BILL ANALYSIS �
AB 1310
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Date of Hearing: April 23, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1310 (Brown) - As Introduced: February 22, 2013
SUBJECT : Medi-Cal; pediatric subacute care.
SUMMARY : Revises provisions relating to the Medi-Cal pediatric
subacute care program. Specifically, this bill :
1)Increases the eligibility age from 21 to 22 for the Medi-Cal
pediatric subacute care program.
2)Revises the definition of pediatric subacute to include a
person who requires treatment for one or more active complex
medical conditions, or requires the administration of one or
more technically complex treatments.
3)Adds the following conditions to the ways in which medical
necessity for eligibility for pediatric subacute services may
be substantiated:
a) Dependence on complex wound care management, including
daily assessment or intervention by a licensed registered
nurse and daily dressing changes, wound packing,
debridement, negative pressure wound therapy, or a special
mattress; or,
b) The patient has a medical condition and requires an
intensity of medical or skilled nursing care such that his
or her health care needs may be satisfied by placement in a
facility providing pediatric subacute care services, but,
in the absence of a facility providing pediatric subacute
care services, the only other inpatient care appropriate to
meet the patient's health care needs under the Medi-Cal
program is in an acute care licensed hospital bed.
4)Makes other technical and clarifying changes.
EXISTING LAW :
1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health benefits to low-income children, their
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parents or caretaker relatives, pregnant women, elderly, blind
or disabled persons, nursing home residents, and refugees who
meet specified eligibility criteria.
2)Establishes a Medi-Cal subacute care program for eligible
individuals in health facilities that meet the subacute
criteria.
3)Defines "pediatric subacute services" in the Medi-Cal program
as the health care services needed by a person under 21 years
of age who uses medical technology that compensates for the
loss of vital bodily functions.
4)Requires that medical necessity be substantiated by one of the
following:
a) Tracheostomy with dependence on mechanical ventilation
for a minimum of six hours each day;
b) Dependence on total parenteral nutrition or other
intravenous nutritional support and one of the following:
i) Dependence on tracheostomy care requiring suctioning
at least every six hours and room air mist or oxygen;
ii) Continuous intravenous therapy as specified;
iii) Peritoneal dialysis;
iv) Tube feeding;
v) Other medical technologies that require the services
of a professional nurse; or,
vi) Biphasic Positive Airway Pressure (BiPAP), as
specified, and lacking cognitive or physical ability to
protect the airway.
c) Dependence on tracheostomy care requiring suctioning at
least every six hours and room air mist or oxygen and one
of the conditions in 4) b) ii) through vi) above;
d) Dependence on skilled nursing care in the administration
of any three of 4) b) i) through vi) above; or,
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e) Dependence on BiPAP and Continuous Positive Airway
Pressure (CPAP), as specified, and one of the conditions in
4) b) i) through vi) above
5)Provides that the medical necessity standard is intended
solely to evaluate the potential eligibility of a patient for
pediatric subacute care who would otherwise be receiving acute
hospital care.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
needed because the current definition of medical necessity has
had the unintended consequence of keeping some children in
acute care hospitals unnecessarily. The author asserts that
children should be released to subacute care when appropriate
and there is no safe alternative at a lesser cost. The author
further states that improvements to the definition of medical
necessity have been identified which accomplish this objective
yet maintain requirements for complexity of care, including
Registered Nurse and/or Respiratory Therapist interventions.
In addition, the author argues, the age range for pediatric
subacute care should correspond with state law for children
receiving school services, since the integration and
continuity of these services is beneficial. In addition, the
current law is interpreted in such a restrictive way that
children, who could benefit from subacute services outside of
the acute care hospital setting, must remain in the hospital
at a cost much higher than the cost of a subacute pediatric
care facility.`
2)BACKGROUND . AB 667 (Mitchell), Chapter 294, Statutes of 2011,
codified and updated the criteria used to evaluate and
authorize admission into Medi-Cal pediatric subacute
facilities. Until then, the criteria were in regulations
adopted in 1989 and included a limited number of specific
qualifying conditions. According to DHCS, these regulations
had never been updated to reflect enhanced and improved
technology such as BiPAP or CPAP which did not exist at the
time the criteria was developed. These devices are now
commonly used as an alternative to a tracheotomy and require
careful supervision by skilled clinical staff - particularly
for young children with serious respiratory issues.
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Established on July 1, 1983 by DHCS, the Medi-Cal subacute care
program makes provisions for patients in facilities who meet
subacute care criteria. Specific reimbursement rates have
been developed for providers of subacute care who have been
licensed and certified. Pediatric subacute care is a level of
care needed by a person less than 21 years of age who uses a
medical technology that compensates for the loss of a vital
bodily function. According to DHCS policies and guidelines,
to be eligible to enter into a contractual agreement with
DHCS, the provider must meet the following criteria:
a) Licensed as an acute care hospital with a distinct part,
skilled nursing facility (SNF);
b) Licensed as a freestanding (FS) SNF;
c) Certified as a long term care Medicare and Medi-Cal
provider;
d) Has a history of compliance with the DHCS Licensing and
Certification program; or,
e) Has professional staff with the ability to provide care
to subacute patients either by experience or demonstrated
competence.
Pediatric subacute care units must employ sufficient subacute
staff, as required by subacute regulation. Staff-to-patient
ratios are a minimum daily average of 5.0 unduplicated
licensed nursing hours per patient day, and 4.0 certified
nurse assistant hours per patient day.
AB 36 (Quakenbush), Chapter 1030, Statutes of 1993, AB 36
authorizes DHCS (formerly the Department of Health Services)
to establish cost-based reimbursement for the provision of
Medi-Cal benefits to any technology dependent child who is
placed at a lower cost facility, establishes the services
required to be provided at the facility and authorizes
adoption of the regulations later codified by AB 667. AB 36
conditions implementation on federal approval and full federal
financial approval through the Medi-Cal Program. AB 36 also
includes a January 1, 1996 repeal date or alternatively, was
repealed by its own terms after the establishment of a
pediatric service continuum, whichever was earlier. AB 36
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contains legislative intent that in determining placement and
treatment needs of technology dependent children, an effort
should be made to place the child in the least costly and
least restrictive level of care that still provides for the
child's medical safety and dignity. Daily reimbursement rates
for pediatric subacute facilities vary depending on the type
of the facility and whether the patient is ventilator
dependent or non-ventilator dependent. Reimbursement rates
for each facility are established by the DHCS based on a model
for pediatric subacute facilities. According to DHCS in 2011,
the pediatric inpatient acute rate was approximately $1,425
per day, whereas the sub-acute ranged from $895 to $706 per
day.
3)BUDGET RATE REDUCTION . AB 97, Chapter 3, Statutes of 2011,
the Omnibus Health Trailer Bill for 2011-12 enacted an overall
10% Medi-Cal provider payment reduction, including to
pediatric subacute facilities. DHCS conducted rate analyses
and access studies where necessary in order to obtain federal
Centers for Medicare and Medicaid Services approval. On April
12, 2013, a State Plan Amendment which requested that Medi-Cal
fee-for-service rates for freestanding pediatric sub-acute
facilities be frozen at the 2008-09 levels and the
implementation of a 5.75% payment reduction effective January
1, 2012 was withdrawn after determining that access to
pediatric sub-acute care would be negatively impacted.
4)POLICY COMMENT . AB 667 and the pediatric subacute care
program were intended as an alternative to acute care for
children who were technology dependent and would otherwise be
in an acute care setting. AB 667 codifies the existing
regulations to that effect. Two of the conditions added by
this bill may be an expansion of eligibility beyond the
original intent. Specifically, these include: a) a person who
requires treatment for one or more active complex medical
conditions; and, b) the expansion of medical necessity to
include dependence on complex wound care management, including
daily assessment or intervention by a licensed registered
nurse and daily dressing changes, wound packing, debridement,
negative pressure wound therapy, or a special mattress. The
author may want to provide examples of how persons meeting
these criteria would otherwise require placement in an acute
care facility.
REGISTERED SUPPORT / OPPOSITION :
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Support
None on file.
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097