Bill Text: CA AB2340 | 2023-2024 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Medi-Cal: EPSDT services: informational materials.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Passed) 2024-09-25 - Chaptered by Secretary of State - Chapter 564, Statutes of 2024. [AB2340 Detail]

Download: California-2023-AB2340-Amended.html

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Amended  IN  Assembly  April 01, 2024

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill

No. 2340

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Introduced by Assembly Member Bonta

February 12, 2024

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An act to add Article 4.12 (commencing with Section 14149.95) to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

AB 2340, as amended, Bonta. Medi-Cal: EPSDT services. services: informational materials.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive medically necessary health care services, through fee-for-service or managed care delivery systems. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, early and periodic screening, diagnostic, and treatment (EPSDT) services are covered under Medi-Cal for an individual under 21 years of age in accordance with certain federal provisions.

Under existing law, for an individual under 21 years of age, a service is medically necessary if the service meets the standards set forth in one of those federal EPSDT provisions, including the correction or amelioration of defects and physical and mental illnesses and conditions discovered by the screening services, whether or not those services are covered under the state plan. Existing law sets forth other provisions on medical necessity standards for covered benefits provided in a Medi-Cal behavioral health delivery system.

This bill would prohibit limits on EPSDT services when those services are medically necessary. The bill would require a Medi-Cal managed care plan to cover all medically necessary EPSDT services, unless otherwise carved out of the contract between the managed care plan and the department, regardless of whether those services are covered under the Medi-Cal State Plan.

The bill would establish definitions for “EPSDT services” and “medically necessary” by making references to the above-described provisions. The bill would specify that EPSDT services also include all age-specific assessments and services listed under the most current periodicity schedule by the American Academy of Pediatrics (AAP) and Bright Futures, and any other medically necessary assessments and services that exceed those listed by AAP and Bright Futures.

The bill would require the department and its contractors to accurately reflect these provisions in any model evidence-of-coverage documents, beneficiary handbooks, and related material.

Existing federal regulations require the state to provide for a combination of written and oral methods designed to inform individuals eligible for EPSDT services, or their families, about the EPSDT program, within 60 days of the individual’s initial Medicaid eligibility determination and, in the case of families that have not utilized EPSDT services, annually thereafter, as specified. Under those regulations, required information includes, among other components, the benefits of preventive health care and the services available under the EPSDT program and where and how to obtain those services.

This bill would require the department to prepare written informational materials that effectively explain and clarify the scope and nature of EPSDT services, as defined, that are available under the Medi-Cal program. Under the bill, the materials would include, but would not be limited to, the information required in the above-described federal regulations or their successor. Under the bill, the informational materials would also include content designed for youth, for purposes of delivery of that content to a beneficiary who is eligible for EPSDT services and who is 12 years of age or older but under 21 years of age.

The bill would authorize the department to standardize the materials, as specified, and would require the department to regularly review the materials to ensure that they are up to date. The bill would require the department to test the quality, clarity, and cultural concordance of translations of the informational materials with Medi-Cal beneficiaries, in order to ensure that the materials use clear and nontechnical language that effectively informs beneficiaries.

The bill would require the department or a Medi-Cal managed care plan, depending on the delivery system, to provide to a beneficiary who is eligible for EPSDT services, or to the parent or other authorized representative of that beneficiary, as applicable, the informational materials within 60 calendar days after that beneficiary’s initial Medi-Cal eligibility determination and annually thereafter.

Digest Key

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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Bill Text

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

SECTION 1.

 Article 4.12 (commencing with Section 14149.95) is added to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to read:

Article  4.12. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services

14149.95.

(a)For Medi-Cal beneficiaries under 21 years of age, early and periodic screening, diagnostic, and treatment (EPSDT) services are covered benefits under the Medi-Cal program when medically necessary, as defined in subdivision (e).

(b)Limits, including, but not limited to, caps on the number of covered visits, on EPSDT services shall not be imposed when those services are medically necessary.

(c)A Medi-Cal managed care plan shall meet both of the following conditions with regard to EPSDT services:

(1)The managed care plan shall provide and cover all medically necessary EPSDT services, unless otherwise carved out of the contract between the managed care plan and the department, regardless of whether those services are covered under the Medi-Cal State Plan.

(2)The managed care plan shall not impose limits on medically necessary EPSDT services, in accordance with subdivision (b).

(d)The department and its contractors shall accurately reflect the provisions of this section in any model evidence-of-coverage documents, beneficiary handbooks, and related material.

14149.95.

 (a) The department shall prepare written informational materials that effectively explain and clarify the scope and nature of early and periodic screening, diagnostic, and treatment (EPSDT) services that are available under the Medi-Cal program. The informational materials shall use clear and nontechnical language.

(b) (1) The informational materials shall include, but not be limited to, the information required in Section 441.56(a) of Title 42 of the Code of Federal Regulations or its successor.

(2) The informational materials shall include content designed for youth, for purposes of delivery of that content to the beneficiaries described in paragraph (2) of subdivision (d).

(3) The department may standardize the informational materials for use by the department and Medi-Cal managed care plans, as deemed appropriate by the department to implement this section.

(c) (1) The department shall, in consultation with stakeholders, regularly review the informational materials to ensure that the materials are up to date.

(2) To ensure that the informational materials use clear and nontechnical language that effectively informs Medi-Cal beneficiaries, the department shall test the quality, clarity, and cultural concordance of translations of the informational materials with Medi-Cal beneficiaries.

(d) (1) The department, for purposes of Medi-Cal beneficiaries under the fee-for-service delivery system, or a Medi-Cal managed care plan, for purposes of Medi-Cal beneficiaries under the managed care delivery system, shall provide to the respective beneficiary who is eligible for EPSDT services, or to the parent or other authorized representative of that beneficiary, as applicable, the informational materials described in this section within 60 calendar days after that beneficiary’s initial Medi-Cal eligibility determination and annually thereafter.

(2) The department or the Medi-Cal managed care plan, as applicable, shall provide the content designed for youth, as described in paragraph (2) of subdivision (b), to a beneficiary who is eligible for EPSDT services and who is 12 years of age or older but under 21 years of age, in accordance with the schedule described in paragraph (1).

(e) For purposes of this section, the following definitions apply:

(1) “EPSDT services” means services covered under subdivision (v) of Section 14132 and that meet the standards set forth in Section 1396d(r) of Title 42 of the United States Code.

(A) In addition to the screening, vision, dental, and hearing services described in Section 1396d(r)(1)-(4) of Title 42 of the United States Code, EPSDT services include such other necessary health care, diagnostic services, treatment, and other measures described in Section 1396d(a) of Title 42 of the United States Code to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not those services are covered under the Medi-Cal State plan, in accordance with Section 1396d(r)(5) of Title 42 of the United States Code.

(B) EPSDT services also include all age-specific assessments and services listed under the most current periodicity schedule by the American Academy of Pediatrics (AAP) and Bright Futures, and any other medically necessary assessments and services that exceed those listed by AAP and Bright Futures.

(2) A service is “medically necessary” if it meets the applicable medical necessity standards set forth in Sections 14059.5 and 14184.402.