CALIFORNIA LEGISLATURE 20212022 REGULAR SESSION Assembly Bill No. 1892Introduced by Assembly Member FloraFebruary 09, 2022 An act to amend Section 14105.21 of the Welfare and Institutions Code, relating to Medi-Cal. LEGISLATIVE COUNSEL'S DIGESTAB 1892, as introduced, Flora. Medi-Cal: orthotic and prosthetic devices.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 establish a list of covered services and maximum allowable reimbursement rates for prosthetic and orthotic appliances and durable medical equipment and publish the list in provider manuals. Existing law prohibits reimbursement for prosthetic and orthotic appliances from exceeding 80% of the lowest maximum allowance for California established by the federal medicare program.This bill would instead require reimbursement for these appliances to be set at 80% of the lowest maximum allowance for California established by the federal medicare program and would require that reimbursement to be adjusted annually.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. This act shall be known and may be cited as the California Orthotic and Prosthetic Patient Access and Fairness Act.SEC. 2. The Legislature finds and declares all of the following:(a) Certified orthotists and prosthetists are medical professionals who have specialized training to assess the mobility and functional needs of patients and apply orthotic and prosthetic devices, as prescribed by an appropriately licensed health care provider.(b) Orthotic and prosthetic devices are worn by the patient to replace or assist the functioning of a natural part of the human body.(c) Most orthotic and prosthetic users must wear a device on a daily basis, and these users rely on their prosthetic limb or orthotic brace to optimize their ability to participate in activities of daily living, including seemingly simple tasks such as walking within their own home, cooking, running errands, and getting to doctor appointments.(d) Lack of access to orthotic and prosthetic professionals, or the incorrect use of these types of devices because of inadequate access, education, and support increases the prevalence of chronic and life-threatening health problems.(e) For patients who require long-term use of their devices there is required maintenance and continued interaction with their orthotic and prosthetic provider to ensure the device is appropriately fitting and functioning. The care needed is not simply a one-time encounter, but many encounters over a long period of time.(f) Medi-Cal enrollees are sometimes left with no choice but to utilize used or obsolete technology, rely on crutches or a wheelchair as their only source of mobility, or continue using ill-fitting devices that could lead to safety concerns.(g) The cost of health care materials, labor, equipment, and utilities needed to fabricate and dispense these products has increased substantially. In many cases, the current Medi-Cal rates are below the actual cost of making and fitting the device. As such, Medi-Cal is no longer accepted by an increasing number of orthotic and prosthetic practitioners throughout California.(h) Without a long-overdue increase to Medi-Cal reimbursement rates for prosthetic and orthotic devices, socially vulnerable patients, many of whom are amputees, will continue to have challenges accessing orthotic and prosthetic care and will suffer from ongoing mobility and independence challenges. SEC. 3. Section 14105.21 of the Welfare and Institutions Code is amended to read:14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed shall be 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services. services and shall be adjusted annually to conform to any relevant changes in the Medicare program.(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.
CALIFORNIA LEGISLATURE 20212022 REGULAR SESSION Assembly Bill No. 1892Introduced by Assembly Member FloraFebruary 09, 2022 An act to amend Section 14105.21 of the Welfare and Institutions Code, relating to Medi-Cal. LEGISLATIVE COUNSEL'S DIGESTAB 1892, as introduced, Flora. Medi-Cal: orthotic and prosthetic devices.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 establish a list of covered services and maximum allowable reimbursement rates for prosthetic and orthotic appliances and durable medical equipment and publish the list in provider manuals. Existing law prohibits reimbursement for prosthetic and orthotic appliances from exceeding 80% of the lowest maximum allowance for California established by the federal medicare program.This bill would instead require reimbursement for these appliances to be set at 80% of the lowest maximum allowance for California established by the federal medicare program and would require that reimbursement to be adjusted annually.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
CALIFORNIA LEGISLATURE 20212022 REGULAR SESSION
Assembly Bill
No. 1892
Introduced by Assembly Member FloraFebruary 09, 2022
Introduced by Assembly Member Flora
February 09, 2022
An act to amend Section 14105.21 of the Welfare and Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 1892, as introduced, Flora. Medi-Cal: orthotic and prosthetic devices.
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 establish a list of covered services and maximum allowable reimbursement rates for prosthetic and orthotic appliances and durable medical equipment and publish the list in provider manuals. Existing law prohibits reimbursement for prosthetic and orthotic appliances from exceeding 80% of the lowest maximum allowance for California established by the federal medicare program.This bill would instead require reimbursement for these appliances to be set at 80% of the lowest maximum allowance for California established by the federal medicare program and would require that reimbursement to be adjusted annually.
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 establish a list of covered services and maximum allowable reimbursement rates for prosthetic and orthotic appliances and durable medical equipment and publish the list in provider manuals. Existing law prohibits reimbursement for prosthetic and orthotic appliances from exceeding 80% of the lowest maximum allowance for California established by the federal medicare program.
This bill would instead require reimbursement for these appliances to be set at 80% of the lowest maximum allowance for California established by the federal medicare program and would require that reimbursement to be adjusted annually.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. This act shall be known and may be cited as the California Orthotic and Prosthetic Patient Access and Fairness Act.SEC. 2. The Legislature finds and declares all of the following:(a) Certified orthotists and prosthetists are medical professionals who have specialized training to assess the mobility and functional needs of patients and apply orthotic and prosthetic devices, as prescribed by an appropriately licensed health care provider.(b) Orthotic and prosthetic devices are worn by the patient to replace or assist the functioning of a natural part of the human body.(c) Most orthotic and prosthetic users must wear a device on a daily basis, and these users rely on their prosthetic limb or orthotic brace to optimize their ability to participate in activities of daily living, including seemingly simple tasks such as walking within their own home, cooking, running errands, and getting to doctor appointments.(d) Lack of access to orthotic and prosthetic professionals, or the incorrect use of these types of devices because of inadequate access, education, and support increases the prevalence of chronic and life-threatening health problems.(e) For patients who require long-term use of their devices there is required maintenance and continued interaction with their orthotic and prosthetic provider to ensure the device is appropriately fitting and functioning. The care needed is not simply a one-time encounter, but many encounters over a long period of time.(f) Medi-Cal enrollees are sometimes left with no choice but to utilize used or obsolete technology, rely on crutches or a wheelchair as their only source of mobility, or continue using ill-fitting devices that could lead to safety concerns.(g) The cost of health care materials, labor, equipment, and utilities needed to fabricate and dispense these products has increased substantially. In many cases, the current Medi-Cal rates are below the actual cost of making and fitting the device. As such, Medi-Cal is no longer accepted by an increasing number of orthotic and prosthetic practitioners throughout California.(h) Without a long-overdue increase to Medi-Cal reimbursement rates for prosthetic and orthotic devices, socially vulnerable patients, many of whom are amputees, will continue to have challenges accessing orthotic and prosthetic care and will suffer from ongoing mobility and independence challenges. SEC. 3. Section 14105.21 of the Welfare and Institutions Code is amended to read:14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed shall be 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services. services and shall be adjusted annually to conform to any relevant changes in the Medicare program.(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. This act shall be known and may be cited as the California Orthotic and Prosthetic Patient Access and Fairness Act.
SECTION 1. This act shall be known and may be cited as the California Orthotic and Prosthetic Patient Access and Fairness Act.
SECTION 1. This act shall be known and may be cited as the California Orthotic and Prosthetic Patient Access and Fairness Act.
### SECTION 1.
SEC. 2. The Legislature finds and declares all of the following:(a) Certified orthotists and prosthetists are medical professionals who have specialized training to assess the mobility and functional needs of patients and apply orthotic and prosthetic devices, as prescribed by an appropriately licensed health care provider.(b) Orthotic and prosthetic devices are worn by the patient to replace or assist the functioning of a natural part of the human body.(c) Most orthotic and prosthetic users must wear a device on a daily basis, and these users rely on their prosthetic limb or orthotic brace to optimize their ability to participate in activities of daily living, including seemingly simple tasks such as walking within their own home, cooking, running errands, and getting to doctor appointments.(d) Lack of access to orthotic and prosthetic professionals, or the incorrect use of these types of devices because of inadequate access, education, and support increases the prevalence of chronic and life-threatening health problems.(e) For patients who require long-term use of their devices there is required maintenance and continued interaction with their orthotic and prosthetic provider to ensure the device is appropriately fitting and functioning. The care needed is not simply a one-time encounter, but many encounters over a long period of time.(f) Medi-Cal enrollees are sometimes left with no choice but to utilize used or obsolete technology, rely on crutches or a wheelchair as their only source of mobility, or continue using ill-fitting devices that could lead to safety concerns.(g) The cost of health care materials, labor, equipment, and utilities needed to fabricate and dispense these products has increased substantially. In many cases, the current Medi-Cal rates are below the actual cost of making and fitting the device. As such, Medi-Cal is no longer accepted by an increasing number of orthotic and prosthetic practitioners throughout California.(h) Without a long-overdue increase to Medi-Cal reimbursement rates for prosthetic and orthotic devices, socially vulnerable patients, many of whom are amputees, will continue to have challenges accessing orthotic and prosthetic care and will suffer from ongoing mobility and independence challenges.
SEC. 2. The Legislature finds and declares all of the following:(a) Certified orthotists and prosthetists are medical professionals who have specialized training to assess the mobility and functional needs of patients and apply orthotic and prosthetic devices, as prescribed by an appropriately licensed health care provider.(b) Orthotic and prosthetic devices are worn by the patient to replace or assist the functioning of a natural part of the human body.(c) Most orthotic and prosthetic users must wear a device on a daily basis, and these users rely on their prosthetic limb or orthotic brace to optimize their ability to participate in activities of daily living, including seemingly simple tasks such as walking within their own home, cooking, running errands, and getting to doctor appointments.(d) Lack of access to orthotic and prosthetic professionals, or the incorrect use of these types of devices because of inadequate access, education, and support increases the prevalence of chronic and life-threatening health problems.(e) For patients who require long-term use of their devices there is required maintenance and continued interaction with their orthotic and prosthetic provider to ensure the device is appropriately fitting and functioning. The care needed is not simply a one-time encounter, but many encounters over a long period of time.(f) Medi-Cal enrollees are sometimes left with no choice but to utilize used or obsolete technology, rely on crutches or a wheelchair as their only source of mobility, or continue using ill-fitting devices that could lead to safety concerns.(g) The cost of health care materials, labor, equipment, and utilities needed to fabricate and dispense these products has increased substantially. In many cases, the current Medi-Cal rates are below the actual cost of making and fitting the device. As such, Medi-Cal is no longer accepted by an increasing number of orthotic and prosthetic practitioners throughout California.(h) Without a long-overdue increase to Medi-Cal reimbursement rates for prosthetic and orthotic devices, socially vulnerable patients, many of whom are amputees, will continue to have challenges accessing orthotic and prosthetic care and will suffer from ongoing mobility and independence challenges.
SEC. 2. The Legislature finds and declares all of the following:
### SEC. 2.
(a) Certified orthotists and prosthetists are medical professionals who have specialized training to assess the mobility and functional needs of patients and apply orthotic and prosthetic devices, as prescribed by an appropriately licensed health care provider.
(b) Orthotic and prosthetic devices are worn by the patient to replace or assist the functioning of a natural part of the human body.
(c) Most orthotic and prosthetic users must wear a device on a daily basis, and these users rely on their prosthetic limb or orthotic brace to optimize their ability to participate in activities of daily living, including seemingly simple tasks such as walking within their own home, cooking, running errands, and getting to doctor appointments.
(d) Lack of access to orthotic and prosthetic professionals, or the incorrect use of these types of devices because of inadequate access, education, and support increases the prevalence of chronic and life-threatening health problems.
(e) For patients who require long-term use of their devices there is required maintenance and continued interaction with their orthotic and prosthetic provider to ensure the device is appropriately fitting and functioning. The care needed is not simply a one-time encounter, but many encounters over a long period of time.
(f) Medi-Cal enrollees are sometimes left with no choice but to utilize used or obsolete technology, rely on crutches or a wheelchair as their only source of mobility, or continue using ill-fitting devices that could lead to safety concerns.
(g) The cost of health care materials, labor, equipment, and utilities needed to fabricate and dispense these products has increased substantially. In many cases, the current Medi-Cal rates are below the actual cost of making and fitting the device. As such, Medi-Cal is no longer accepted by an increasing number of orthotic and prosthetic practitioners throughout California.
(h) Without a long-overdue increase to Medi-Cal reimbursement rates for prosthetic and orthotic devices, socially vulnerable patients, many of whom are amputees, will continue to have challenges accessing orthotic and prosthetic care and will suffer from ongoing mobility and independence challenges.
SEC. 3. Section 14105.21 of the Welfare and Institutions Code is amended to read:14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed shall be 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services. services and shall be adjusted annually to conform to any relevant changes in the Medicare program.(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.
SEC. 3. Section 14105.21 of the Welfare and Institutions Code is amended to read:
### SEC. 3.
14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed shall be 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services. services and shall be adjusted annually to conform to any relevant changes in the Medicare program.(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.
14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed shall be 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services. services and shall be adjusted annually to conform to any relevant changes in the Medicare program.(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.
14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed shall be 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services. services and shall be adjusted annually to conform to any relevant changes in the Medicare program.(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.
14105.21. (a) An assistive device and sickroom supply dealer may not bill the Medi-Cal program for prosthetic and orthotic appliances.
(b) A pharmacy may not bill the Medi-Cal program for prosthetic or orthotic appliances, unless the pharmacy is certified by the National Community Pharmacists Association and only for prosthetic and orthotic appliances that have been identified pursuant to subdivision (c) or otherwise approved by the department.
(c) The department shall establish a list of covered services and maximum allowable reimbursement rates, subject to Section 14107.7, rates for prosthetic and orthotic appliances, and the list shall be published in provider manuals.
(d) Reimbursement for prosthetic and orthotic appliances, as defined in Section 51160 of Title 22 of the California Code of Regulations, may not exceed shall be 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar services. services and shall be adjusted annually to conform to any relevant changes in the Medicare program.
(e) The department shall repeal Section 51515 of Title 22 of the California Code of Regulations, as it read on the effective date of the act adding this section.
(f) The department may implement this section by provider manual or bulletin. Notwithstanding the 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, actions under this section shall not be subject to the rulemaking provisions of the Administrative Procedure Act or to the review and approval of the Office of Administrative Law.