BILL ANALYSIS                                                                                                                                                                                                    

                             Senator Ricardo Lara, Chair
                            2015 - 2016  Regular  Session

          AB 521 (Nazarian) - HIV testing
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          |Version: June 29, 2015          |Policy Vote: HEALTH 6 - 2       |
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          |Urgency: No                     |Mandate: No                     |
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          |Hearing Date: August 17, 2015   |Consultant: Brendan McCarthy    |
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          This bill meets the criteria for referral to the Suspense File.

          Summary:  AB 521 would require a general acute care hospital to  
          offer an HIV test to any individual who has been admitted to the  
          hospital through the emergency department and who has blood  
          drawn after admission to the hospital.

           By requiring hospitals to offer additional HIV testing to  
            patients, the bill will increase the number of tests provided  
            and the number of previously undiagnosed individuals who will  
            be diagnosed with HIV, typically leading to treatment. The  
            number of additional tests provided and the number of  
            previously undiagnosed cases of HIV discovered through those  
            tests is subject to uncertainty. Based on information  
            developed by the Office of Statewide Planning and Development,  
            there are about 11.6 million emergency department patient  
            encounters per year, of which about 160,000 lead to an  
            inpatient admission at a hospital. If 50% of those admissions  
            lead to an HIV test and the population accepting the test has  


          AB 521 (Nazarian)                                      Page 1 of  
            roughly the same rate of undiagnosed HIV as the overall state  
            population, there would be about 60 newly diagnosed cases of  
            HIV identified under the bill per year. This would result in  
            the following state costs:

               o      About $300,000 per year for additional HIV testing  
                 (including follow up testing for positive test results)  
                 by the Medi-Cal program (General Fund and federal funds).

               o      About $300,000 per year to provide medical care  
                 Medi-Cal enrollees newly diagnosed with HIV (General Fund  
                 and federal funds).

               o      About $200,000 per year to provide medical care to  
                 new Aids Drug Assistance Program enrollees (federal funds  
                 and drug rebate funds).

           Unknown long-term cost savings to Medi-Cal due to earlier  
            medical intervention for HIV-positive Medi-Cal enrollees. To  
            the extent that HIV-positive Medi-Cal enrollees are diagnosed  
            earlier and begin treatment earlier, it is likely that the  
            long-term health status of those individuals will improve and  
            some of the health effects of HIV will be delayed or avoided.  
            There are indications that untreated HIV causes long-term  
            health impacts such as elevated risk of diabetes and heart  
            disease, even before the effects of compromised immune system  
            function associated with HIV infection become evident. Earlier  
            diagnosis and treatment for HIV-positive individuals may to  
            reduce long-term Medi-Cal expenditures for those individuals.  
            However, to some unknown extent the improvement in health  
            status and reduction in health care needs will be offset by  
            longer lifespans, potentially offsetting cost savings.

           Unknown cost savings due to reduced HIV infections in the  
            state, including amongst Medi-Cal beneficiaries. There is  
            academic findings that diagnosis of HIV significantly reduces  
            the likelihood that an HIV positive individual will infect  
            others. This is due both to a reduction in risky behavior by  
            those aware of their HIV positive status and reductions in  
            viral loads in the blood due to antiretroviral treatments. To  
            the extent that the bill results in new diagnoses of HIV and  
            that newly diagnosed individuals are able to access  
            appropriate medical care, the bill is likely to prevent future  
            HIV infections.


          AB 521 (Nazarian)                                      Page 2 of  

          Background:  Under current law, patients who have blood drawn at primary  
          care clinics must be offered an HIV test by the clinic.
          Under state and federal law, the Department of Health Care  
          Services operates the Medi-Cal program, which provides health  
          care coverage to low income individuals, families, and children.  
          Medi-Cal provides coverage to childless adults and parents with  
          household incomes up to 138% of the federal poverty level and to  
          children with household incomes up to 266% of the federal  
          poverty level. The federal government provides matching funds  
          that vary from 50% to 90% of expenditures depending on the  
          category of beneficiary.

          In addition, the Department of Public Health manages the Aids  
          Drug Assistance Program which offers coverage for treatment of  
          HIV to those who do not qualify for Medi-Cal. 

          Current law mandates that all individual and group health plans  
          and insurance policies provide coverage for HIV testing.

          Proposed Law:  
            AB 521 would require a general acute care hospital to offer an  
          HIV test to any individual who has been admitted to the hospital  
          through the emergency department and who has blood drawn after  
          admission to the hospital.
          The bill would specify that the emergency department of a  
          hospital is not required to offer an HIV test.

          Legislation:  AB 446 (Mitchell, Statutes of 2013) requires  
          community clinics to offer HIV testing to patients.

          Comments:  Current law requires health plans and health insurers  


          AB 521 (Nazarian)                                      Page 3 of  
          to cover HIV testing. However, the enrollee cost sharing for  
          such testing will vary based on the individual's plan and the  
          network status of the hospital providing the HIV test. An  
          individual with commercial health insurance may be required to  
          pay a deductible or copay associated with the test required in  
          the bill. In addition, if the hospital is not in the enrollee's  
          plan network, the enrollee may be required to cover a larger  
          share of cost, potentially the entire cost of the test,  
          depending on the terms of coverage.
          The state's Medi-Cal program covers HIV testing with no cost  
          sharing for beneficiaries. However, because regular HIV  
          screening has not been recommended for all individuals by the  
          United States Preventative Services Taskforce, the Department of  
          Health Care Services indicates that it is not clear whether  
          federal matching funds would be available for HIV tests  
          requested by individuals who do not meet the criteria for  
          regular HIV screening. Under state law, hospitals would not be  
          allowed to bill a Medi-Cal beneficiary for the costs of an HIV  

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