BILL ANALYSIS AB 2352 Page 1 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 Page 2 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 Page 3 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 AB 2352 Page 4 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