BILL ANALYSIS Ó
AB 2545
Page 1
Date of Hearing: April 24, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 2545 (Logue) - As Amended: April 18, 2012
SUBJECT : Medi-Cal: nonemergency medical transportation.
SUMMARY : Requires nonemergency medical transportation services
(NEMT) provided to Medi-Cal beneficiaries by managed care
organizations directly or under contractual arrangements to be
subject to the same personnel, equipment, and inspection
requirements as NEMT services provided by fee-for-service (FFS)
enrolled providers. The requirements must be consistent with
existing regulations, but allow for additional standards for
NEMT providers as long as they are consistent with current
regulations.
EXISTING LAW :
1)Establishes the Medi-Cal program, administered by Department
of Health Care Services (DHCS), which provides comprehensive
health benefits to low-income children, their parents or
caretaker relatives, pregnant women, elderly, blind or
disabled persons, nursing home residents, and refugees who
meet specified eligibility criteria.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes emergency and NEMT.
3)Defines NEMT, through regulation, as transportation by
ambulance, litter van and wheelchair van of the sick, injured,
invalid, convalescent, infirm or otherwise incapacitated
persons whose medical conditions requires medical
transportation services but do not require emergency services
or equipment during transport.
4)Establishes, through regulation, maximum reimbursement rates
for medical transportation services under Medi-Cal, and
prohibits billing from exceeding charges made to the general
public.
5)Defines, under Medi-Cal, a service as "medically necessary" or
a "medical necessity" when it is reasonable and necessary to
protect life, prevent significant illness or significant
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disability, or alleviate severe pain.
6)Defines a Medi-Cal managed care (MCMC) plan as any entity that
enters into one of several types of contracts with DHCS
including County Organized Health System (COHS), geographic
managed care (GMC) plans, commercial plans, and Local
Initiatives (LI).
7)Authorizes DHCS to require the mandatory enrollment of seniors
and people with disabilities (SPDs) in a Medi-Cal managed care
plan commencing the later of either June 1, 2011, or obtaining
federal approval and allows a phase-in over a 12 month period.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . The California Medical Transportation
Association (CMTA) is the sponsor of this measure. According
to CMTA, NEMT is a form of transportation for a patient who is
stable, but still in need of support in their movement from
one location to another. Current NEMT regulations set
standards for NEMT drivers and vehicles in order to ensure the
safe transport of Medi-Cal patients. FFS NEMT providers have
adhered to these rules for years, but with the transition of
many Medi-Cal enrollees into managed care settings, it is
unclear whether managed care NEMT providers will adhere to the
same standards. Concerns have been raised about ensuring
patient continuum of care, which is essential for the fragile,
chronically ill patients in the population of SPDs and the
dual eligible (those people eligible for both Medi-Cal and
Medicare).
2)BACKGROUND . Medi-Cal covers ambulance and other medical
transportation when ordinary public or private conveyance is
medically contraindicated and transportation is required for
obtaining needed medical care. Generally, Medi-Cal covers
both emergency transportation and NEMT under specified
circumstances. NEMT is covered only when a recipient's
medical and physical condition does not allow that recipient
to travel by bus, passenger car, taxicab, or another form of
public or private conveyance. NEMT is provided by three types
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of vehicles: ambulance, litter van, and wheelchair van. All
NEMT requires a physician's, dentist's, or podiatrist's
prescription and prior authorization, as specified. The
prescription must include the purpose of the trip, frequency
of necessary medical visits/trips or the inclusive dates of
the requested medical transportation, and the medical or
physical condition that makes normal public or private
transportation inadvisable.
Ambulances are generally used for emergencies, but may provide
non-emergency transport for certain types of recipients, which
can include: transfer between facilities for a recipient who
requires continuous intravenous medication, medical
monitoring, or observation; transfers from an acute care
facility to another acute care facility; transport for a
recipient recently placed on oxygen, as specified; and,
transport for recipients with chronic conditions. Regulations
require litter vans to be operated by a certified driver and
an attendant, and wheelchair vans to be operated by a
certified driver and where applicable, an attendant.
Additionally, operators of litter vans and wheelchair vans
must possess a current California driver's license or a
current California Ambulance Driver Certificate issued by the
state Department of Motor Vehicles (DMV), be at least 18 years
of age, possess a current American Red Cross Standard First
Aid and Personal Safety Certificate or equivalent, passed a
physical examination within the past two years and possess a
current DMV form DL-51, Medical Examination Report, and not
act as a driver or attendant under the following: when
required by law to register as a sex offender, as specified;
habitual user of narcotics or dangerous drugs, as specified;
and, habitually or excessively uses intoxicating beverages.
Additionally, regulations specify equipment requirements for
litter and wheelchair vans, including requirements on the size
of the loading entrance, emergency exit, locking devices,
approved seat belt assemblies, fasteners, lighting, fire
extinguisher, and seat covers.
3)MANDATORY SPD ENROLLMENT . On November 2, 2010, the Secretary
of Health and Human Services approved a section 1115 Medicaid
Demonstration Waiver entitled "California's Bridge to Reform."
The waiver, which is approved for the five-year period ending
October 31, 2015, makes up to roughly $10 billion in federal
Medicaid matching funds available for expanding coverage to
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low-income uninsured adults and preserving and improving the
county-based safety net. The waiver also allows the state to
enroll Medicaid-eligible SPDs into MCMC plans that meet
specified plan readiness requirements, including network
adequacy. In most counties, SPDs must be able to choose
between at least two plans that meet these requirements. (In
counties with County-Operated Health Systems (COHS), the SPD
population, like other groups of Medi-Cal beneficiaries, is
already enrolled in the COHS, which will have two years to
meet the standards specified in the waiver.) Enrollment began
June 1, 2011. As of March 2012, over 200,000 SPDs had been
enrolled in managed care plans. The waiver specifies annual
projections for SPD enrollment in managed care. If these
projections are not met, federal Medicaid matching funds
available under the waiver are reduced.
The readiness requirements specified by the waiver for managed
care plans are extensive, reflecting the high needs of the SPD
population. To ensure network adequacy, the waiver requires
that each plan have a sufficient supply and continuum of
providers to meet the unique needs of the population served
and an accessible network (including specialty providers)
within reasonable geographic proximity to the individuals
enrolled. Other plan readiness requirements include having
the capacity to provide a full range of care coordination
services, mechanisms to ensure seamless care with existing
providers for 12 months after enrollment, person-centered
planning and treatment approaches, physically accessible
accommodations, interpreter services, non-emergency medical
transportation, and timely access to non-network specialty
providers. To permit an assessment of performance, plans will
be required to submit, on a monthly basis, comprehensive
encounter data on the use of services.
Under longstanding administrative practice, Section 1115 waivers
must be budget neutral for the federal government. This means
that federal Medicaid spending under a waiver must not exceed
the amount the federal government would have spent on the
state's Medicaid program without the waiver. In general, if a
waiver includes new federal spending for coverage expansions
to individuals a state cannot otherwise cover through Medicaid
or delivery systems improvements, the state will have to
achieve offsetting savings for the federal government
elsewhere in its Medicaid program. In the case of the
California demonstration waiver, the offsetting savings will
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come, in part, from mandatory enrollment of SPDs in managed
care plans. To ensure that these savings are realized, the
waiver limits the per capita amounts that the state Medicaid
agency can pay managed care plans on behalf of each SPD,
limits the annual increases in these amounts, and requires
that certain numbers of SPDs are enrolled. If actual
enrollment of SPDs in managed care plans is more than 10%
below projections for the year ending June 30, 2012, the
amount of federal Medicaid matching payments available to
public hospitals for delivery system reforms is reduced by
$350 million for the period July 2012 through June 2013. The
same applies to the subsequent 6-month period ending December
31, 2012; if actual enrollment is more than 10% below
projections, federal funds will be lowered by $350 million for
the period July 2014 through June 2015.
4)SUPPORT . The National Association of Social Workers,
California Chapter (NASW), states this bill is an important
protective measure that ensures that MCMC recipients receive
the same treatment as their FFS counterparts. NASW believes
that all individuals should have equal health care services.
5)OPPOSITION . Logisticare states that it is the largest NEMT
broker in the state. Logisticare states that this measure
would dramatically restrict the ability of MCMC plans to
provide reliable, efficient, low-cost NEMT services to
enrollees, and would severely inhibit the state's ability to
score the savings that non-emergency medical services are able
to provide. For instance, because Logisticare is able to
negotiate directly with the plans, it is able to tailor its
services specifically to these needs and at a cost that is
reasonable to plans. Logisticare argues that MCMC plans
should be allowed to continue to adopt their own credentialing
requirements for personnel and vehicles. Furthermore,
Logisticare states that when California began moving seniors
and persons with disabilities into MCMC, it worked
collaboratively with its health plan partners to make sure
these enrollees have the services they need to safely travel
to their regularly scheduled medical appointments. As a
condition of its contracts, it requires that transportation
providers go through regular training sessions that focus on
increasing sensitivity to fragile populations.
The California Association of Health Plans states that this bill
will subject plans to existing fee-for-service restriction on
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the types of vehicles that can be used for nonmedical
transportation, will not create new managed care consumer
protections and instead prohibit plans from using taxis,
private cars, or bus services to assist members in getting to
their appointment, and would have to use ambulances,
wheelchairs or other modes of transportation.
6)PREVIOUS LEGISLATION . AB 1174 (Hernandez) of 2009, would have
required Medi-Cal to cover ambulance services when a patient
reasonably believes that without an ambulance a serious health
condition, as specified, might result. AB 1174 died in
Assembly Appropriations Committee.
7)POLICY CONSIDERATION . According to DHCS, MCMC plans are
contractually obligated to adhere to regulations governing
NEMT via the definition of "Non-Emergency Medical
Transportation" in the plan contracts, which explicitly
references wheelchair and litter van regulations. If this is
the case, why are some of these NEMT services not complying
with these requirements? Additionally, it is not clear why
the opposition believes that it would apply to the use of
taxis, private cars or bus service as they do not qualify as
NEMT.
REGISTERED SUPPORT / OPPOSITION :
Support
California Medical Transport Association (sponsor)
National Association of Social Workers, California Chapter
Opposition
California Association of Health Plans
Logisticare
Local Health Plans of California
Analysis Prepared by : Rosielyn Pulmano and Marjorie Swartz /
HEALTH / (916) 319-2097