2005 California Welfare and Institutions Code Sections 14125-14125.9 Article 3.7. Incontinence Medical Supplies

14125.  The purpose of this article is to establish provider
reimbursement rates for incontinence medical supplies covered by the
Medi-Cal program.  Reimbursement for incontinence medical supplies
shall consist of the weighted average of the negotiated contract
prices within each product category, plus a markup fee equal to 38
percent of the resulting adjusted contract price.
14125.1.  Unless the context requires otherwise, the definitions set
forth in this section shall govern the construction and meaning of
the terms and phrases used in this article.
   (a) "Incontinence medical supplies" means disposable medical
supplies that are covered benefits under the Medi-Cal program
pursuant to subdivision (s) of Section 14132 when prescribed by a
physician for the treatment of individuals who are incontinent.
Incontinence medical supplies include, but are not limited to,
disposable diapers, briefs, underpads, undergarments, liners or pads,
pant and pad systems, and skin care products.
   (b) "Department" means the State Department of Health Services.
   (c) "Manufacturer" means any person, partnership, or corporation
who assembles or combines the components of incontinence supplies
into a final product sold to dealers.
   (d) "Principal labeler" means any person, partnership, or
corporation who purchases from a manufacturer an assembled product
which is sold to dealers under the principal labeler's label.
   (e) "Dealer" means any person, partnership, corporation, or other
entity that is recognized by the manufacturer or principal labeler as
a provider or retail outlet for its line of incontinence medical
supplies, and which provide these supplies directly to consumers.
The term "dealer" includes a retailer.
14125.2.  (a) (1) To qualify for Medi-Cal coverage a product shall
be in general retail distribution, sold to the general public, and
comply with any standards for products established by law or
regulation.  No product that is manufactured, distributed, or
otherwise promoted for the exclusive use of beneficiaries of the
Medi-Cal program shall be a Medi-Cal benefit.
   (2) For purposes of this section, "product" means any product
which is in general retail distribution.
   (3) For purposes of this subdivision, "general retail distribution"
means either of the following:
   (A) The product is included in a listing of approved products for
purchase either by the federal or state government.
   (B) The product is on display and available for purchase by
customers for private payment at retail outlets which are open to the
general public.
   (b) In order to qualify as a Medi-Cal provider of incontinence
medical supplies, a dealer shall have an established place of
business that is readily identifiable as a medical supply business,
be open to the general public at regularly established business
hours, have incontinence supplies in stock on the premises or in a
warehouse under the provider's direct control, and meet all local
laws and ordinances regarding business licensing and operations.  The
department shall establish additional rules and regulations for
participation in the Medi-Cal program as it deems necessary to ensure
adequate safeguards to the integrity of the Medi-Cal program.
14125.3.  The department shall reduce the weighted average of the
negotiated contract prices within each product category in effect on
June 30, 1992, as follows:
   (a) For all premium underpads, as defined by the department, by 24
percent.
   (b) For all other incontinence medical supply products, as defined
by the department, by 14 percent.
14125.4.  (a) No later than January 1, 1994, the department shall
establish utilization controls that limit expenditures for
incontinence medical supplies per beneficiary to no more than one
hundred sixty-five dollars ($165) per month.  Incontinence creams and
washes shall be excluded from this limitation.  The expenditure
limit established by this section may be adjusted in the annual
Budget Act to reflect changes in wholesale prices.  These utilization
controls shall be published in provider bulletins.
   (b) The department shall, by prior authorization, allow a
beneficiary to exceed the utilization limits established by this
section when justified to the department's satisfaction not later
than January 1, 1994.
   (c) Notwithstanding any other provision of law, no regulations
shall be necessary to define the incontinence medical supplies
subject to the reductions required in Section 14125.3, or to
establish and implement the utilization controls required in this
section.
14125.8.  (a) In order to more fully identify the owner or owners of
companies or corporations that apply to be or currently are
providers of incontinence medical supplies, within 30 days of the
receipt of a request from the department, or a request to the
department from the Department of Justice, the applicant or provider
shall provide, as part of the application process or as a condition
of continued participation in the Medi-Cal program, the following:
   (1) The name of the corporation, the official titles of the
applicants, and a  list of all the corporate officers.
   (2) The California driver's license or California identification
card number of the applicants, coowners, corporate officers, and
financially interested parties.
   (3) The applicant's business permit control number, issued by the
State Board of Equalization, for the business location where services
are rendered to the public.
   (4) A statement of all current sources of capital, identity of all
investors, disclosure of all manufacturers, suppliers, and providers
currently doing business with the applicant, and disclosure of all
entities to whom the applicant has extended a line of credit.
   (5) A statement certifying that all information supplied pursuant
to this section is accurate.
   (b) A Medi-Cal provider of incontinence supplies shall not submit
a claim for goods or services to the department prior to the date the
goods or services are  delivered to the Medi-Cal beneficiary.  The
date of delivery to a beneficiary shall be the earlier of the date
the beneficiary actually received the goods or services, or the date
the goods were posted or otherwise dispatched from the provider's
premises and control.  A claim submitted to the department prior to
the date of delivery shall not be paid.  Violation of this
subdivision shall be grounds for expulsion from the Medi-Cal program.
   (c) The department may implement a 180-day moratorium on the
issuance of new provider numbers for incontinence medical supply
dealers when the department determines this action is necessary to
safeguard public funds or to maintain the fiscal integrity of the
program.
14125.9.  Nothing in this section shall be interpreted as limiting
or interfering in any way with the department's authority to contract
for the provision of incontinence medical supplies pursuant to
subdivision (b) of Section 14105.3.