This bill would make California’s law regarding the medical necessity standard for children under age 21 in Medi-Cal consistent with federal standards, thereby, helping to ensure that California’s children and youth get the health, behavioral health and dental services they need.
AAP Positional Letter
May 8, 2018
Senator Ed Hernandez
State Capitol, Room 2080
Sacramento, CA 95814
RE: SB 1287 (Hernandez): Medical necessity for children on Medi-Cal
AAP-CA Position: Support
Dear Senator Hernandez,
The American Academy of Pediatrics, California (AAP-CA), representing over 5,000 California pediatricians, supports your proposed legislation SB 1287 to make California’s law regarding the medical necessity standard for children under age 21 in Medi-Cal consistent with federal standards, thereby, helping to ensure that California’s children and youth get the health, behavioral health and dental services they need.
Current California law defining “medical necessity” for Medi-Cal covered services inappropriately provides a single standard for all Medi-Cal recipients, including children, even though children under age 21 are entitled to a broader standard under the federal Medicaid Act’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. An amendment to the state’s statute is necessary to clarify the correct medical necessity standard. This will ensure children with Medi-Cal coverage receive the services to which they are entitled.
There is confusion among many health plans and providers regarding EPSDT benefits, given the many different state regulations governing this benefit under Medi-Cal. As a result, in some circumstances the medical necessity standard for adults is incorrectly applied to children, and services are denied. Clarifying the state law will help to ensure the correct standard is applied moving forward so that essential services are received.
SB 1287 (Hernandez) would ensure that beneficiaries under age 21 get access to medically necessary EPSDT covered Medi-Cal services by aligning current state with federal law and regulations.
Pediatrician members of AAP California Chapters 1, 2, 3 and 4 statewide strongly support proposed legislation SB 1287 (Hernandez). Thank you for your public service and leadership on behalf of the health and wellbeing of children, youth, and families in California.
Chief Executive Officer, American Academy of Pediatrics, California
cc: AAP-CA Leadership; Lobbyist Lydia Bourne
Children Now (Sponsors)