Christopher Cabaldon

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 prohibits Medi-Cal reimbursement to providers for clinical laboratory or laboratory services from exceeding the lowest of the following: (1) the amount billed; (2) the charge to the general public; (3) 100% of the lowest maximum allowance established by the federal Medicare Program; or (4) a reimbursement rate based on an average of the lowest amount that other payers and other state Medicaid programs are paying.

This bill would instead require the above-described Medi-Cal reimbursement to equal the lowest of those metrics. The bill would carve out, from the above-described provision, for dates of service on or after July 1, 2027, or when funding is appropriated to implement this provision, whichever is sooner, Medi-Cal reimbursement to providers for clinical laboratory or laboratory services related to the diagnosis and treatment of sexually transmitted infections, and would apply that threshold but excluding the reimbursement rate described in clause (4) above.

The bill would exempt data on those services related to the diagnosis and treatment of sexually transmitted infections from certain data-reporting requirements that are applicable to the reimbursement rate described in clause (4) , for dates of service on or after January 1, 2027, or when funding is appropriated to implement the above-described provision, whichever is sooner.

Under existing law, data reports provided to the department pursuant to those data-reporting requirements are confidential and exempt from disclosure under the California Public Records Act.

This bill would require the department to make available to the public a dataset, as specified, of the deidentified raw data reported pursuant to the above-described data-reporting requirements by any applicable laboratory service providers that reported a volume greater than 10 tests for the data-collection period. The bill would require the department to publish the associated dataset coincident with publishing updated reimbursement rates.

Existing law requires, with exemptions, that payments be reduced by up to 10% for clinical laboratory or laboratory services, in addition to other specified payment reductions under other existing law.

This bill would delete that 10% payment reduction.