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---



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            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.





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                        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;




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                  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.





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          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  




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               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  




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            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.




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