BILL NUMBER: AB 813	ENROLLED
	BILL TEXT

	PASSED THE ASSEMBLY  MAY 15, 2006
	PASSED THE SENATE  MAY 11, 2005
	AMENDED IN SENATE  MAY 11, 2006
	AMENDED IN SENATE  MAY 9, 2006
	AMENDED IN SENATE  MAY 8, 2006
	AMENDED IN SENATE  JUNE 9, 2005
	AMENDED IN ASSEMBLY  MAY 3, 2005
	AMENDED IN ASSEMBLY  APRIL 18, 2005
	AMENDED IN ASSEMBLY  MARCH 29, 2005

INTRODUCED BY   Assembly Member Nunez
   (Principal coauthor: Senator Perata)
   (Coauthor: Assembly Member Baca)

                        FEBRUARY 18, 2005

   An act to amend Section 14133.23 of the Welfare and Institutions
Code, and to amend Section 2 of Chapter 2 of the Statutes of 2006,
relating to Medi-Cal, making an appropriation therefor, and declaring
the urgency thereof, to take effect immediately.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 813, Nunez  Medi-Cal: emergency drug benefits.
   Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Services and under
which qualified low-income persons receive health care benefits,
including, for certain beneficiaries, prescription drug benefits. The
Medi-Cal program is, in part, governed and funded by federal
Medicaid provisions.
   Existing law provides for the federal Medicare Program, which
provides health care benefits, including prescription drug benefits,
to persons 65 years of age and older and other specified persons.
Under the Medicare Program, prescription drug benefits are obtained
through enrollment in a prescription drug plan offered under the
program.  Existing law requires Medicare-eligible persons who are
also eligible for Medi-Cal prescription drug benefits to obtain those
benefits through a prescription drug plan under the Medicare
Program, except as specified.
   Existing law requires the department, through February 15, 2006,
and only to the extent that funds are appropriated for this purpose,
to provide drug benefits, when any of specified conditions exists, to
a Medicare-eligible person who is also eligible for Medi-Cal
prescription drug benefits and who is not able to obtain drug
benefits from his or her prescription drug plan under the Medicare
Program. Existing law allows the Governor, after that date, and upon
notice to the Joint Legislative Budget Committee, to extend coverage
for those drug benefits for coverage periods of up to 30 days each,
but in no event beyond May 16, 2006. Existing law appropriates
$127,500,000 to implement these provisions until June 30, 2007, upon
which date any unexpended funds would revert to the General Fund.
   This bill would require the department, beginning May 17, 2006,
and ending January 31, 2007, and only to the extent that funds are
appropriated for this purpose, to provide emergency drug benefits to
a Medicare-eligible person who is also eligible for Medi-Cal
prescription drug benefits but is unable to obtain drug benefits from
his or her Medicare Drug Plan only when one or more of certain
conditions are met. The bill would give pharmacies specified duties
in this regard, including making a specified certification under
penalty of perjury. By expanding the crime of perjury, the bill would
impose a state-mandated local program.
   The bill would reduce the above appropriation to $120,000,000,
would revise the appropriation to allow the appropriated funds to
also be used for the implementation of the bill, and would delete the
June 30, 2007, reversion provision. By expanding the scope of an
existing appropriation, this bill would create an appropriation.
  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.
   This bill would declare that it would take effect immediately as
an urgency statute.
   Appropriation: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  Section 14133.23 of the Welfare and Institutions Code
is amended to read:
   14133.23.  (a) To the extent that federal financial participation
is not available, the provision of drug benefits under this chapter
to full-benefit dual eligible beneficiaries who are eligible for drug
benefits under Part D of Title XVIII of the Social Security Act (42
U.S.C. Sec. 1395w-101 et seq.) or under a Medicare
Advantage-Prescription Drug plan (MA-PD plan) under Part C of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.),
is eliminated, except as otherwise provided under this section.
   (b) (1) Notwithstanding any other provision of law, only drug
benefits for which federal financial participation is available shall
be provided under this chapter to a full-benefit dual eligible
beneficiary, except as otherwise provided under subdivision (c).
   (2) As a benefit under this chapter, the department, subject to
the approval of the Department of Finance and only to the extent that
federal financial participation is available, may elect to provide a
drug or drugs in a class of drugs not covered under Part D of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.)
or under a MA-PD plan under Part C of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-21 et seq.) to full-benefit dual
eligible beneficiaries.
   (3) As a benefit under this chapter, and only to the extent that
federal financial participation is available, the department shall
provide a drug or drugs to full-benefit dual eligible beneficiaries
who are otherwise eligible to receive the drug or drugs due to their
entitlement under Title 42 United States Code, Chapter 7, Title
XVIII, Part A or their enrollment under Title 42 United States Code,
Chapter 7, Title XVIII, Part B.
   (4) Except as provided under paragraph (3) and subdivision (c),
nothing in this section shall be interpreted to require the
department to provide any drug or drugs not covered under Part D of
Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et
seq.) or under a MA-PD plan under Part C of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-21 et seq.) if federal financial
participation is not available.
   (c) (1) The department shall review the drug formularies of
prescription drug plans under Part D of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or MA-PD plans under
Part C of Title XVIII of the Social Security Act (42 U.S.C. Sec.
1395w-21 et seq.) available to full-benefit dual eligible
beneficiaries.
   (2) The department shall develop a process that would allow the
department to provide to a full-benefit dual eligible beneficiary, on
an emergency basis only, coverage for a drug or drugs not included
on the full-benefit dual eligible beneficiary's prescription drug
plan's formulary or by prior authorization under Part D of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-101 et seq.)
or MA-PD plans under Part C of Title XVIII of the Social Security Act
(42 U.S.C. Sec. 1395w-21 et seq.) for which federal financial
participation is not available.
   (3) Only to the extent that the Legislature made a specific
appropriation to fund the provision of emergency drug benefits for
which federal financial participation is not available to
full-benefit dual eligible beneficiaries, the department shall
provide, through the process described in paragraph (2), these
emergency drug benefits to a full-benefit dual eligible beneficiary
only when all of the following conditions are met:
   (A) The drug is not available to the full-benefit dual eligible
beneficiary under his or her plan's drug formulary or by prior
authorization.
   (B) The pharmacist provides or dispenses the drug as an emergency
service.
   (C) The quantity of the drug provided or dispensed in no greater
than a 60-day supply.
   (D) The pharmacist has not previously provided or dispensed nor
has knowledge that another pharmacist has provided or dispensed the
same drug for that full-benefit dual eligible beneficiary on or after
January 1, 2006.
   (E) The date of service is from January 1, 2006, through December
31, 2006, inclusive.
   (4) The department may impose a pre- or post-service prepayment or
postpayment review or audit, to review the medical necessity of
emergency services provided to full-benefit dual eligible
beneficiaries.
   (d) The department shall seek approval of any amendments to the
state plan necessary to implement this section as required by Title
XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.).
   (e) 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, interpret or make specific this section by
means of all county letters, provider bulletins, or similar
instructions. Thereafter, the department may 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.
   (f) (1) Notwithstanding any other provision of this section, and
only to the extent that funds are appropriated for this purpose, the
department shall provide on a time-limited basis, as described in
paragraphs (7) and (8), drug benefits to a full-benefit dual eligible
beneficiary who is not able to obtain drug benefits from his or her
Medicare Drug Plan only when one or more of the following conditions
are met:
   (A) The pharmacy has submitted a claim for the provision of drug
benefits to the full-benefit dual eligible beneficiary's Medicare
Drug Plan and the claim has been denied payment for reasons other
than processing errors or omissions made by the pharmacy, lack of
medical necessity, or health or safety reasons.
   (B) The pharmacy is unable to submit a claim for the provision of
drug benefits solely due to the unavailability of complete or
accurate Medicare Drug Plan enrollment information from the
full-benefit dual eligible beneficiary's Medicare Drug Plan, the
federal Centers for Medicare and Medicaid Services, or entities under
contract with the Centers for Medicare and Medicaid Services to
provide enrollment information.
   (C) The Medicare Drug Plan provides information that the
full-benefit dual eligible beneficiary's deductible or copayment
amount is higher than the copayment amounts that are established by
Medicare for full-benefit dual eligible beneficiaries.
   (2) The director may impose a pre- or post-service prepayment or
postpayment review or audit to determine whether a pharmacy has
accurately and in good faith established the existence of any
condition certified by the pharmacy pursuant to subparagraph (A),
(B), or (C) of paragraph (1) in support of a submitted claim to the
department.
   (3) If the claim submitted by the pharmacy to the Medicare Drug
Plan meets the circumstances described in subparagraph (C) of
paragraph (1), the department shall pay the Medi-Cal rate less the
Medicare Drug Plan reimbursement amount and the Medicare copayment
amount.
   (4) To obtain reimbursement from the department, a pharmacy must
be an enrolled provider in the Medi-Cal program and certify on its
claims under penalty of perjury that one of the conditions specified
in paragraph (1) exists.
   (5) The department shall seek reimbursement from the federal
government of all funds spent to comply with the provisions of this
subdivision.
   (6) To the extent that the department reimburses a pharmacy for
claims authorized under this subdivision, the director shall have the
right to recover or recoup the full cost expended by the state for
that reimbursement from the full-benefit dual eligible beneficiary's
Medicare Drug Plan.
   (7) Reimbursement for claims authorized under this subdivision
shall be limited to those drug benefits provided to a full-benefit
dual eligible beneficiary from January 12, 2006, to February 15,
2006, inclusive.
   (8) After February 15, 2006, the Governor may, upon notice to the
Joint Legislative Budget Committee, extend coverage for drug benefits
to a full-benefit dual eligible beneficiary for coverage periods of
up to 30 days each. In no event shall the reimbursement authorized by
this paragraph extend beyond May 16, 2006.
   (9) Any drug benefits made available to full-benefit dual eligible
beneficiaries under the authority of this subdivision shall be
limited to the funds appropriated by the Legislature to the
department for this purpose. These drug benefits shall not be deemed
to be an entitlement.
   (g) (1) Notwithstanding any other provision of this section, and
only to the extent that funds are appropriated for this purpose,
beginning May 17, 2006, and ending January 31, 2007, the department
shall provide emergency drug benefits to a full-benefit dual eligible
beneficiary who is unable to obtain drug benefits from his or her
Medicare Drug Plan only when one or more of the following conditions
are met:
   (A) The pharmacy has submitted a claim for the provision of drug
benefits to the full-benefit dual eligible beneficiary's Medicare
Drug Plan and the claim has been denied payment due to error by the
Medicare Program and the pharmacy has made a good faith effort to
resolve the error with the Medicare Drug Plan and the Medicare
Program.
   (B) The pharmacy is unable to submit a claim for the provision of
drug benefits solely due to incomplete or inaccurate Medicare Drug
Plan enrollment information from the full-benefit dual eligible
beneficiary's Medicare Drug Plan, the federal Centers for Medicare
and Medicaid Services, or entities under contract with the Centers
for Medicare and Medicaid Services to provide enrollment information,
and the pharmacy has attempted to resolve these problems with the
Medicare facilitated enrollment contractor and the Medicare Drug
Plan, where appropriate.
   (C) The Medicare Drug Plan provides information that the
full-benefit dual eligible beneficiary's deductible or copayment
amount is higher than the copayment amounts that are established by
Medicare for full-benefit dual eligible beneficiaries.
   (D) Request for prior authorization or exception to the
full-benefit dual eligible beneficiary's Medicare Drug Plan is
required and was sought by the pharmacist, but the pharmacy does not
receive a response within 24 hours for an emergency drug or within 72
hours for a nonemergency drug. When submitting a request for prior
authorization to the department, a pharmacy shall show proof of the
submission of the request that was made to either the Medicare Drug
Plan or the beneficiary's prescribing physician.
   (2) In providing these benefits, the department shall implement
prepayment utilization controls, including prior authorization, and
may implement postpayment reviews or audits to determine whether a
pharmacy has accurately and in good faith established the existence
of any condition certified by the pharmacy pursuant to subparagraph
(A), (B), (C), or (D) of paragraph (1) in support of a submitted
claim to the department.
   (3) If the claim submitted by the pharmacy to the Medicare Drug
Plan meets the circumstances described in subparagraph (C) of
paragraph (1), the department shall pay only the difference between
the copayment amount established by Medicare for full-benefit dual
eligible beneficiaries and the actual copayment amount charged.
   (4) To obtain reimbursement from the department, a pharmacy must
be an enrolled provider in the Medi-Cal program and certify on its
claims under penalty of perjury that one of the conditions specified
in paragraph (1) exists.
   (5) To the extent that the department reimburses a pharmacy for
claims authorized under this subdivision, the director shall have the
right to recover or recoup the full cost expended by the state for
that reimbursement from the full-benefit dual eligible beneficiary's
Medicare Drug Plan.
   (6) Any drug benefits made available to full-benefit dual eligible
beneficiaries under the authority of this subdivision shall not be
deemed to be an entitlement. Beginning September 1, 2006, the
department shall not cover drug benefits when prior authorization or
exception to the full-benefit dual eligible beneficiary's Medicare
Drug Plan is required, unless that authorization was sought by the
physician and the Medicare Drug Plan does not provide a response
within 24 hours for an emergency drug or within 72 hours for a
nonemergency drug.
   (h) (1) For the purposes of this section, a "full-benefit dual
eligible beneficiary" means an individual who meets both of the
following criteria:
   (A) The beneficiary is eligible or would be eligible for coverage
for the month for covered Part D drugs under a prescription drug plan
under Part D of Title XVIII of the Social Security Act (42 U.S.C.
Sec. 1395w-101 et seq.) or under a MA-PD plan under Part C of Title
XVIII of the Social Security Act (42 U.S.C. Sec. 1395w-21 et seq.).
   (B) Notwithstanding any other provision of this section, the
beneficiary is determined eligible for full-scope services, including
drug benefits, for which federal financial participation is
available.
   (2) For the purposes of this section, "Medicare Drug Plan" means a
prescription drug plan under Part D of Title XVIII of the Social
Security Act (42 U.S.C. Sec. 1395w-101 et seq.) or under a MA-PD plan
under Part C of Title XVIII of the Social Security Act (42 U.S.C.
Sec. 1395w-21 et seq.).
   (i) Subdivisions (a) and (b) and paragraph (3) of subdivision (c)
shall become operative on January 1, 2006.
  SEC. 2.  Section 2 of Chapter 2 of the Statutes of 2006, as amended
by Section 2 of Chapter 7 of the Statutes of 2006, is amended to
read:
  Sec. 2.  There is hereby appropriated from the General Fund the sum
of one hundred twenty million dollars ($120,000,000) to the State
Department of Health Services to implement subdivisions (f) and (g)
of Section 14133.23 of the Welfare and Institutions Code, as amended
during the 2006 portion of the 2005-06 Regular Session.
  SEC. 3.  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.
  SEC. 4.  This act is an urgency statute necessary for the immediate
preservation of the public peace, health, or safety within the
meaning of Article IV of the Constitution and shall go into immediate
effect. The facts constituting the necessity are:
   In order to ensure that Medi-Cal beneficiaries receive
prescription drug benefits without delay or extra cost, it is
necessary that this act take effect immediately.