Medi-Cal: application for enrollment: prescription drugs.
(1) 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 requires the department to create and implement a simplified application package for children, families, and adults applying for Medi-Cal benefits.
Existing federal law, the Telephone Consumer Protection Act, among other provisions, prohibits any person within the United States, or any person outside the United States if the recipient is within the United States, from making any call to any telephone number assigned to a paging service, cellular telephone service, specialized mobile radio service, or other radio common carrier service, or any service for which the called party is charged for the call, without the prior express consent of the called party, using any automatic telephone dialing system or an artificial or prerecorded voice. Under existing case law, a text message is considered a call for purposes of those provisions.
This bill would require the application for enrollment to include a statement that if the applicant is approved for Medi-Cal benefits, the applicant agrees that the department, county welfare department, and a managed care organization or health care provider to which the applicant is assigned may communicate with them regarding their care or benefits through all standard forms of communication, including, but not limited to, Free to End User text messaging.
(2) Existing federal law, known as the 340B discount drug purchasing program, generally requires pharmaceutical manufacturers participating in Medicaid to give discounts on pharmaceutical drugs to covered entities, as defined, serving the Medicaid population. This program is commonly referred to as the 340B program.
Under existing law, the Medi-Cal program requires a covered entity to dispense only drugs purchased through the 340B program to a Medi-Cal beneficiary. Existing law, if a covered entity is unable to purchase a drug for a Medi-Cal beneficiary through the 340B program, authorizes the covered entity to dispense a drug purchased at a regular drug wholesale rate, and limits the amount the covered entity may charge the Medi-Cal program for reimbursement of the purchase of the drug.
This bill would provide that those reimbursement requirements do not apply to federally qualified health centers (FQHCs) or rural health clinics (RHC) that are subject to federal minimum payment provisions, which calculate payment for services of the FQHCs and RHCs according to a specified formula. The bill would require the department to adopt regulations to establish and implement specified contract pharmacy auditing for the program, to retrospectively identify 340B drugs dispensed to Medi-Cal fee-for-service beneficiaries through a covered entity, as specified. The bill would only apply with respect to 340B drugs dispensed before April 1, 2022, unless the department adopts implementing regulations before that date.
(3) The Medi-Cal program administers a program known as the Family Planning, Access, Care, and Treatment (Family PACT) Program to provide comprehensive clinical family planning services to a person who has a family income at or below 200% of the federal poverty level and who is eligible to receive those services. Existing law requires reimbursement for drugs and supplies covered under the Medi-Cal program and the Family PACT Program by a licensed community clinic or free clinic, or an intermittent clinic, to be the lesser of cost or the clinic’s usual charge made to the general public. Existing law defines “cost” for these purposes as an aggregate amount equivalent to the sum of the actual acquisition cost of a drug or supply plus a clinic dispensing fee not to exceed $12 per billing unit, as specified. Existing law also sets the cost for a take-home drug that is dispensed for use by the patient within a specific timeframe of 5 or fewer days from the date medically indicated at the actual acquisition cost for that drug plus a clinic dispensing fee, not to exceed $17 per prescription.
This bill would instead define “cost” for these purposes as a $35 dispensing fee, established by the bill, plus the National Average Drug Acquisition Cost (NADAC) of the drug, or if a NADAC is not available, the Wholesale Acquisition Cost of the drug (WAC) plus zero.