CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 2340Introduced by Assembly Member BontaFebruary 12, 2024 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 DIGESTAB 2340, as introduced, Bonta. Medi-Cal: EPSDT services.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.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. 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) Services14149.95. (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.(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.
CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 2340Introduced by Assembly Member BontaFebruary 12, 2024 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 DIGESTAB 2340, as introduced, Bonta. Medi-Cal: EPSDT services.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.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION
Assembly Bill
No. 2340
Introduced by Assembly Member BontaFebruary 12, 2024
Introduced by Assembly Member Bonta
February 12, 2024
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
## LEGISLATIVE COUNSEL'S DIGEST
AB 2340, as introduced, Bonta. Medi-Cal: EPSDT services.
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 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.
## Digest Key
## 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) Services14149.95. (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.(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.
The people of the State of California do enact as follows:
## 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) Services14149.95. (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.(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.
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:
### SECTION 1.
Article 4.12. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services14149.95. (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.(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.
Article 4.12. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services14149.95. (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.(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.
Article 4.12. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
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.(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.
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.
(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.