BILL ANALYSIS Ó COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: AB 582 AUTHOR: Chesbro AMENDED: June 13, 2013 HEARING DATE: June 26, 2013 CONSULTANT: Bain SUBJECT : Medi-Cal: complex rehabilitation technology. SUMMARY : Renames, for purposes of the Medi-Cal program, "custom rehabilitation equipment" as "custom rehabilitation technology". Defines a "complex rehabilitation technology provider" and establishes requirements for these providers, including requiring prompt services and repair for all custom rehabilitation technology supplied by the provider. Requires custom rehabilitation technology to be recognized as a separate benefit by the Medi-Cal program in both fee-for-service and managed care delivery systems. Sunsets the provisions of this bill on January 1, 2019. Existing law: 1.Requires any provider of custom rehabilitation equipment (CRE) and custom rehabilitation technology services (CRTS) to a Medi-Cal beneficiary to have on staff, either as an employee or independent contractor, or have a contractual relationship with, a qualified rehabilitation professional (QRP) who was directly involved in determining the specific custom rehabilitation equipment needs of the patient and was directly involved with, or closely supervised, the final fitting and delivery of the CRE. 2.Requires a medical provider to conduct a physical examination of an individual before prescribing a motorized wheelchair or scooter for a Medi-Cal beneficiary. Requires a medical provider to complete a certificate of medical necessity, developed by the Department of Health Care Services (DHCS) that documents the medical condition that necessitates the motorized wheelchair or scooter, and verifies that the patient is capable of using the wheelchair or scooter safely. 3.Defines CRE as any item, piece of equipment, or product system, whether modified or customized, that is used to increase, maintain, or improve functional capabilities with respect to mobility and reduce anatomical degradation and Continued--- AB 582 | Page 2 complications of individuals with disabilities. CRE includes, but is not limited to, nonstandard manual wheelchairs, power wheelchairs and seating systems, power scooters that are specially configured, ordered, and measured based on patient height, weight, and disability, specialized wheelchair electronics and cushions, custom bath equipment, standers, gait trainers, and specialized strollers. 4.Defines CRTS as the application of enabling technology systems designed and assembled to meet the needs of a specific person experiencing any permanent or long-term loss or abnormality of physical or anatomical structure or function with respect to mobility. These services include, but are not limited to, the evaluation of the needs of a patient with a disability, including an assessment of the patient for the purpose of ensuring that the proposed equipment is appropriate, the documentation of medical necessity, the selection, fit, customization, maintenance, assembly, repair, replacement, pick-up and delivery, and testing of equipment and parts, and the training of an assistant caregiver and of a patient who will use the equipment or individuals who will assist the client in using the equipment. 5.Defines a "qualified rehabilitation professional" (QRP) as an individual to whom any one of the following applies: a. The individual is a physical therapist (PT), occupational therapist (OT), or other qualified health care professional approved by DHCS; b. The individual is a registered member in good standing of the National Registry of Rehabilitation Technology Suppliers (NRRTS), or other credentialing organization recognized by DHCS; and, c. The individual has successfully passed one of the following credentialing examinations administered by the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA): i. The Assistive Technology Supplier examination. ii. The Assistive Technology Practitioner examination. AB 582 | Page 3 iii. The Rehabilitation Engineering Technologist examination. This bill: 1.Changes the name of CRE to "custom rehabilitation technology" (CRT) and deletes specially configured, ordered and measured power scooters from the new definition. 2.Requires CRT to be recognized as a separate benefit by the Medi-Cal program in both fee-for-service and managed care delivery systems. Requires contracts initiated by DHCS with managed care plans to be consistent with the requirements of this bill. 3.Requires CRT to be subject to the Medi-Cal prior authorization process in which services are approved based on the medical, physical, and functional needs of the patient, as demonstrated in documents prescribed by DHCS. Permits prior authorization to be obtained through the treatment authorization request (TAR) process set forth in regulation. Permits DHCS to adopt additional utilization controls for CRT, as appropriate. 4.Deletes from the definition of a QRTP a PT, OT or other qualified health care professional approved by DHCS, and changes the criteria an individual must meet to be a QRTP. 5.Permits DHCS to adopt additional requirements for Medi-Cal coverage of CRT, including a specialty evaluation by a PT, OT, or other licensed health care professional approved by DHCS. Prohibits the licensed health professional performing the specialty evaluation from having a financial relationship with the CRT. 6.Defines a "complex rehabilitation technology provider" (CRT provider) as a company or entity that complies with all of the following: a. Meets the supplier and quality standards established for a durable medical equipment (DME) supplier under the Medicare Program and is enrolled as a provider in the Medi-Cal program; b. Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology; AB 582 | Page 4 c. Employs or contracts with at least one QRTP for each distribution location; d. Has the QRTP physically present for the evaluation and determination of the complex rehabilitation technology provided; and, e. Maintains a reasonable supply of parts, adequate physical facilities, and qualified service or repair technicians, and provides patients with prompt services and repair for all complex rehabilitation technology supplied. 7.Deletes the authority of DHCS to recognize a credentialing organization of a qualified rehabilitation professional other than an individual who is a member of the NRRTS. FISCAL EFFECT : According to the Assembly Appropriations Committee, unknown costs and/or savings, likely less than $100,000 General Fund annually. The custom equipment at issue in this bill is very expensive but is used by only a small percentage of Medi-Cal beneficiaries. PRIOR VOTES : Assembly Health: 19- 0 Assembly Appropriations: 16- 0 Assembly Floor: 76- 0 COMMENTS : 1.Author's statement. According to the author, AB 582 establishes enhanced consumer protections by requiring CRT providers to service and repair the equipment they provide. Additionally this bill establishes CRT services as a separate benefit under the Medi-Cal program, differentiating it from other less complicated/costly DME and updating current code to reflect contemporary terminology and credentialing options. Used properly complex rehab technology helps promote independence, avoid institutionalization and reduce related medical complications. AB 582 is necessary to ensure that this cost-beneficial category of products/services receives the appropriate level of targeted analysis when DHCS is considering benefit reductions, rate cuts and other program changes that will impact the lives of those who depend upon complex rehab for their very existence. AB 582 | Page 5 2.Background. DME is a covered benefit in Medi-Cal, subject to utilization controls (through a TAR), and includes hospital beds, wheelchairs, and walkers. CRT is a subset of DME involving complex adjustable custom-fitted electronic devices intended for long-term use by individuals with progressive diagnoses that can be designed to provide pressure management, and accommodate ventilators. This bill makes a number of changes to existing law. The rationale for the proposed changes made by this bill, as provided by proponents, are as follows: a. Renaming CRE to CRT. This bill renames CRE to CRT and deletes power scooters from the definition. The purpose of the change from "equipment" to "technology" is to use the term currently used by providers, payers and others to describe these items, and to distinguish these products (which are complex adjustable electrical equipment) from other DME products, which typically involve a static piece of equipment. Power scooters are deleted from the definition of CRE because scooters are not considered complex rehabilitation technology because they do not involve the customization or hands-on attention that technology items require (patient assessment, selection of parts from various sources, individual configuration, assembly, fit, periodic adjustment, maintenance, and service). b. Definition and requirement for CRTP. This bill defines a CRTP as a company or entity that meets specified criteria, providing patients with prompt services and repair for all CRT supplied. The purpose of this change is to ensure that CRTPs meet minimum standards for competent provision of CRT, to ensure provider integrity, and to strengthen the provision of repair services so that CRTP must "service what they sell" because access to these services has become problematic for consumers. c. Separate benefit in Medi-Cal. This bill requires CRT to be recognized as a separate benefit by the Medi-Cal program in both fee-for-service and managed care delivery systems. The purpose of this change is to distinguish CRT from other types of DME, and is intended to have DHCS differentiate CRT from DME when evaluating access, formulating policies, establishing purchasing practices, adopting utilization controls, setting reimbursement rates, and audit guidelines AB 582 | Page 6 in this critical area. d. Medi-Cal managed care contracts. This bill requires contracts initiated by DHCS with Medi-Cal managed care plans to be consistent with the requirements of this bill. The purpose of this provision is to ensure that the standards for CRT provided to Medi-Cal beneficiaries is consistent across all payer types. e. QRP definition. Existing law defines a QRP, and this bill deletes from that definition PT, OTs and other qualified health care professionals. This bill would instead permit DHCS to adopt additional requirements for Medi-Cal coverage of CRT, including a specialty evaluation by a PT, OT, or other licensed health care professional approved by DHCS. This change was made because OTs and PTs are not typically hired (or contracted) as part of the CRTP that furnish the CRT to the patient. Instead, PTs and OTs are typically part of the medical team that determines the need and appropriate type of technology for a patient. f. Credentialing organization changes. In addition, this bill deletes the authority of DHCS to recognize a separate credentialing organization other than the NRRTS. This bill also requires the QRP to hold the designation of Certified Complex Rehabilitation Technology Specialist or requires the individual to have successfully passed the credentialing examination and received the credential of Assistive Technology Professional from RESNA. This bill deletes the three examinations listed in existing law. The rationale for these changes is there are no other comparable credentialing organizations other than NRRTS, and the listed exams are no longer offered and have been replaced by the 'Assistive Technology Professional' exam and credential now offered by NRRTS. 3.Prior legislation. AB 258 (Matthews) Chapter 523, Statutes of 2005 established the requirements in existing law regarding CRE, CRTs, and QRP. AB 258 also required that a physical examination be conducted before a motorized wheelchair or scooter is prescribed, and required the prescribing medical provider to complete a certificate of medical necessity, developed by DHCS for the motorized wheelchair or scooter. 4.Support. This bill is supported by DME providers, patient and low-income advocacy groups to provide a better focus on the AB 582 | Page 7 provision of this specialized equipment and to ensure CRT providers offer service and maintenance so as to ensure greater access to repair services by patients. The National Multiple Sclerosis Society - CA Action Network, a co-sponsor of this bill, argues this bill will result in well-functioning CRT equipment and less consumer cost for on-going CRT upkeep and modifications. MS Society states that, for those who depend on a wheelchair, good-functioning CRT can mean the difference between independence and being immobile. 5.Policy issues. a. This bill deletes the authority of DHCS to recognize a separate credentialing organization other than RESNA. The rationale for this change is there is not a currently comparable organization. However, limiting the credentialing organization in statute to one entity grants that entity a great deal of authority over the profession which the proponents indicate is already in short supply. It may be appropriate to continue to grant DHCS the authority to recognize other credentialing organizations in the event credentialing entities other RESNA emerge in the future. b. This bill prohibits the licensed health professional performing the specialty evaluation from having a financial relationship with the complex rehabilitation technology. This provision is intended to refer to the relationship between the health care professional and the complex rehabilitation technology provider . An amendment is needed to clarify this provision. SUPPORT AND OPPOSITION : Support: National Multiple Sclerosis Society-California Action Network (co-sponsor) Assistive Technology Group California ALS Advocacy Committee California Chronic Care Coalition California Physical Therapy Association California Association of Medical Product Suppliers Multiple Sclerosis Society - California Action Committee State Independent Living Council Western Center on Law and Poverty Oppose: None received. AB 582 | Page 8 -- END --