BILL ANALYSIS Ó
AB 690
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Date of Hearing: April 7, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 690
(Wood) - As Introduced February 25, 2015
SUBJECT: Medi-Cal: federally qualified health centers: rural
health clinics.
SUMMARY: Adds marriage and family therapist (MFT) to the list
of health care providers that qualify for a face-to-face
encounter with a patient at a Federally Qualified Health Center
(FQHC) or Rural Health Center (RHC) for purposes of a per visit
Medi-Cal payment under the prospective payment system (PPS).
EXISTING LAW:
1)Establishes the Medi-Cal program to provide comprehensive health
benefits to low-income persons.
2)Establishes a statutory structure for Medi-Cal payments being
made under the PPS. These payments are for services provided
by FQHCs on a per-visit basis with rates determined
prospectively. Federal law requires states to use a PPS
system to pay clinics.
3)Existing law also identifies those services that may be
reimbursed as services identified in federal law as covered
benefits for FQHCs and requires FQHCs to be reimbursed on a
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per-visit basis with rates determined prospectively.
4)Defines visit as a face to face encounter with a physicians,
physician assistant, nurse practitioner, certified nurse
midwife, clinical psychologist, licensed clinical social
worker (LCSW), visiting nurse, osteopath, podiatrist, dentist,
dental hygienists, optometrist, chiropractor, comprehensive
perinatal services practitioner, adult day health care center.
Authorizes other providers if identified in the state plan.
5)Allows only one visit per day to be reimbursed by Medi-Cal,
except for a subsequent visit by a patient to a dental
provider
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. The author argues that community
clinics and health centers provide health care to one in seven
Californians and this figure is even higher in rural or remote
areas that struggle to attract and retain health care
providers. Mental health and substance abuse services are
part of the essential health care benefits under Patient
Protection and Affordable Care Act (ACA). As such they are a
part of Medi-Cal.
Along with the expansion of these benefits, the expansion of
the Medi-Cal program overall has increased the number of
beneficiaries to over 12 million. By adding MFT to the list
of PPS billable providers, this bill brings parity throughout
the delivery system in the ability to utilize all qualified
mental health providers regardless of how or where you are
receiving treatment. The author notes that as of February
2012, there were 19,009 LCSW and 16,228 licensed
psychologists; as well as 31,865 MFTs in California. Allowing
full access to the entire population of qualified mental
health providers for all aspects of the health care delivery
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system will help to meet the increased demands of the Medi-Cal
population. The author concludes that integration has taken
place in other settings, including Medi-Cal managed care. It
is time to remove the financial and workforce barrier that
exists in many rural and remote areas of California.
2)BACKGROUND.
a) Clinics. FQHCs and RHCs serve a significant portion of
the uninsured and underinsured in California. They are
open-door providers that treat patients on a sliding fee
scale basis and make their services available regardless of
a patient's ability to pay. Currently, there are
approximately 600 FQHCs and 350 RHCs in California. All
FQHCs, and a majority of the RHCs, either are non-profit
community clinics or government entities. Because clinics
are safety net providers, their continued survival depends
heavily on the stability and adequacy of revenues from the
Medi-Cal program. FQHCs and RHCs are paid by Medi-Cal on a
per visit basis in an amount equal to the clinic's cost of
delivering services. Essentially, the department
calculates the annual cost of care provided by each clinic
and divides the total by the number of visits to determine
a per visit rate.
b) Rural Mental Health. According to a 2010 Behavior Risk
Factor Survey, a higher proportion of rural residents
self-declare a mental health issue compared to urban county
residents. Additionally, within a primary care setting, up
to 26% of patients have some mental health disorder.
Further complicating the care environment is the fact that
while chronic conditions, such as heart disease and
diabetes are common among the adult population, adults with
mental health needs have an even higher incidence of
chronic disease. Adults with mental health needs are 1.5
times more likely to have high blood pressure, heart
disease or asthma. This situation reinforces the value of
integrating mental health services into the primary care
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settings or rural clinics and FQHCs.
c) MFTs and Medi-Cal. A state plan amendment allows MFTs
to provide Medi-Cal services in County mental health
plans, MediCal managed care plans and as Medi-Cal
fee-for-service providers. Their services are not included
as those that can be billed as a face-to-face encounter
with a qualified provider type. MFTS can still be employed
by clinics. If the cost of the MFT is included in the PPS
rate calculation initially, although the clinic cannot bill
for a visit, since the MFT is part of the cost structure,
each time the clinic is paid their PPS they are reimbursed
a portion of the cost. In the aggregate, with all visits
included, the cost of the MFT would be completely
reimbursed to the clinic, provided the cost of hiring the
MFT was part of the costs used to calculate the PPS rate.
3)SUPPORT. The sponsor, the California Primary Care Association
(CPCA), argues by adding MFTs to the list of PPS billable
providers will help solve existing gaps in workforce capacity
by providing FQHCs and RHCs with an adequate source of funding
for their employment and will help to meet the demand for
mental health services in the public health setting. CPCA
notes that as part of California's implementation of health
care reform, mental health and substance abuse disorder
services are deemed an essential health benefit for Medi-Cal
managed care plans. In addition, they state, that along with
the expansion of behavioral health benefits for Medi-Cal, the
significant expansion of the Medi-Cal program itself has
increased demands for mental health services.
Supporters argue that MFTS are uniquely qualified to address and
resolve familial and contextual issues that arise from, or
contribute to, mental and emotional distress. They also argue
that many low income people on Medi-Cal may require a marriage
and family therapist in order to receive treatment for a
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mental illness or to discuss a personal and possibly dangerous
matter that is affecting their physical and mental well-being.
4)OPPOSITION. The National Association of Social
Workers-California Chapter (NASW-CA) opposes the bill because
they believe there is a sufficient workforce of social workers
and only social workers have the training and skills necessary
to treat this community. NASW-CA maintains these clinics
serve a population that is very diverse and in poverty and
while both MFT's and social workers have mental health
training, only social workers are properly trained to provide
a full range of services to this community. A social worker
is trained to view clients from the
person-in-the-environment/whole person perspective, as opposed
to simply focusing on the pathology of mental illness,
according to NASW-CA. As an example, they cite the possible
case of a homeless person who is exhibiting signs of a mental
illness. A clinical social worker can provide clinical
services to that person, but they will also look at that
person's immediate needs, such as the need for food and
shelter. NASW-CA argues that social workers are trained and
very experienced in obtaining services that their clients need
to survive and if a person who has a mental illness is
homeless, even if you alleviate some of their mental health
issues, if they remain homeless, they are in a very unstable
environment that could easily put them into a downward spiral.
5)RELATED LEGISLATION. AB 858 (Wood) provides that a maximum of
two visits taking place on the same day at a single clinic
location shall be reimbursed, as specified. AB 858 is in the
Assembly Health Committee.
6)PREVIOUS LEGISLATION. AB 1785 (Lowenthal) of 2012 was
similar to this bill. AB 1785 was held on the Suspense file
of the Assembly Appropriations Committee.
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REGISTERED SUPPORT / OPPOSITION:
Support
California Primary Care Association (Sponsor)
Alameda Health Consortium
American Association for Marriage and Family Therapy, California
Division
American Federation of State, County and Municipal Employees
Ampla Health
California Association of Marriage and Family Therapists
California Association of Rural Health Centers
California Council of Community Mental Health Agencies
California Immigrant Policy Center
California Medical Association
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California School-Based Health Alliance
Central Valley Health Network
Clinica Sierra Vista
Community Clinic Consortium
Community Health Partnership
County Behavioral Health Directors Association
Family HealthCare Network
Family Health Centers of San Diego
Hill Country Community Clinic
Livingston Community Health
Mendocino Coast Clinics
Mountain Valleys Health Centers
North Coast Clinics Network
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Northeast Valley Health Corporation
Ritter Health Center
San Francisco Community Clinic Consortium
San Ysidro Health Center
SEIU California
Opposition
National Association of Social Workers-California Chapter
Analysis Prepared by:Roger Dunstan / HEALTH / (916) 319-2097
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