CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 1437Introduced by Assembly Members Irwin and Quirk-SilvaFebruary 17, 2023 An act to add Section 14133.19 to the Welfare and Institutions Code, relating to Medi-Cal.LEGISLATIVE COUNSEL'S DIGESTAB 1437, as introduced, Irwin. Medi-Cal: serious mental illness.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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.Existing law sets forth a schedule of benefits under the Medi-Cal program, including specialty and nonspecialty mental health services through different delivery systems, in certain cases subject to utilization controls, such as prior authorization. Under existing law, prior authorization is approval of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Existing law sets forth various provisions relating to processing, or appealing the decision of, treatment authorization requests, and provisions relating to certain services requiring or not requiring a treatment authorization request.After a determination of cost benefit, existing law requires the Director of Health Care Services to modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment that costs less than $100, except for prescribed drugs, as specified.Under this bill, a treatment authorization request would not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness, as defined. Under the bill, a prescription for a drug for serious mental illness would automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.The bill would condition the above-described provisions on the prescription being for a person 18 years of age or over, and on the person not being within the transition jurisdiction of the juvenile court, as specified.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 14133.19 is added to the Welfare and Institutions Code, to read:14133.19. (a) Notwithstanding any other law, subject to subdivision (c), a treatment authorization request shall not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness.(b) Notwithstanding any other law, subject to subdivision (c), a prescription for a drug for serious mental illness shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.(c) Subdivisions (a) and (b) shall apply only if both of the following conditions are met:(1) The prescription is for a person 18 years of age or over.(2) The person is not within the transition jurisdiction of the juvenile court, as described in Section 450.(d) (1) For purposes of this section, serious mental illness means a mental disorder that is identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and that is severe in degree and persistent in duration, presents a major risk to the persons health and well-being, causes behavioral functioning that interferes substantially with the primary activities of daily living, and results in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.(2) Serious mental illness may include, but is not limited to, schizophrenia, post-traumatic stress disorder, bipolar disorder, other major affective disorders, or other severely disabling mental disorders pursuant to paragraph (1).
CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 1437Introduced by Assembly Members Irwin and Quirk-SilvaFebruary 17, 2023 An act to add Section 14133.19 to the Welfare and Institutions Code, relating to Medi-Cal.LEGISLATIVE COUNSEL'S DIGESTAB 1437, as introduced, Irwin. Medi-Cal: serious mental illness.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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.Existing law sets forth a schedule of benefits under the Medi-Cal program, including specialty and nonspecialty mental health services through different delivery systems, in certain cases subject to utilization controls, such as prior authorization. Under existing law, prior authorization is approval of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Existing law sets forth various provisions relating to processing, or appealing the decision of, treatment authorization requests, and provisions relating to certain services requiring or not requiring a treatment authorization request.After a determination of cost benefit, existing law requires the Director of Health Care Services to modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment that costs less than $100, except for prescribed drugs, as specified.Under this bill, a treatment authorization request would not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness, as defined. Under the bill, a prescription for a drug for serious mental illness would automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.The bill would condition the above-described provisions on the prescription being for a person 18 years of age or over, and on the person not being within the transition jurisdiction of the juvenile court, as specified.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION
Assembly Bill
No. 1437
Introduced by Assembly Members Irwin and Quirk-SilvaFebruary 17, 2023
Introduced by Assembly Members Irwin and Quirk-Silva
February 17, 2023
An act to add Section 14133.19 to the Welfare and Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 1437, as introduced, Irwin. Medi-Cal: serious mental illness.
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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.Existing law sets forth a schedule of benefits under the Medi-Cal program, including specialty and nonspecialty mental health services through different delivery systems, in certain cases subject to utilization controls, such as prior authorization. Under existing law, prior authorization is approval of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Existing law sets forth various provisions relating to processing, or appealing the decision of, treatment authorization requests, and provisions relating to certain services requiring or not requiring a treatment authorization request.After a determination of cost benefit, existing law requires the Director of Health Care Services to modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment that costs less than $100, except for prescribed drugs, as specified.Under this bill, a treatment authorization request would not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness, as defined. Under the bill, a prescription for a drug for serious mental illness would automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.The bill would condition the above-described provisions on the prescription being for a person 18 years of age or over, and on the person not being within the transition jurisdiction of the juvenile court, as specified.
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 health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing law sets forth a schedule of benefits under the Medi-Cal program, including specialty and nonspecialty mental health services through different delivery systems, in certain cases subject to utilization controls, such as prior authorization. Under existing law, prior authorization is approval of a specified service in advance of the rendering of that service based upon a determination of medical necessity. Existing law sets forth various provisions relating to processing, or appealing the decision of, treatment authorization requests, and provisions relating to certain services requiring or not requiring a treatment authorization request.
After a determination of cost benefit, existing law requires the Director of Health Care Services to modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment that costs less than $100, except for prescribed drugs, as specified.
Under this bill, a treatment authorization request would not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness, as defined. Under the bill, a prescription for a drug for serious mental illness would automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.
The bill would condition the above-described provisions on the prescription being for a person 18 years of age or over, and on the person not being within the transition jurisdiction of the juvenile court, as specified.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 14133.19 is added to the Welfare and Institutions Code, to read:14133.19. (a) Notwithstanding any other law, subject to subdivision (c), a treatment authorization request shall not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness.(b) Notwithstanding any other law, subject to subdivision (c), a prescription for a drug for serious mental illness shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.(c) Subdivisions (a) and (b) shall apply only if both of the following conditions are met:(1) The prescription is for a person 18 years of age or over.(2) The person is not within the transition jurisdiction of the juvenile court, as described in Section 450.(d) (1) For purposes of this section, serious mental illness means a mental disorder that is identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and that is severe in degree and persistent in duration, presents a major risk to the persons health and well-being, causes behavioral functioning that interferes substantially with the primary activities of daily living, and results in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.(2) Serious mental illness may include, but is not limited to, schizophrenia, post-traumatic stress disorder, bipolar disorder, other major affective disorders, or other severely disabling mental disorders pursuant to paragraph (1).
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 14133.19 is added to the Welfare and Institutions Code, to read:14133.19. (a) Notwithstanding any other law, subject to subdivision (c), a treatment authorization request shall not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness.(b) Notwithstanding any other law, subject to subdivision (c), a prescription for a drug for serious mental illness shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.(c) Subdivisions (a) and (b) shall apply only if both of the following conditions are met:(1) The prescription is for a person 18 years of age or over.(2) The person is not within the transition jurisdiction of the juvenile court, as described in Section 450.(d) (1) For purposes of this section, serious mental illness means a mental disorder that is identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and that is severe in degree and persistent in duration, presents a major risk to the persons health and well-being, causes behavioral functioning that interferes substantially with the primary activities of daily living, and results in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.(2) Serious mental illness may include, but is not limited to, schizophrenia, post-traumatic stress disorder, bipolar disorder, other major affective disorders, or other severely disabling mental disorders pursuant to paragraph (1).
SECTION 1. Section 14133.19 is added to the Welfare and Institutions Code, to read:
### SECTION 1.
14133.19. (a) Notwithstanding any other law, subject to subdivision (c), a treatment authorization request shall not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness.(b) Notwithstanding any other law, subject to subdivision (c), a prescription for a drug for serious mental illness shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.(c) Subdivisions (a) and (b) shall apply only if both of the following conditions are met:(1) The prescription is for a person 18 years of age or over.(2) The person is not within the transition jurisdiction of the juvenile court, as described in Section 450.(d) (1) For purposes of this section, serious mental illness means a mental disorder that is identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and that is severe in degree and persistent in duration, presents a major risk to the persons health and well-being, causes behavioral functioning that interferes substantially with the primary activities of daily living, and results in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.(2) Serious mental illness may include, but is not limited to, schizophrenia, post-traumatic stress disorder, bipolar disorder, other major affective disorders, or other severely disabling mental disorders pursuant to paragraph (1).
14133.19. (a) Notwithstanding any other law, subject to subdivision (c), a treatment authorization request shall not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness.(b) Notwithstanding any other law, subject to subdivision (c), a prescription for a drug for serious mental illness shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.(c) Subdivisions (a) and (b) shall apply only if both of the following conditions are met:(1) The prescription is for a person 18 years of age or over.(2) The person is not within the transition jurisdiction of the juvenile court, as described in Section 450.(d) (1) For purposes of this section, serious mental illness means a mental disorder that is identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and that is severe in degree and persistent in duration, presents a major risk to the persons health and well-being, causes behavioral functioning that interferes substantially with the primary activities of daily living, and results in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.(2) Serious mental illness may include, but is not limited to, schizophrenia, post-traumatic stress disorder, bipolar disorder, other major affective disorders, or other severely disabling mental disorders pursuant to paragraph (1).
14133.19. (a) Notwithstanding any other law, subject to subdivision (c), a treatment authorization request shall not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness.(b) Notwithstanding any other law, subject to subdivision (c), a prescription for a drug for serious mental illness shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.(c) Subdivisions (a) and (b) shall apply only if both of the following conditions are met:(1) The prescription is for a person 18 years of age or over.(2) The person is not within the transition jurisdiction of the juvenile court, as described in Section 450.(d) (1) For purposes of this section, serious mental illness means a mental disorder that is identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and that is severe in degree and persistent in duration, presents a major risk to the persons health and well-being, causes behavioral functioning that interferes substantially with the primary activities of daily living, and results in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.(2) Serious mental illness may include, but is not limited to, schizophrenia, post-traumatic stress disorder, bipolar disorder, other major affective disorders, or other severely disabling mental disorders pursuant to paragraph (1).
14133.19. (a) Notwithstanding any other law, subject to subdivision (c), a treatment authorization request shall not be required for the provision of a prescription drug prescribed to prevent, assess, or treat a serious mental illness.
(b) Notwithstanding any other law, subject to subdivision (c), a prescription for a drug for serious mental illness shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.
(c) Subdivisions (a) and (b) shall apply only if both of the following conditions are met:
(1) The prescription is for a person 18 years of age or over.
(2) The person is not within the transition jurisdiction of the juvenile court, as described in Section 450.
(d) (1) For purposes of this section, serious mental illness means a mental disorder that is identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and that is severe in degree and persistent in duration, presents a major risk to the persons health and well-being, causes behavioral functioning that interferes substantially with the primary activities of daily living, and results in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period of time.
(2) Serious mental illness may include, but is not limited to, schizophrenia, post-traumatic stress disorder, bipolar disorder, other major affective disorders, or other severely disabling mental disorders pursuant to paragraph (1).