BILL ANALYSIS                                                                                                                                                                                                    

                                                                     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  
          FISCAL EFFECT:  This bill has not yet been analyzed by a fiscal  


          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.


             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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          California Primary Care Association (Sponsor)

          Alameda Health Consortium

          American Association for Marriage and Family Therapy, California  

          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


          National Association of Social Workers-California Chapter 

          Analysis Prepared by:Roger Dunstan / HEALTH / (916) 319-2097


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