BILL ANALYSIS �
AB 1310
Page 1
ASSEMBLY THIRD READING
AB 1310 (Brown)
As Amended May 24, 2013
Majority vote
HEALTH 19-0 APPROPRIATIONS 17-0
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|Ayes:|Pan, Logue, Ammiano, |Ayes:|Gatto, Harkey, Bigelow, |
| |Atkins, Bonilla, Bonta, | |Bocanegra, Bradford, Ian |
| |Chesbro, Gomez, Roger | |Calderon, Campos, |
| |Hern�ndez, Lowenthal, | |Donnelly, Eggman, Gomez, |
| |Maienschein, Mansoor, | |Hall, Ammiano, Linder, |
| |Mitchell, Nazarian, | |Pan, Quirk, Wagner, Weber |
| |Nestande, | | |
| |V. Manuel P�rez, Wagner, | | |
| |Wieckowski, Wilk | | |
| | | | |
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SUMMARY : Revises provisions relating to the Medi-Cal pediatric
subacute care program. Specifically, this bill :
1)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.
2)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
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program is in an acute care licensed hospital bed.
3)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
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
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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,
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 : According to the Assembly Appropriations
Committee, likely costs of at least $50,000 General Fund
annually, depending on the extent to which definition changes
lead to an increase in the number of pediatric subacute care bed
days.
COMMENTS : 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 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.
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
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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 were 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.
AB 36 (Quakenbush), Chapter 1030, Statutes of 1993, authorized
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 included 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 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 subacute ranged from $895 to $706 per day.
AB 97 (Budget Committee), 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 subacute
facilities be frozen at the 2008-09 levels and the
implementation of a 5.75% payment reduction effective January 1,
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2012, was withdrawn after determining that access to pediatric
subacute care would be negatively impacted.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097
FN: 0001002