CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 2983Introduced by Assembly Member HoldenFebruary 21, 2020 An act to amend Section 14105.455 of the Welfare and Institutions Code, relating to Medi-Cal. LEGISLATIVE COUNSEL'S DIGESTAB 2983, as introduced, Holden. Pharmacy provider: billing. Existing law establishes 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. Pursuant to a schedule of benefits, these services include prescription drugs that are subject to the Medi-Cal List of Contract Drugs. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Existing law requires pharmacy providers to submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs, and to keep and maintain records of those charges for a period of 3 years from the date the service was rendered.This bill would prohibit pharmacy providers from billing the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 14105.455 of the Welfare and Institutions Code is amended to read:14105.455. (a) Pharmacy providers A pharmacy provider shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs. any prescribed drug, except as specified in subdivision (f).(b) Usual and customary charge means the lower of the following:(1) The lowest price reimbursed to the pharmacy by other a third-party payers payer in California, excluding any Medi-Cal managed care plans plan and Medicare Part D prescription drug plans. plan.(2) The lowest price routinely offered to any segment of the general public.(c) Donations or discounts Any donation or discount provided to a charitable organization are is not considered a usual and customary charges. charge.(d) Pharmacy providers A pharmacy provider shall keep and maintain records of their any usual and customary charges charge for a period of three years from the date the service was rendered. that they rendered the service.(e) Payment to pharmacy providers a pharmacy provider shall be the lower of the pharmacys usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.(f) A pharmacy provider shall not bill the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.(f)(g) 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 a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.
CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION Assembly Bill No. 2983Introduced by Assembly Member HoldenFebruary 21, 2020 An act to amend Section 14105.455 of the Welfare and Institutions Code, relating to Medi-Cal. LEGISLATIVE COUNSEL'S DIGESTAB 2983, as introduced, Holden. Pharmacy provider: billing. Existing law establishes 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. Pursuant to a schedule of benefits, these services include prescription drugs that are subject to the Medi-Cal List of Contract Drugs. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Existing law requires pharmacy providers to submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs, and to keep and maintain records of those charges for a period of 3 years from the date the service was rendered.This bill would prohibit pharmacy providers from billing the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
CALIFORNIA LEGISLATURE 20192020 REGULAR SESSION
Assembly Bill
No. 2983
Introduced by Assembly Member HoldenFebruary 21, 2020
Introduced by Assembly Member Holden
February 21, 2020
An act to amend Section 14105.455 of the Welfare and Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 2983, as introduced, Holden. Pharmacy provider: billing.
Existing law establishes 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. Pursuant to a schedule of benefits, these services include prescription drugs that are subject to the Medi-Cal List of Contract Drugs. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Existing law requires pharmacy providers to submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs, and to keep and maintain records of those charges for a period of 3 years from the date the service was rendered.This bill would prohibit pharmacy providers from billing the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.
Existing law establishes 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. Pursuant to a schedule of benefits, these services include prescription drugs that are subject to the Medi-Cal List of Contract Drugs. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Existing law requires pharmacy providers to submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs, and to keep and maintain records of those charges for a period of 3 years from the date the service was rendered.
This bill would prohibit pharmacy providers from billing the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 14105.455 of the Welfare and Institutions Code is amended to read:14105.455. (a) Pharmacy providers A pharmacy provider shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs. any prescribed drug, except as specified in subdivision (f).(b) Usual and customary charge means the lower of the following:(1) The lowest price reimbursed to the pharmacy by other a third-party payers payer in California, excluding any Medi-Cal managed care plans plan and Medicare Part D prescription drug plans. plan.(2) The lowest price routinely offered to any segment of the general public.(c) Donations or discounts Any donation or discount provided to a charitable organization are is not considered a usual and customary charges. charge.(d) Pharmacy providers A pharmacy provider shall keep and maintain records of their any usual and customary charges charge for a period of three years from the date the service was rendered. that they rendered the service.(e) Payment to pharmacy providers a pharmacy provider shall be the lower of the pharmacys usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.(f) A pharmacy provider shall not bill the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.(f)(g) 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 a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 14105.455 of the Welfare and Institutions Code is amended to read:14105.455. (a) Pharmacy providers A pharmacy provider shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs. any prescribed drug, except as specified in subdivision (f).(b) Usual and customary charge means the lower of the following:(1) The lowest price reimbursed to the pharmacy by other a third-party payers payer in California, excluding any Medi-Cal managed care plans plan and Medicare Part D prescription drug plans. plan.(2) The lowest price routinely offered to any segment of the general public.(c) Donations or discounts Any donation or discount provided to a charitable organization are is not considered a usual and customary charges. charge.(d) Pharmacy providers A pharmacy provider shall keep and maintain records of their any usual and customary charges charge for a period of three years from the date the service was rendered. that they rendered the service.(e) Payment to pharmacy providers a pharmacy provider shall be the lower of the pharmacys usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.(f) A pharmacy provider shall not bill the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.(f)(g) 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 a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.
SECTION 1. Section 14105.455 of the Welfare and Institutions Code is amended to read:
### SECTION 1.
14105.455. (a) Pharmacy providers A pharmacy provider shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs. any prescribed drug, except as specified in subdivision (f).(b) Usual and customary charge means the lower of the following:(1) The lowest price reimbursed to the pharmacy by other a third-party payers payer in California, excluding any Medi-Cal managed care plans plan and Medicare Part D prescription drug plans. plan.(2) The lowest price routinely offered to any segment of the general public.(c) Donations or discounts Any donation or discount provided to a charitable organization are is not considered a usual and customary charges. charge.(d) Pharmacy providers A pharmacy provider shall keep and maintain records of their any usual and customary charges charge for a period of three years from the date the service was rendered. that they rendered the service.(e) Payment to pharmacy providers a pharmacy provider shall be the lower of the pharmacys usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.(f) A pharmacy provider shall not bill the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.(f)(g) 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 a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.
14105.455. (a) Pharmacy providers A pharmacy provider shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs. any prescribed drug, except as specified in subdivision (f).(b) Usual and customary charge means the lower of the following:(1) The lowest price reimbursed to the pharmacy by other a third-party payers payer in California, excluding any Medi-Cal managed care plans plan and Medicare Part D prescription drug plans. plan.(2) The lowest price routinely offered to any segment of the general public.(c) Donations or discounts Any donation or discount provided to a charitable organization are is not considered a usual and customary charges. charge.(d) Pharmacy providers A pharmacy provider shall keep and maintain records of their any usual and customary charges charge for a period of three years from the date the service was rendered. that they rendered the service.(e) Payment to pharmacy providers a pharmacy provider shall be the lower of the pharmacys usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.(f) A pharmacy provider shall not bill the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.(f)(g) 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 a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.
14105.455. (a) Pharmacy providers A pharmacy provider shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs. any prescribed drug, except as specified in subdivision (f).(b) Usual and customary charge means the lower of the following:(1) The lowest price reimbursed to the pharmacy by other a third-party payers payer in California, excluding any Medi-Cal managed care plans plan and Medicare Part D prescription drug plans. plan.(2) The lowest price routinely offered to any segment of the general public.(c) Donations or discounts Any donation or discount provided to a charitable organization are is not considered a usual and customary charges. charge.(d) Pharmacy providers A pharmacy provider shall keep and maintain records of their any usual and customary charges charge for a period of three years from the date the service was rendered. that they rendered the service.(e) Payment to pharmacy providers a pharmacy provider shall be the lower of the pharmacys usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.(f) A pharmacy provider shall not bill the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.(f)(g) 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 a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.
14105.455. (a) Pharmacy providers A pharmacy provider shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs. any prescribed drug, except as specified in subdivision (f).
(b) Usual and customary charge means the lower of the following:
(1) The lowest price reimbursed to the pharmacy by other a third-party payers payer in California, excluding any Medi-Cal managed care plans plan and Medicare Part D prescription drug plans. plan.
(2) The lowest price routinely offered to any segment of the general public.
(c) Donations or discounts Any donation or discount provided to a charitable organization are is not considered a usual and customary charges. charge.
(d) Pharmacy providers A pharmacy provider shall keep and maintain records of their any usual and customary charges charge for a period of three years from the date the service was rendered. that they rendered the service.
(e) Payment to pharmacy providers a pharmacy provider shall be the lower of the pharmacys usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.
(f) A pharmacy provider shall not bill the Medi-Cal program for any prescribed drug that has been automatically filled, regardless of whether that prescribed drug has been dispensed by mail order or retail.
(f)
(g) 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 a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.