BILL ANALYSIS Ó
AB 858
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Date of Hearing: April 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 858
(Wood) - As Introduced February 26, 2015
SUBJECT: Medi-Cal: federally qualified health centers and
rural health clinics.
SUMMARY: Allows federally qualified health centers (FQHCs) and
Rural Health Center (RHCs) to be reimbursed a per visit Medi-Cal
payment under the prospective payment system (PPS), for multiple
visits by a patient with a single or different health care
professional on the same day at a single location.
Specifically, this bill:
1)Allows clinics to obtain reimbursement for two visits in the
same day when a patient has a medical visit, as defined, and
another health visit on the same day. Defines "another health
visit" is a face-to-face encounter between a clinic patient
and a clinical psychologist, licensed clinical social worker,
dentist, dental hygienist, or registered dental hygienist in
alternative practice.
2)Allows clinics to obtain reimbursement for two visits in the
same day when a patient has had an illness or injury requiring
additional diagnosis or treatment.
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3)Requires FQHCs and RHCs to apply to the Department of Health
Care Services (DHCS) for an adjustment of their PPS rate by
January 1, 2017.
4)Requires DHCS to submit a state plan amendment to the federal
Centers for Medicare and Medicaid Services (CMS) for approval
of the changes contained in this bill.
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 and RHCs on a per-visit basis with rates determined
prospectively. Federal law requires states to use a PPS
system to pay clinics.
3)Identifies those services that may be reimbursed as services
identified in federal law as covered benefits for FQHCs and
RHCs and requires FQHCs and RHCs to be reimbursed on a
per-visit basis with rates determined prospectively.
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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, visiting nurse, osteopath, podiatrist, dentist, dental
hygienists, optometrist, chiropractor, comprehensive perinatal
services practitioner, or 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 been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, one in seven
Californians are served by clinics and with the increased
number of Californians eligible for Medi-Cal, this number is
likely to increase. The author cites research showing that
within a primary care setting, up to 26% of patients have some
mental disorder and that adults with mental health needs are
1.5 times more likely to have a chronic condition such as high
blood pressure, heart disease, or asthma. Yet currently
clinics cannot be reimbursed for a mental health visit on the
same day that they are reimbursed for a medical visit.
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The author argues that we need to adopt policies that encourage
integrated care and invest in the long-term health of
Californians and continuing to view various aspects of health
care in silos does a disservice to patients who should be
treated in a more holistic manner. California has recognized
that oral health services are a critical part of overall
health and has acknowledged that fact by adopting a payment
policy in clinics that allows for a dental visit to be
reimbursed when on the same day as a medical visit. The
author concludes that given the statistics on the connection
between physical health and mental health, we need to adopt a
similar policy in this area.
2)BACKGROUND. 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, DHCS 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.
Community clinics and health centers provide health care to 14%
Californians. 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 the Patient
Protection and Affordable Care Act. As such they are a part
of Medi-Cal. Along with the expansion of these benefits, the
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expansion of the Medi-Cal program overall has increased the
number of beneficiaries to over 12 million placing even
greater demands on Medi-Cal providers.
3)SUPPORT. The California Primary Care Association (CPCA), the
sponsor, states that clinics have been working to integrate
behavioral health services and were recognized as leaders in
this effort. However, they note the results from a
University of California, Los Angeles (UCLA) study which
suggests that the current Medi-Cal rules frustrate their
efforts. Medi-Cal will not reimburse a patient's visit to a
primary care provider and a visit to a mental health provider
on the same day. CPCA explains the results of a UCLA study
which found that 70% of behavioral health conditions are first
diagnosed in the primary care setting. The rule against
reimbursing for two visits in one day requires many vulnerable
patients to navigate the complexities of two separate systems
of care. CPCA states that same day reimbursement is allowed
for medical and dental services, but mental health services
are excluded, as the state has not adopted this option, even
though federal law allows reimbursement for same day visits.
Supporters argue that there is a high correlation between
serious mental illness and high rates of physical health
problems which creates a need for integrated care on the same
day.
4)RELATED LEGISLATION. AB 690 (Wood) adds marriage and family
therapist to the list of health care providers that qualify
for a face-to-face encounter with a patient at a FQHC or RHC
for purposes of a per visit Medi-Cal payment PPS. AB 690
passed this committee on April 7 2015, by an 18-0 vote and is
now pending hearing in the Assembly Appropriation Committee.
5)PREVIOUS LEGISLATION. SB 260 (Steinberg) of 2007 was
substantially similar to this bill. SB 260 was vetoed by
Governor Schwarzenegger who cited concerns about the fiscal
impact of the bill.
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6)COMMITTEE AMENDMENTS. The bill contains conflicting provisions
on when the department should seek approval from CMS. The
following should be deleted as the date falls too soon after
enactment for DHCS to be able to meet, leaving a required date
of March 30, 2016 for DHCS to have sought all necessary
federal approvals.
Page 10, beginning line 34:
(4) The department shall, by January 15, 2016, submit a
state plan amendment to the federal Centers for Medicare
and Medicaid Services reflecting the changes described in
this subdivision.
REGISTERED SUPPORT / OPPOSITION:
Support
California Primary Case Association (sponsor)
Association of California Healthcare Districts
California Chapter, American College of Emergency Physicians
California Medical Association
California Psychological Association
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Council of Community Clinics
Opposition
None on file.
Analysis Prepared by:Roger Dunstan / HEALTH / (916) 319-2097