the United States Department of Health and Human Services that makes evidence-based findings and recommendations about interventions to improve population health.
</html:p>
<html:p>
(k)
<html:span class="EnSpace"/>
According to the Community Preventive Services Task Force, school-based fluoride varnish delivery programs may be administered by the school (e.g., school health center) or by outside entities (e.g., federally qualified health centers, state oral health programs, dental schools), and
state Medicaid reimbursement policies regarding who can bill for preventive dental services and who can deliver them may pose greater barriers for nondental providers.
</html:p>
<html:p>
(
<html:i>l</html:i>
)
<html:span class="EnSpace"/>
Lack of regular application of fluoride varnish results in more dental caries and worse oral health outcomes for children.
</html:p>
<html:p>
(m)
<html:span class="EnSpace"/>
For applicable commercial health plans and insurance policies, the application of fluoride varnish is covered as an essential health benefit (EHB) under requirements for pediatric oral health coverage, pursuant to state and federal law for children under 19 years of age.
</html:p>
<html:p>
(n)
<html:span class="EnSpace"/>
Pursuant to a United States Preventive Services Task Force (USPSTF) recommendation, the application of fluoride varnish in the primary care setting is specifically covered for zero to five, inclusive, years of age under a federal preventive
services coverage requirement that applies to most private health plans. USPSTF recommends with a “B” grade that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. In its recommendation statement, the USPSTF states it only reviewed the evidence for preventive interventions of dental caries in children zero to five, inclusive, years of age. The USPSTF states that this should not be construed to imply that preventive interventions for dental caries should cease after five years of age.
</html:p>
<html:p>
(o)
<html:span class="EnSpace"/>
Although older children are more likely than infants and toddlers to receive regular preventive care in a dental setting, the application of fluoride varnish outside a dental setting may be medically necessary for children who are not regularly receiving fluoride varnish in a dental setting.
</html:p>
<html:p>
(p)
<html:span class="EnSpace"/>
Removal of
fluoride from community water systems and recent federal action to remove ingestible fluoride prescription drug products for children from the market only increases the importance of ensuring widespread access to topical fluoride varnish.
</html:p>
<html:p>
(q)
<html:span class="EnSpace"/>
It is the intent of the Legislature that expanding the type of personnel who can apply fluoride varnish in Medi-Cal and ensuring coverage of fluoride varnish outside of the dental setting for all children will create more opportunities to apply fluoride varnish within school-based and primary care settings, improve Medi-Cal quality metrics, and lead to fewer cavities, fewer school absences, and healthier California children.
</html:p>
</ns0:Content>
</ns0:BillSection>
<ns0:BillSection id="id_2CE3B8EA-A115-4B00-884B-99965D73AA0F">
<ns0:Num>SEC. 2.</ns0:Num>
<ns0:ActionLine action="IS_ADDED" ns3:href="urn:caml:codes:HSC:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2F%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'1367.73'%5D)" ns3:label="fractionType: LAW_SECTION" ns3:type="locator">
Section 1367.73 is added to the
<ns0:DocName>Health and Safety Code</ns0:DocName>
, to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_00DF6479-5B1E-4EB9-9069-04389F6901E5">
<ns0:Num>1367.73.</ns0:Num>
<ns0:LawSectionVersion id="id_E9BEA18C-B075-4161-9994-73F4105EAEC2">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
A health care service plan contract issued, amended, or renewed on or after January 1, 2026, that provides coverage for the application of fluoride varnish as a pediatric oral care benefit shall provide coverage for the application of fluoride varnish as medically necessary regardless of whether the service is billed as a dental benefit or as a
medical benefit, and shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement for that coverage.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
This section does not apply to a specialized health care service plan contract, as defined in subdivision (o) of Section 1345, or a Medicare supplement contract.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
Subdivision (a) does not diminish a plan’s responsibility under the federal Patient Protection and Affordable Care Act (Public Law 111-148) to cover services that are assigned either a grade of A or a grade of B by the United States Preventive Services Task Force for all populations subject to that recommendation.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
If the requirements
of subdivision (a) create an obligation for the state to defray costs for any individual, subdivision (a) shall cease to apply to a health care service plan subject to this section unless there is an appropriation in the annual Budget Act or other legislation for this purpose.
</html:p>
</ns0:Content>
</ns0:LawSectionVersion>
</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_586A9420-C873-4FB2-89DB-8D7FD19EE27A">
<ns0:Num>SEC. 3.</ns0:Num>
<ns0:ActionLine action="IS_ADDED" ns3:href="urn:caml:codes:INS:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2F%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'10120.45'%5D)" ns3:label="fractionType: LAW_SECTION" ns3:type="locator">
Section 10120.45 is added to the
<ns0:DocName>Insurance Code</ns0:DocName>
, to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_143423D5-7E4A-478E-B997-519CDBFF107B">
<ns0:Num>10120.45.</ns0:Num>
<ns0:LawSectionVersion id="id_DBD911E8-EF78-400B-9B55-CCD6BBC3EFDA">
<ns0:Content>
<html:p>
(a)
<html:span class="EnSpace"/>
A health insurance policy issued, amended, or renewed on or after January 1, 2026, that provides coverage for the application of fluoride varnish as a pediatric oral care benefit shall provide coverage for the application of fluoride varnish as medically necessary regardless of whether the service is billed as a dental benefit or as a medical
benefit, and shall not impose a deductible, coinsurance, copayment, or other cost-sharing requirement for that coverage.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
This section does not apply to a specialized health insurance
policy, as defined in subdivision (c) of Section 106, or a Medicare supplement policy.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
Subdivision (a) does not diminish an insurer’s responsibility under the federal Patient Protection and Affordable Care Act (Public Law 111-148) to cover services that are assigned either a grade of A or a grade of B by the United States Preventive Services Task Force for all populations subject to that recommendation.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
If the requirements of subdivision (a) create an obligation for the state to defray costs for any individual, subdivision (a) shall cease to apply to a health insurance policy subject to this section unless there is an appropriation in the annual Budget Act or other legislation for this purpose.
</html:p>
</ns0:Content>
</ns0:LawSectionVersion>
</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_3CEA8F57-78B2-46AE-B9F4-516ACB048CDF">
<ns0:Num>SEC. 4.</ns0:Num>
<ns0:ActionLine action="IS_AMENDED" ns3:href="urn:caml:codes:WIC:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2Fcaml%3ALawHeading%5B%40type%3D'DIVISION'%20and%20caml%3ANum%3D'9.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'PART'%20and%20caml%3ANum%3D'3.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'CHAPTER'%20and%20caml%3ANum%3D'7.'%5D%2Fcaml%3ALawHeading%5B%40type%3D'ARTICLE'%20and%20caml%3ANum%3D'4.'%5D%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'14132.'%5D)" ns3:label="fractionType: LAW_SECTION" ns3:type="locator">
Section 14132 of the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
is amended to read:
</ns0:ActionLine>
<ns0:Fragment>
<ns0:LawSection id="id_493C3221-0C67-441D-B961-069EF673F41A">
<ns0:Num>14132.</ns0:Num>
<ns0:LawSectionVersion id="id_EC61B4D4-5AFD-4F0B-9A0B-09AF2E7992DD">
<ns0:Content>
<html:p>The following is the schedule of benefits under this chapter:</html:p>
<html:p>
(a)
<html:span class="EnSpace"/>
Outpatient services are covered as follows:
</html:p>
<html:p>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.</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Inpatient hospital services, including, but not limited to, physician and podiatric services, physical therapy, and occupational therapy, are covered subject to utilization controls.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
For a Medi-Cal fee-for-service beneficiary, 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 does not 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” have the same meanings as those terms are defined in Section 1317.1 of the Health and Safety Code.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
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 persons with developmental disabilities are covered subject to utilization controls.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Purchase of prescribed drugs is covered subject to the Medi-Cal List of Contract Drugs and utilization controls.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
(i)
<html:span class="EnSpace"/>
For the purposes of this paragraph, nonlegend has the same meaning as defined in subdivision (a) of Section 14105.45.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Nonlegend acetaminophen-containing products, including children’s acetaminophen-containing products, selected by the department are covered benefits.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Nonlegend cough and cold products selected by the department are covered benefits.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
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 without taking regulatory action.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
Outpatient dialysis services and home hemodialysis services, including physician services, medical supplies, drugs, and equipment required for dialysis, are covered, subject to utilization controls.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
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. This subdivision does not 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.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
Blood and blood derivatives are covered.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
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 that 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’s Services program.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
For persons 21 years of age or older, the services specified in paragraph (1) shall be provided subject to the following conditions:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Periodontal treatment is not a benefit.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Endodontic therapy is not a benefit except for vital pulpotomy.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Laboratory processed crowns are not a benefit.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Removable prosthetics shall be a benefit only for patients as a requirement for employment.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Paragraph (2) shall become inoperative on July 1, 1995.
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Medical transportation is covered, subject to utilization controls.
</html:p>
<html:p>
(j)
<html:span class="EnSpace"/>
Home health care services are covered, subject to utilization controls.
</html:p>
<html:p>
(k)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
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. If 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.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Therapeutic shoes and inserts are covered when provided to a beneficiary with a diagnosis of diabetes, subject to utilization controls, to the extent that federal financial participation is available.
</html:p>
<html:p>
(l)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(m)
<html:span class="EnSpace"/>
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).
</html:p>
<html:p>
(n)
<html:span class="EnSpace"/>
Family planning services are covered, subject to utilization controls.
However, for Medi-Cal managed care plans, utilization controls shall be subject to Section 1367.25 of the Health and Safety Code.
</html:p>
<html:p>
(o)
<html:span class="EnSpace"/>
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:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(p)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Adult day health care is covered in accordance with Chapter 8.7 (commencing with Section 14520).
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
As provided in accordance with paragraph (4), adult day health care is covered for a maximum of five days per week.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(q)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Application of fluoride, or other appropriate fluoride treatment as defined by the department, and other prophylaxis treatment for children under 21 years of age are covered.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
No later than January 1, 2027, the department shall establish and promulgate a billing policy, as follows:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
A policy specifying that paragraph (1) includes the application of fluoride varnish as medically necessary regardless of whether the service is billed as a dental benefit or as a medical benefit, for children under 21 years of age, subject to utilization controls.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
A policy that allows a Medi-Cal enrolled provider who is authorized to apply and bill for the application of fluoride varnish to be reimbursed for that service, if the fluoride
varnish is physically applied by a person who is both of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Employed by the Medi-Cal enrolled provider or working in a contractual relationship with the Medi-Cal provider.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Otherwise authorized under law, including under Section 104762 or 104830 of the Health and
Safety Code, to apply fluoride varnish.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(r)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
A provider enrolled under this subdivision shall satisfy all applicable statutory and regulatory
requirements for becoming a Medi-Cal provider.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
This subdivision shall be implemented only to the extent funding is available under Section 14106.6.
</html:p>
<html:p>
(s)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
In-home medical care services are covered when medically appropriate and subject to utilization controls, for a beneficiary 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 a patient placed in a shared or congregate living arrangement, if a home setting is not medically appropriate or available to the beneficiary.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
As used in this subdivision, “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.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
As used in this subdivision, in-home medical care services include, but are not limited to:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Level-of-care and cost-of-care evaluations.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Expenses, directly attributable to home care activities, for materials.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Physician fees for home visits.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Expenses directly attributable to home care
activities for shelter and modification to shelter.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Expenses directly attributable to additional costs of special diets, including tube feeding.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
Medically related personal services.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
Home nursing education.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
Emergency maintenance repair.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Home health agency personnel benefits that permit coverage of care during periods when regular personnel are on vacation or using sick leave.
</html:p>
<html:p>
(J)
<html:span class="EnSpace"/>
All services needed to maintain antiseptic conditions at stoma or shunt sites on the body.
</html:p>
<html:p>
(K)
<html:span class="EnSpace"/>
Emergency and nonemergency medical transportation.
</html:p>
<html:p>
(L)
<html:span class="EnSpace"/>
Medical supplies.
</html:p>
<html:p>
(M)
<html:span class="EnSpace"/>
Medical equipment, including, but not limited to, scales, gurneys, and equipment racks suitable for paralyzed patients.
</html:p>
<html:p>
(N)
<html:span class="EnSpace"/>
Utility use directly attributable to the requirements of home care activities that are in addition to normal utility use.
</html:p>
<html:p>
(O)
<html:span class="EnSpace"/>
Special drugs and medications.
</html:p>
<html:p>
(P)
<html:span class="EnSpace"/>
Home health agency supervision of visiting staff that is medically necessary, but not included in the home health agency rate.
</html:p>
<html:p>
(Q)
<html:span class="EnSpace"/>
Therapy services.
</html:p>
<html:p>
(R)
<html:span class="EnSpace"/>
Household appliances and household utensil costs directly attributable to home care activities.
</html:p>
<html:p>
(S)
<html:span class="EnSpace"/>
Modification of medical equipment for home use.
</html:p>
<html:p>
(T)
<html:span class="EnSpace"/>
Training and orientation for use of life-support systems, including, but not limited to, support of respiratory functions.
</html:p>
<html:p>
(U)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
A beneficiary receiving in-home medical care services is 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.
</html:p>
<html:p>
(t)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(u)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>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.</html:p>
<html:p>
(v)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(w)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Hospice services are covered, in accordance with Medicare requirements, and are subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are incurred.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Notwithstanding any other law, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions.
</html:p>
<html:p>
(x)
<html:span class="EnSpace"/>
When a claim for treatment provided to a beneficiary includes both services that are authorized and reimbursable under this chapter and services 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.
</html:p>
<html:p>
(y)
<html:span class="EnSpace"/>
Home- and community-based services approved by the United States Department of Health and Human Services for a beneficiary with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex, who requires intermediate care or a higher level of care.
</html:p>
<html:p>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 that 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 a beneficiary in accordance with the client’s needs as identified in the plan of care, and subject to medical necessity and applicable utilization control.</html:p>
<html:p>The director may, under this section, contract with organizations qualified to provide, directly or by subcontract, services provided for in this subdivision to an eligible beneficiary. Contracts or agreements entered into pursuant to this division shall not be subject to the Public Contract Code.</html:p>
<html:p>
(z)
<html:span class="EnSpace"/>
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).
</html:p>
<html:p>
(aa)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
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. This section does not prohibit the department from seeking the Family PACT successor state plan amendment during the operation of the waiver.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Solely for the purposes of the waiver or Family PACT successor state plan amendment and notwithstanding any other law, the collection and use of an individual’s social security number shall
be necessary only to the extent required by federal law.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
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 law under the Medi-Cal program or the State-Only Family Planning Program shall apply to the program provided for under this subdivision.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
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 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.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
If 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.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
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 spend down of excess income, 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 spend down of excess income or if they are otherwise eligible under
Section 24003.
</html:p>
<html:p>
(8)
<html:span class="EnSpace"/>
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:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
Culturally and linguistically appropriate health education and counseling services, including informed consent, that include all of the following:
</html:p>
<html:p>
(i)
<html:span class="EnSpace"/>
Psychosocial and medical aspects of contraception.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Sexuality.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Fertility.
</html:p>
<html:p>
(iv)
<html:span class="EnSpace"/>
Pregnancy.
</html:p>
<html:p>
(v)
<html:span class="EnSpace"/>
Parenthood.
</html:p>
<html:p>
(vi)
<html:span class="EnSpace"/>
Infertility.
</html:p>
<html:p>
(vii)
<html:span class="EnSpace"/>
Reproductive health care.
</html:p>
<html:p>
(viii)
<html:span class="EnSpace"/>
Preconception and nutrition counseling.
</html:p>
<html:p>
(ix)
<html:span class="EnSpace"/>
Prevention and treatment of sexually transmitted infection.
</html:p>
<html:p>
(x)
<html:span class="EnSpace"/>
Use of contraceptive methods, federal Food and Drug Administration-approved contraceptive drugs, devices, and supplies.
</html:p>
<html:p>
(xi)
<html:span class="EnSpace"/>
Possible contraceptive consequences and followup.
</html:p>
<html:p>
(xii)
<html:span class="EnSpace"/>
Interpersonal communication and negotiation of relationships to assist individuals and couples in effective contraceptive method use and planning families.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
A complete physical examination on initial and subsequent periodic visits.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
Services, drugs, devices, and supplies deemed by the federal Centers for Medicare and Medicaid Services to be appropriate for inclusion
in the program.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
(i)
<html:span class="EnSpace"/>
Home test kits for sexually transmitted diseases, including any laboratory costs of processing the kit, that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal or Family PACT clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
For purposes of this subparagraph, “home test kit” means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or
FDA-approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
</html:p>
<html:p>
(iii)
<html:span class="EnSpace"/>
Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Family PACT provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
</html:p>
<html:p>
(9)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(ab)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Purchase of prescribed enteral nutrition products is covered, subject to the Medi-Cal list of enteral nutrition products and utilization controls.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
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. A beneficiary under the Early and Periodic Screening, Diagnostic, and Treatment Program shall be exempt from this paragraph.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
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.
</html:p>
<html:p>
(ac)
<html:span class="EnSpace"/>
Diabetic testing supplies are covered when provided by a pharmacy, subject to utilization controls.
</html:p>
<html:p>
(ad)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Nonmedical transportation is covered, subject to utilization controls and permissible time and distance standards, for a beneficiary to obtain covered Medi-Cal services.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
(A)
<html:span class="EnSpace"/>
(i)
<html:span class="EnSpace"/>
Nonmedical transportation includes, at a minimum, round trip
transportation for a beneficiary to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance, and mileage reimbursement when conveyance is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers, or train tickets.
</html:p>
<html:p>
(ii)
<html:span class="EnSpace"/>
Nonmedical transportation does not include the transportation of a sick, injured, invalid, convalescent, infirm, or otherwise incapacitated beneficiary by ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Nonmedical transportation shall be provided for a beneficiary who can attest in a manner to be specified by the department that other currently
available resources have been reasonably exhausted. For a beneficiary enrolled in a managed care plan, nonmedical transportation shall be provided by the beneficiary’s managed care plan. For a Medi-Cal fee-for-service beneficiary, the department shall provide nonmedical transportation when those services are not available to the beneficiary under Sections 14132.44 and 14132.47.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Nonmedical transportation shall be provided in a form and manner that is accessible, in terms of physical and geographic accessibility, for the beneficiary and consistent with applicable state and federal disability rights laws.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
It is the intent of the Legislature in enacting this subdivision to affirm the requirement under Section 431.53 of Title 42 of the Code of Federal Regulations, in which the
department is required to provide necessary transportation, including nonmedical transportation, for recipients to and from covered services. This subdivision shall not be interpreted to add a new benefit to the Medi-Cal program.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The department shall seek any federal approvals that may be required to implement this subdivision, including, but not limited to, approval of revisions to the existing state plan that the department determines are necessary to implement this subdivision.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized and any necessary federal approvals have been obtained.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
Prior to the effective date of
any necessary federal approvals, nonmedical transportation was not a Medi-Cal managed care benefit with the exception of when provided as an Early and Periodic Screening, Diagnostic, and Treatment service.
</html:p>
<html:p>
(8)
<html:span class="EnSpace"/>
Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations 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. Commencing January 1, 2018, and notwithstanding Section 10231.5
of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.
</html:p>
<html:p>
(9)
<html:span class="EnSpace"/>
This subdivision shall not be implemented until July 1, 2017.
</html:p>
<html:p>
(ae)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
No sooner than January 1, 2022, Rapid Whole Genome Sequencing, including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal beneficiary who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of
the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
This subdivision shall be implemented only to the extent that any necessary federal approvals are obtained, and federal financial participation is available and not otherwise jeopardized.
</html:p>
<html:p>
(af)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Home test kits for sexually transmitted diseases that are deemed medically necessary or appropriate and ordered directly by an enrolled Medi-Cal clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
For purposes of this subdivision, “home test kit” means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or FDA-approved, or developed by a laboratory in accordance with established regulations and quality standards, to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Reimbursement under this subparagraph shall be contingent upon the addition of codes specific to home test kits
in the Current Procedural Terminology or Healthcare Common Procedure Coding System to comply with Health Insurance Portability and Accountability Act requirements. The home test kit shall be sent by the enrolled Medi-Cal provider to a Medi-Cal-enrolled laboratory with fee based on Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
This subdivision shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, and any necessary federal approvals have been obtained.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement this subdivision by means of all-county
letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.
</html:p>
<html:p>
(ag)
<html:span class="EnSpace"/>
(1)
<html:span class="EnSpace"/>
Violence prevention services are covered, subject to medical necessity and utilization controls.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
This subdivision shall be implemented only to the extent that any necessary federal approvals
are obtained, and federal financial participation is available and not otherwise jeopardized.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
The department shall post on its internet website the date upon which violence prevention services may be provided and billed pursuant to this subdivision.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
“Violence prevention services” means evidence-based, trauma-informed, and culturally responsive preventive services provided to reduce the incidence of violent injury or reinjury, trauma, and related harms and promote trauma recovery, stabilization, and improved health outcomes.
</html:p>
</ns0:Content>
</ns0:LawSectionVersion>
</ns0:LawSection>
</ns0:Fragment>
</ns0:BillSection>
<ns0:BillSection id="id_9488A3D0-CAA4-4E4A-A4EC-37252AC84FD2">
<ns0:Num>SEC. 5.</ns0:Num>
<ns0:Content>
<html:p>
No reimbursement is required by this act pursuant to Section 6 of Article XIII
<html:span class="ThinSpace"/>
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
<html:span class="ThinSpace"/>
B
of the California Constitution.
</html:p>
</ns0:Content>
</ns0:BillSection>
</ns0:Bill>
</ns0:MeasureDoc>
|