BILL ANALYSIS                                                                                                                                                                                                    Ó



          
          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 366    
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          |AUTHOR:        |Bonta                                          |
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          |VERSION:       |July 7, 2015                                   |
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          |HEARING DATE:  |July 15, 2015  |               |               |
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          |CONSULTANT:    |Scott Bain                                     |
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           SUBJECT :  Medi-Cal: annual access monitoring report.

           SUMMARY  :  Requires the Department of Health Care Services (DHCS) to  
          submit to the Legislature, and post on the DHCS' Internet Web  
          site, a Medi-Cal access monitoring report. Requires the report  
          to present results of DHCS' ongoing access monitoring efforts in  
          fee-for-service and managed care and to compare the level of  
          access to care and services available through Medi-Cal, to the  
          level of access to care and services available to the general  
          population in different geographic areas of California.
          
          Existing law:
          1)Establishes the Medi-Cal program, administered by DHCS, under  
            which qualified low-income individuals receive health care  
            services. 

          2)Requires payments to be reduced by 10% for Medi-Cal  
            fee-for-service (FFS) benefits for dates of service on and  
            after June 1, 2011. Requires payments to Medi-Cal managed care  
            plans to be reduced by the actuarial equivalent amount of the  
            10% payment reduction. This is referred to as the "AB 97  
            reductions."

          3)Requires the Director of the Department of Health Services  
            (DHS was the predecessor to DHCS) to annually review the  
            reimbursement levels for physician and dental services under  
            Medi-Cal, taking into account the following factors:

               a)     Annual cost increases for physicians as reflected by  
                 the Consumer Price Index;
               b)     Physician reimbursement levels of Medicare, Blue  
                 Shield, and other third-party payers;







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               c)     Prevailing customary physician charges within the  
                 state and in various geographical areas;
               d)     Procedures reflected by the current Relative Value  
                 Studies (RVS); and,
               e)     Characteristics of the current population of  
                 Medi-Cal beneficiaries and the medical services needed.
          This bill:
          1)Requires DHCS to submit to the Legislature, and post on the  
            DHCS Internet Web site, a Medi-Cal access monitoring report.  
            Requires the annual report to be completed by March 15, 2016,  
            and annually thereafter by February 1st, and to include the  
            following:

                  a)        Present results of DHCS' ongoing access  
                    monitoring efforts in FFS and managed care. Requires,  
                    for managed care, the report to include results from  
                    the Department of Managed Health Care's oversight of  
                    provider networks and timely access in Medi-Cal  
                    managed care.

                  b)        Compare the level of access to care and  
                    services available through Medi-Cal, to the level of  
                    access to care and services available to the general  
                    population in different geographic areas of  
                    California;
                  c)        Include access measurements of sufficient  
                    granularity to reflect patient experience of access to  
                    particular services or provider types, or in  
                    particular geographic areas;
                  d)        Identify particular services, provider types,  
                    or geographic areas for which the level of access is  
                    less than the level of access to care and services  
                    available to the general population in the geographic  
                    area. Requires, for those services, provider types, or  
                    geographic areas, the annual report to assess and  
                    report on the adequacy of provider payment rates and  
                    identify any other factors that impede access; 
                  Use language clearly understandable to the public; and,
                  e)        Use more than one valid, generally accepted  
                    method to assess access to care.

          2)Requires DHCS, at least once annually, to hold a public  
            meeting to present and discuss the access monitoring report,  
            and to accept public comment from stakeholders at the public  
            meeting.








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          3)Permits DHCS to enter into a contract with an independent  
            entity to perform an ongoing assessment of access to care and  
            the adequacy of provider payment rates in Medi-Cal.

          4)Requires, for services, provider types, or geographic areas  
            for which rates are identified in the annual report as  
            inadequate, rate increases to be implemented to the extent  
            funding is provided in the annual Budget Act and federal  
            financial participation is available.
          
          5)Makes legislative findings and declarations that it is  
            important to ensure adequate access to care in the Medi-Cal  
            program as new enrollees seek appropriate care, that the state  
            needs to assess the gaps in access to care and act swiftly to  
            address those gaps, that one area of anticipated need is the  
            availability of more Medi-Cal providers, that Medi-Cal  
            provider reimbursement rates have historically been among the  
            lowest in the nation, that during recent years, the state has  
            reduced reimbursement rates to Medi-Cal providers due to  
            budget constraints, and that an assessment of gaps in access  
            should include a determination of whether current provider  
            rates are sufficient to ensure access to care.

          6)States legislative intent that an annual access monitoring  
            report provide a valid, clear, and public assessment of access  
            to care in Medi-Cal, and provide a basis to evaluate the  
            adequacy of Medi-Cal rates and the existence of other barriers  
            to access to care.

           FISCAL  
          EFFECT  :  According to the Assembly Appropriations Committee,  
          costs in the range of $1 million (General Fund/federal funds)  
          for enhanced monitoring and reporting of access and adequacy of  
          provider rates.

           PRIOR  
          VOTES  :  
          
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          |Assembly Floor:                     |77 - 0                      |
          |------------------------------------+----------------------------|
          |Assembly Appropriations Committee:  |17 - 0                      |
          |------------------------------------+----------------------------|
          |Assembly Health Committee:          |16 - 0                      |








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          COMMENTS  :
          1)Author's statement.  According to the author, this bill would  
            provide critical stability to health care provider networks  
            and ensure access to health care services for people receiving  
            services in the Medi-Cal program. The author notes that with  
            the dramatic expansion of enrollment in California's Medi-Cal  
            program, there is increased concern about access to care.   
            That concern stems from the low rates in the program.  
            California already pays its Medi-Cal FFS providers some of the  
            lowest rates in the entire country (for primary care and  
            obstetric care, California ranked 48th among all states in  
            2012, and overall, Medi-Cal compensated physicians at only 51  
            % of Medicare levels). Having expanded Medi-Cal under the  
            Patient Protection and Affordable Care Act (ACA), California  
            needs to ensure that Medi-Cal beneficiaries have sufficient  
            access to care.


          2)Medi-Cal budget. The 2015-16 DHCS budget assumes average  
            monthly enrollment in Medi-Cal of 12.4 million individuals,  
            and total expenditures of $91.3 billion ($18.1 billion General  
            Fund). Each monthly, DHCS assumes 9.5 million individuals, or  
            76.6% of program enrollment, to be in Medi-Cal managed care  
            plans, and 23.3%, or 2.9 million, to be in FFS.

          3)Medi-Cal rates. To achieve budget savings in Medi-Cal during  
            the state's fiscal crisis, the state has three principle  
            policy and fiscal choices: (a) to reduce or restrict who is  
            eligible for Medi-Cal benefits; (b) to reduce the scope of  
            benefits provided in the program; and, (c) to reduce the  
            payments to health care providers and managed care plans for  
            Medi-Cal services. Federal law has prevented or limited the  
            state's ability to reduce eligibility, but the state  
            previously eliminated benefits in Medi-Cal, most notably adult  
            dental services (which were partially restored in May 2014).  
            In addition, the state has attempted several times to reduce  
            Medi-Cal payments to health plans, health facilities and  
            health care providers. However, some of these rate reductions  
            did not, and have not taken effect because of court  
            injunctions, while other reductions have expired by their own  








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            terms and been replaced by different rate reductions.



          While the number of people receiving health care through  
            Medi-Cal has grown dramatically, beginning in 2008, Medi-Cal  
            payment rates to health plans and providers in the program  
            were reduced to help address state budget deficits.  In 2011,  
            the Legislature passed and Governor Brown signed AB 97 into  
            law, which largely replaced prior Medi-Cal rate reductions and  
            which remains in effect today. Major provisions of AB 97  
            include the following:
             a.   Reduced Medi-Cal provider payments, with specified  
               exceptions, by 10% for FFS benefits for dates of service on  
               and after June 1, 2011;
             b.   Required Medi-Cal managed care plan rates to be reduced  
               by the actuarial equivalent amount of the FFS reduction,  
               effective July 1, 2011;
             c.   Froze rates at the 2008-09 rate year and then applied  
               the 10% rate reduction for certain types of facility  
               providers;
             d.   Required the payment reductions to be applied  
               retroactively to June 1, 2011 or on such other date as may  
               be applicable when federal approval is obtained;
             e.   Conditioned the implementation of the payment reductions  
               on the reductions complying with federal Medicaid  
               requirements;
             f.   Granted the Director of DHCS the discretion to not  
               implement a particular payment reduction or adjustment, or  
               to adjust the payment as necessary to comply with federal  
               Medicaid requirements, to the extent that the director  
               determines that the payments do not comply with the federal  
               Medicaid requirements or that federal financial  
               participation is not available with respect to any payment  
               that is reduced; and,
             g.   Prohibited implementation until federal approval was  
               obtained.

            Federal approval of the AB 97 rate reductions was obtained in  
            October 2011, but a court injunction prevented DHCS from  
            implementing many of these reductions. In June 2013, the  
            injunctions were lifted, giving the state authority to (1)  
            apply the reductions to current and future payments to  
            providers on an ongoing basis; and, (2) retroactively recoup  
            the reductions from past payments that were made to providers  








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            during the period in which the injunctions were in effect  
            (this is commonly referred to as a "claw back").


            The AB 97 reductions did not apply to certain provider  
            categories, including hospital inpatient and outpatient  
            services, critical access hospitals, federally qualified  
            health centers and hospices, services provided under Family  
            PACT and payments funded by intergovernmental transfers or  
            certified public expenditures. Entities subject to the AB 97  
            rate reduction include physician services to adults, other  
            health care providers (such as nurse practitioners,  
            psychologists, podiatrists, optometrists, physical  
            therapists), blood banks, adult day care centers, MSSP  
            providers, medical transportation providers, durable medical  
            equipment/supply providers, dental service providers, clinics  
            and pharmacy providers.


            Since the 2013-14 budget was enacted, several types of  
            providers and services have been exempted from the ongoing  
            payment reductions through either administrative decisions by  
            DHCS or through subsequently enacted legislation. DHCS  
            administratively exempted from the Medi-Cal managed care plans  
            from the AB 97 retroactive reduction, and the following  
            providers/services were exempted prospectively:


             a)   Pediatric health care;
             b)   Audiology rates by a particular type of provider;
             c)   Residential care facilities for the elderly and care  
               coordinator agencies;
             d)   Genetic disease screening program;
             e)   Community-based adult services providers located in San  
               Francisco;
             f)   Non-profit dental pediatric surgery centers that provide  
               at least 99 % of their services under general anesthesia to  
               children with severe dental disease under age 21;
             g)   For-profit dental pediatric surgery centers that provide  
               services to at least 95 % of their Medi-Cal beneficiaries  
               under age 21; and,
             h)   Certain prescription drugs (or categories of drugs) that  
               are generally high-cost drugs used to treat extremely  
               serious conditions, such as hemophilia, multiple sclerosis,  
               hepatitis.








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            Providers subject to the retroactive payment recoveries  
            include pharmacies, durable medical equipment/supply  
            providers, clinical laboratories/laboratory services, distinct  
            part skilled nursing facilities, and radiology service  
            providers. DHCS has indicated these retroactive payment  
            recoveries will not occur until after the prospective 10 %  
            provider payment reductions are implemented, and DHCS has  
            indicated it will provide at least 60 days advanced  
            notification of scheduled recoveries.



            DHCS assumes total fund savings from the AB 97 reductions of  
            $550 million ($275 million General Fund) in 2015-16. The  
            provisions of AB 97 were not changed in the most recently  
            enacted 2015-16 budget, except for Denti-Cal services. The AB  
            97 10% rate reduction was repealed for dental services for by  
            the health budget trailer bill, SB 75 (Committee on Budget and  
            Fiscal Review) Chapter 18, Statutes of 2015. Specifically, the  
            10% rate reduction was repealed for dental services and  
            applicable ancillary services for dates of service on or after  
            July 1, 2015, or the effective date of any necessary federal  
            approvals, whichever is later, and for Denti-Cal managed care  
            plans for contract amendments or change orders effective on or  
            after July 1, 2015, or the effective date of any necessary  
            federal approvals, whichever is later.
          1)Physician and dentist participation in Medi-Cal. Surveys of  
            physicians and dentists have found lower participation in  
            Medi-Cal and lower reimbursement rates as compared to Medicare  
            and private insurance. A survey of physicians through the  
            Medical Board of California found the percentage of California  
            physicians accepting new patients in 2013 was 62 % for  
            Medi-Cal, compared to 79 % for private insurance and 75% for  
            Medicare. The percentage of physicians with any Medi-Cal  
            patients in their practice (69%) was significantly lower than  
            the percentage with any Medicare patients (77 %) and much  
            lower than the percentage with any privately insured patients  
            (92%). A March 2015 National Centers for Health Statistics  
            Data Brief found 76.6% of California physicians were accepting  
            new privately insured patients, 77.2 were accepting new  
            Medicare patients, as compared to 54.2 % of California  
            physicians who were accepting new Medi-Cal patients. The  
            national average for accepting new Medicaid patients was  
            68.9%.








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          A December 2012 publication by the Kaiser Commission on Medicaid  
            and the Uninsured (KCMU) showed how states compare in their  
            2012 Medicaid fee levels, and how Medicaid fees compared to  
            Medicare fees. In California, Medi-Cal fees for all services  
            were 51 % of Medicare, primary care physician fees were 43% of  
            Medicare, obstetrical care services were 54% of Medicare, and  
            other services were 67% of Medicare. A December 2014 Bureau of  
            State Audits (BSA) review of California's Denti-Cal Program  
            found that California had similar access to care problems for  
            children needing dental services, as five counties may lack  
            active providers, an additional 11 counties had no providers  
            willing to accept new Medi-Cal patients, and 16 other counties  
            appear to have an insufficient number of providers. The BSA  
            stated a primary reason for low dental provider participation  
            rates is low reimbursement rates compared to national and  
            regional averages and to the reimbursement rates of other  
            states BSA examined.
          2)Access to care in Medi-Cal. Surveys of Californians conducted  
            before coverage expansions enacted under the ACA consistently  
            showed a wide gap between Medi-Cal enrollees and other insured  
            populations with respect to access to care. A 2011 survey  
            funded by the California HealthCare Foundation (CHCF) of over  
            1,500 Medi-Cal beneficiaries identified difficulties in  
            finding health care providers who accept their coverage, as  
            34% of Medi-Cal beneficiaries said it was difficult to find  
            health care providers who accept their insurance, compared to  
            13% for people with other coverage. The survey found a higher  
            percentage of adults with Medi-Cal say they have more  
            difficulty getting appointments with specialists and primary  
            care providers than adults with other health coverage (42% v.  
            24% for specialists and 26% v. 15% for primary care  
            providers).



          Similarly, the 2012 California Health Interview Survey asked how  
            access to care in Medi-Cal compares to access to care in  
            employer-sponsored insurance (ESI) for adults with similar  
            health care needs.  Medi-Cal had bigger gaps in access to  
            care, including Medi-Cal beneficiaries being less likely to  
            have a usual source of care other than the emergency room as  
            compared to individuals with ESI (21.5% v. 8.1%, Medi-Cal  








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            beneficiaries were more likely to have used the emergency room  
            than individuals with ESI (3.7% v. 0.5%), and Medi-Cal  
            beneficiaries were either sometimes or never able to get a  
            physician appointment within two days of seeking an  
            appointment compared to individuals with ESI (46% v. 20.6%).
          3)Primary care rate bump under ACA. The expansion of Medicaid  
            under the ACA has exacerbated concerns about whether the  
            supply of primary care providers would be sufficient to ensure  
            access to care for this new population, particularly given low  
            reimbursement rates offered by many Medicaid programs. For  
            this reason, the ACA included a "primary care bump," which  
            required states, for 2013 and 2014, to increase their Medicaid  
            primary care rates to those rates provided by Medicare, and  
            provided states federal funds to make up the difference  
            between state rates and Medicare rates. Final federal  
            regulations were released in November 2012, but a state plan  
            amendment California submitted to implement the federal  
            requirement was only approved October 24, 2013, nearly 11  
            months after the effective date. The increased payments  
            covered the two years the primary care bump was in effect, but  
            the increased payments ended December 31, 2014.


          4)Medi-Cal FFS.  Medi-Cal rates and access to care requirements  
            vary by FFS versus managed care, and are governed by a complex  
            mix of state and federal laws and regulations, administrative  
            decisions by DHCS and the federal Centers for Medicare and  
            Medicaid Services (CMS), and court interpretation of federal  
            Medicaid requirements.



          Medicaid is a cooperative federal-state program, and in order to  
            qualify for federal funds, states must submit their Medicaid  
            plan and any amendments to CMS. Before approving a Medicaid  
            State Plan Amendments (SPA), CMS conducts a review to  
            determine whether they comply with federal requirements. For  
            the AB 97 FFS rate reductions, the state submitted several  
            SPAs for federal approval. Relevant federal law (Section  
            1902(a)(30)(A) of the Social Security Act) for the AB 97 SPAs  
            is as follows (emphasis added):
                 "provide such methods and procedures relating to the  
                 utilization of, and the payment for, care and services  
                 available under the plan . . . as may be necessary to  
                 safeguard against unnecessary utilization of such care  








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                 and services and to assure that payments are consistent  
                 with efficiency, economy, and quality of care and are  
                 sufficient to enlist enough providers so that care and  
                 services are available under the plan at least to the  
                 extent that such care and services are available to the  
                 general population in the geographic area;"


            As a condition of approval of the AB 97 FFS rate reductions in  
            California's SPA, CMS required DHCS to monitor health care  
            access. DHCS was required to provide metrics which adequately  
            demonstrated beneficiary access to CMS, and a monitoring plan  
            that would apply to the services where rates were being  
            reduced. DHCS developed a health care access monitoring system  
            to detect if Medi-Cal beneficiaries are experiencing  
            difficulties accessing health care services in FFS Medi-Cal.   
            CMS indicated DHCS would monitor predetermined metrics on a  
                                                                  quarterly or annual basis in order to ensure the beneficiary  
            access is comparable to services available to the general  
            population in the geographic area. DHCS indicates it will  
            report on 23 access measures annually and a subset of four  
            access measures quarterly. The four areas reported quarterly  
            are changes in physician supply, Medi-Cal beneficiary  
            participation, service utilization rates per 1,000 member  
            months, and beneficiary feedback.



          5)Medi-Cal managed care. Medi-Cal managed care rates are also  
            set under state and federal requirements. State law requires  
            DHCS to pay capitation rates to health plans participating in  
            the Medi-Cal managed care program using actuarial methods  
            under what is commonly referred to as the "Mercer methodology"  
            (Mercer is DHCS' actuarial consulting firm).  Medi-Cal managed  
            care plans must provide DHCS with financial and utilization  
            data to establish rates. DHCS is required to utilize a county-  
            and model-specific rate methodology to develop Medi-Cal  
            managed care capitation rates that includes health  
            plan-specific encounter and claims data, supplemental  
            utilization and cost data submitted by the health plans, FFS  
            data for the underlying county of operation or other  
            appropriate counties as deemed necessary by DHCS. 


          Federal regulations for Medicaid managed care plans require all  








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            payments under risk contracts (such as to Medi-Cal managed  
            care plans) and all risk-sharing mechanisms in contracts to be  
            actuarially sound.  
            For enrollees of Medi-Cal managed care plans, DHCS has  
            requirements for network adequacy in existing law, regulation,  
            contracts with health plans, and through All Plan Letters  
            issued by DHCS. For example, DHCS contractually requires  
            Medi-Cal managed care plans to abide by the time and distance  
            standards in the Knox-Keene Health Care Service Plan Act of  
            1974 (Knox Keene Act). The Knox-Keene Act is the body of law  
            regulating health plans, and it requires a primary care  
            physician to be no more than 15 miles or 30 minutes from the  
            place of residence or work of the member unless the member  
            chooses a different provider; the Medi-Cal standard is 10  
            miles from a member's residence unless the plan has a  
            DHCS-approved alternative.



            In addition, the Knox-Keene Act requires Medi-Cal managed care  
            plans (except for County Organized Health Systems, which are  
            exempt from the Knox-Keene Act) to make all services be  
            readily available at reasonable times to each enrollee  
            consistent with good professional practice.  Regulations  
            implementing the Knox-Keene Act require timely access to care  
            by requiring urgent and non-urgent appointments to be provided  
            within specified timeframes.  
          6)Recent Supreme Court decision on Medicaid rates. In March  
            2014, the United States Supreme Court issued a decision in  
            Armstrong et al. v. Exceptional Child Center, Inc., et al. In  
            that case, providers of "habilitation services" under Idaho's  
            Medicaid plan are reimbursed by the Idaho's Department of  
            Health and Welfare. Section 1902(a)(30)(A) of the federal  
            Medicaid Act requires Idaho's plan to "assure that payments  
            are consistent with efficiency, economy, and quality of care"  
            while "safeguard[ing] against unnecessary utilization of . .  
            .care and services. The providers of habilitation services  
            sued the Idaho Health and Welfare Department officials,  
            claiming that petitioner Idaho reimbursed them at rates lower  
            than §30(A) permits, and sought to enjoin Idaho to increase  
            these rates. The District Court entered summary judgment for  
            the providers. The Ninth Circuit affirmed, concluding that the  
            Supremacy Clause gave the providers an implied right of  
            action, and that they could sue under this implied right of  
            action to seek an injunction requiring Idaho to comply with  








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            §30(a). 



          The Supreme Court reversed this decision in a 5-4 opinion. The  
            Supreme Court concluded that the Supremacy Clause of the  
            Constitution does not confer a private right of action, and  
            that Medicaid providers cannot sue for an injunction requiring  
            compliance with §30(a). The Supreme Court also stated that the  
            providers of habilitation services suit cannot proceed in  
            equity as the power of federal courts of equity to enjoin  
            unlawful executive action is subject to express and implied  
            statutory limitations. In this case, the express provision of  
            a single remedy for a State's failure to comply with  
            Medicaid's requirements-the withholding of Medicaid funds by  
            the federal Secretary of Health and Human Services, and the  
            sheer complexity associated with enforcing §30(A) combine to  
            establish Congress's "intent to foreclose" equitable relief. 
          7)Related legislation. Last session, SB 870 (Senate Budget and  
            Fiscal Review Committee), was signed by Governor Brown on June  
            20, 2014. Among its provisions is uncodified legislative  
            intent language that requires DHCS to continue to monitor  
            access to and utilization of Medi-Cal services in the FFS and  
            managed care settings during the 2014-15 fiscal year, in  
            conjunction with DHCS' federally approved plan to monitor  
            health care access for Medi-Cal beneficiaries and any other  
            methods deemed appropriate by the director. The language would  
            further require DHCS to use this information to evaluate  
            current reimbursement levels for Medi-Cal providers and to  
            make recommendations for targeted changes to the reductions in  
            reimbursement levels made pursuant to AB 97 (Committee on  
            Budget, Chapter 3, Statutes of 2011), to the extent DHCS finds  
            those changes appropriate.
          
            SB 243 (Hernandez), would have repealed prior year Medi-Cal  
            provider and managed care rate reductions, including the AB 97  
            reductions. SB 243 would have increased specified FFS Medi-Cal  
            provider rates to Medicare levels, required rates paid to  
            Medi-Cal managed care plans to be actuarially equivalent to  
            the payment rates established under the Medicare program,  
            required Medi-Cal hospital inpatient claims for  
            diagnosis-related groups to be increased by 16% for the  
            2015-16 fiscal year, and to be increased annually thereafter,  
            and required Medi-Cal managed care plan rates to be increased  
            by a proportionately equal amount for increased payments for  








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            hospital services. SB 243 was held on the Senate  
            Appropriations Committee suspense file.
            
          8)Support. This bill is supported by rural county  
            representatives, some health care providers, and labor groups,  
            which argue this bill is important to document the  
            shortcomings in the Medi-Cal delivery system and the need to  
            increase reimbursement rates in order to improve access to  
            care. Supporters argue that as the state expands Medi-Cal  
            cover increasing numbers of Californians, it is critical to  
            perform a regular assessment of access to care the adequacy of  
            provider payments in the program. Supporters conclude that  
            requiring a regular assessment of access issues and provider  
            rates is an important part in ensuring the quality and  
            long-term sustainability of the Medi-Cal program.
          
          
           SUPPORT AND OPPOSITION  :
          Support:  California Academy of Family Physicians (co-sponsor)
                    ALS Association Golden West Chapter
                    Association of California Healthcare Districts
                    California Association for Health Services at Home
                    California Hospital Association
                    California Immigrant Policy Center
                    California Labor Federation
                    California Medical Association
                    California School Employees Association
                    Community Clinic Association of Los Angeles County
                    Health Access California
                    LIUNA Local 777
                    LIUNA Local 792
                    Planned Parenthood Affiliates of California
                    Rural County Representatives of California
                    Silicon Valley Leadership Group
                    Western Center on Law and Poverty

          Oppose:   None received

          
                                      -- END --
          
          
          










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