BILL ANALYSIS                                                                                                                                                                                                    



                                                                  AB 2352
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          Date of Hearing:   April 20, 2010

                            ASSEMBLY COMMITTEE ON HEALTH
                              William W. Monning, Chair
             AB 2352 (John A. Perez) - As Introduced:  February 19, 2010
           
          SUBJECT  :  Medi-Cal: organ transplants: antirejection medication.

           SUMMARY  :  Requires Medi-Cal beneficiaries to remain eligible to  
          receive Medi-Cal coverage for anti-rejection medication for up  
          to two years following an organ transplant unless during that  
          time the beneficiary becomes eligible for Medicare or private  
          health insurance that would cover the medication.

           EXISTING LAW  :

          1)Establishes the Medicaid (Medi-Cal in California) Program,  
            administered by the Department of Health Care Services (DHCS),  
            under which basic health care services are provided to  
            qualified low-income persons. 

          2)Requires organ transplants and donor surgeries to be covered  
            under the Medi-Cal Program when an organ transplant is  
            provided to a Medi-Cal beneficiary who is eligible for  
            full-scope benefits under the Medi-Cal Program in a medical  
            facility that meets the requirements of and is approved by  
            DHCS.

          3)Requires, under federal law, eligibility in Medi-Cal be  
            re-determined at least every twelve months, with the exception  
            that disability can be authorized to continue until a review  
            team authorized under federal regulations determines that a  
            recipient's disability no longer meets the definition of  
            disability contained in the plan.

          4)Requires, under federal law, that states, by January 2014,  
            offer Medicaid coverage to all adults up to 133% of the  
            federal poverty level (FPL) and authorizes a phase-in  
            immediately. 

           FISCAL EFFECT  :  This bill has not been analyzed by a fiscal  
          committee.

           COMMENTS  :   









                                                                  AB 2352
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           1)PURPOSE OF THIS BILL  .  According to the author, there are  
            currently some patients that qualify for Medi-Cal under a  
            federal rule allowing coverage for patients with end-stage  
            renal disease (on dialysis).  Those patients, if they are able  
            to receive a kidney and have an organ transplant, will only  
            receive coverage for their immunosuppressive medication for  
            one year post-transplant.  However, a person's Medi-Cal  
            eligibility ends when he or she no longer meets the  
            eligibility requirement of end-stage renal disease.  

          Patients in this particular group may not be eligible for  
            Medi-Cal under any other eligibility criteria, and they may  
            also be ineligible for Medicare, either because they have not  
            paid into Social Security for a sufficient time or because of  
            their immigration status.  The author states if these patients  
            were dual-eligible for Medicare and Medi-Cal, Medicare would  
            pay for immunosuppressive coverage for an additional two  
            years, so the patient would have immunosuppressive drugs for a  
            total of three years post-transplant.  Because patients who  
            have had a kidney transplant must have immunosuppressive drugs  
            or their body will naturally reject the organ, they have a  
            medical need for the anti-rejection medication to prevent  
            kidney failure, being placed back on dialysis or, in a  
            worst-case scenario, death.  The author argues the state has  
            already paid for the organ transplant surgery (the cost of  
            transplant surgery is $50,000 to $100,000 according to the  
            author) and it makes no sense to drop Medi-Cal coverage for  
            these patients after only a year when many organ transplant  
            patients are not yet stable or ready to enter the workforce.

           2)BACKGROUND  .  This bill creates continuity of treatment for  
            patients who are initially on a specific dialysis-only  
            Medi-Cal program which serves beneficiaries with chronic  
            kidney disease and who require dialysis.  Dialysis is a  
            substitute for the normal functioning of the kidneys.  It  
            filters waste products from the blood.  Following a kidney  
            transplant, these patients no longer require dialysis and are  
            no longer deemed disabled for the purposes of their very  
            narrow Medi-Cal coverage.  If a patient has no Medi-Cal,  
            private insurance, or Medicare coverage, they are at risk for  
            organ failure, a return to dialysis, death, or a new  
            transplant. The author indicates a significant investment has  
            already been made via the transplant and patients should be  
            afforded continuity of care at a much lower costs than  
            alternatives.








                                                                  AB 2352
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           3)FEDERAL HEALTH CARE REFORM  .  On March 23, 2010, President  
            Obama signed the Patient Protection and Affordable Care Act  
            (the Affordable Care Act); P. L. 111-148, as amended by the  
            Health Care and Education Reconciliation Act of 2010; P. L.  
            111-152.  Among other provisions, the Affordable Act requires  
            states, as of January 2014 to include all adults up to 133% of  
            the FPL in its Medicaid Program and provides an enhanced  
            federal matching assistance funds (FMAP).  States have the  
            option to begin providing medical assistance to individuals  
            eligible under this new group as of April 1, 2101.  Transplant  
            patients who have income under 133% of FPL will have  
            full-scope Medi-Cal once this is implemented.


           4)SUPPORT  .  The National Kidney Foundation of Northern  
            California and Nevada writes in support that access to  
            anti-rejection drugs is necessary and must be a priority in  
            the health care delivery system for transplant patients  
            because they help to suppress the immune system rejection of  
            the new organ.  BIOCOM writes in support that advances in  
            anti-rejection medications have decreased the incidence of  
            adverse reactions to a donated organ significantly, but it  
            still remains one of the gravest dangers facing transplant  
            recipients.  Extending the Medi-Cal coverage period gives  
            transplant recipients another year of guaranteed access to  
            these products, and they can continue to recover and grow  
            stronger.  

           5)PRIOR LEGISLATION  .  AB 998 (John A. Perez) would have provided  
            that Medi-Cal beneficiaries shall remain eligible to receive  
            Medi-Cal coverage for anti-rejection medication for up to 3  
            years following an organ transplant, unless the beneficiary  
            becomes eligible for Medicare or private health insurance that  
            would cover the medication.  AB 998 died on the Assembly  
            Appropriations Committee suspense file. 

           6)POLICY QUESTIONS.   DHCS indicates that fee-for-service  
            Medi-Cal provided coverage for 2,447 major organ transplants  
            in 2008; 2,619 in 2007; and 2,528 in 2006.  These numbers  
            include individuals who may also have had Medicare coverage.   
            Of these transplant recipients, the number of beneficiaries  
            who had 36 months of continuous Medi-Cal eligibility was 271  
            in 2008; 298 in 2007 and 346 in 2006.  Current federal law  
            requires the eligibility of Medicaid recipients be  








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            re-determined at least every twelve months, with the exception  
            that disability can be authorized to continue until a review  
            team determines that a recipient's disability no longer meets  
            the definition of disability.  In addition, state law requires  
            a mid-year status report for adults and an annual  
            reaffirmation of Medi-Cal eligibility.  For those Medi-Cal  
            beneficiaries whose disability (and therefore Medi-Cal  
            eligibility) ends but who have an on-going need for  
            anti-rejection medication, Medi-Cal coverage ends unless the  
            person is otherwise eligible under another Medi-Cal  
            eligibility provision.  By requiring that Medi-Cal  
            beneficiaries remain eligible to receive Medi-Cal coverage for  
            anti-rejection medication for up to two years following an  
            organ transplant (unless the beneficiary becomes eligible for  
            Medicare or private health insurance that covers the  
            medication), this bill may establish a state-only Medi-Cal  
            Program [meaning FMAP would not be available] for  
            anti-rejection medication for these individuals.  Is that the  
            author's intent?

           REGISTERED SUPPORT / OPPOSITION  :   

           Support 
           
          American Federation of State, County and Municipal Employees,  
          AFL-CIO
          Astellas Pharma
          BIOCOM
          California Healthcare Institute
          Donate Life California
          National Kidney Foundation of Northern California and Northern  
          Nevada
          California Transplant Organ Network
          Western Center on Law and Poverty

           Opposition 
           
          None on file.

           
          Analysis Prepared by  :    Marjorie Swartz / HEALTH / (916)  
          319-2097