BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 858
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|AUTHOR: |Wood |
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|VERSION: |May 28, 2015 |
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|HEARING DATE: |June 17, 2015 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medi-Cal: federally qualified health centers and rural
health clinics.
SUMMARY : Requires Medi-Cal reimbursement to Federally Qualified
Health Centers (FQHC) and Rural Health Clinics (RHC) for two
visits taking place on the same day at a single location when
the patient suffers illness or injury requiring additional
diagnosis or treatment after the first visit, or when the
patient has a medical visit and another health visit with a
mental health provider or dental provider. Adds marriage and
family therapists 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 the per visit Medi-Cal payment billed by
FQHCs and RHCs.
Existing law:
1.Establishes the Medi-Cal program as California's Medicaid
program, administered by the Department of Health Care
Services (DHCS), which provides comprehensive health care
coverage for low-income individuals. Federally Qualified
Health Center (FQHC) and Rural Health Clinic (RHC) services
are covered benefits under the Medi-Cal program.
2.Requires FQHCs and RHCs to be reimbursed on a per-visit basis.
Defines a "visit" as a face-to-face encounter between an FQHC
or RHC patient and the following health care providers: a
physician, physician assistant, nurse practitioner, certified
nurse midwife, clinical psychologist, licensed clinical social
worker, visiting nurse, podiatrist, dentist, optometrist,
chiropractor, comprehensive perinatal services practitioner
providing comprehensive perinatal services, a four-hour day of
attendance at an Adult Day Health Care Center; and, any other
provider identified in the state plan's definition of an FQHC
AB 858 (Wood) Page 2 of ?
or RHC visit.
3.Requires FQHC and RHC per-visit rates to be increased by the
Medicare Economic Index applicable to primary care services in
the manner provided for in federal law.
4.Permits FQHC or RHC to apply for an adjustment to its
per-visit rate based on a change in the scope of services
provided by the FQHC or RHC. Requires rate changes based on a
change in the scope of services provided by an FQHC or RHC to
be evaluated in accordance with Medicare reasonable cost
principles.
This bill:
1)Adds marriage and family Therapists (MFTs) 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 under the prospective payment
system (PPS).
2)Requires an FQHC or RHC that currently includes the cost of
services of a MFT for the purposes of establishing its FQHC or
RHC rate to apply for an adjustment to its per-visit rate,
and, after the rate adjustment has been approved by DHCS, to
bill these services as a separate visit.
3)Requires an FQHC or RHC that does not provide the services of
a MFT, and later elects to add these services, to process the
addition of these services as a change in scope of service.
4)Requires a maximum of two visits taking place on the same day
at a single location to be reimbursed when one or more of the
following conditions exist:
a. After the first visit the patient suffers
illness or injury requiring additional diagnosis or
treatment; or,
b. The patient has a medical visit and another
health visit.
5)Defines a "medical visit" as a face-to-face encounter between
an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, visiting nurse,
or a comprehensive perinatal practitioner providing
comprehensive perinatal services.
AB 858 (Wood) Page 3 of ?
6)Defines "another health visit" as a face-to-face encounter
between an FQHC or RHC patient and a clinical psychologist,
licensed clinical social worker, marriage and family
therapist, dentist, dental hygienist, or registered dental
hygienist in alternative practice.
7)Requires an FQHC or RHC that currently includes the cost of
encounters with more than one health professional that take
place on the same day at a single location as constituting a
single visit for purposes of establishing its FQHC or RHC
rate, by January 1, 2017, to apply for an adjustment to its
per-visit rate. Requires an FQHC or RHC, after the rate
adjustment has been approved by the DHCS, to bill a medical
visit and another health visit that take place on the same day
at a single location as separate visits.
8)Requires DHCS, by July 1, 2016, to develop and adjust all
appropriate forms to determine which FQHC's or RHC's rates
must be adjusted and to facilitate the calculation of the
adjusted rates.
9)Prohibits an FQHC's or RHC's application for a rate from
constituting a change in scope of service.
10)Permits an FQHC or RHC that applies for an adjustment to its
rate pursuant to continue to bill for all other FQHC or RHC
visits at its existing per-visit rate, and requires the FQHC
or RHC to be reimbursed on a per-visit basis in accordance
with the definition of "visit," subject to reconciliation,
until the rate adjustment has been approved.
11)Requires DHCS, no later than March 30, 2016, to promptly seek
all necessary federal approvals in order to implement the same
day visit provisions of this bill, including any necessary
amendments to the state plan.
FISCAL
EFFECT : According to the Assembly Appropriations Committee:
1)If this bill increases access to mental health services in
Medi-Cal by incentivizing clinics to provide more mental
health visits, it could result in cost pressure to Medi-Cal to
fund additional visits, potentially in the millions of dollars
(General Fund (GF)/federal funds).
AB 858 (Wood) Page 4 of ?
2)If 1,000 clinics submit for a recalculation of their rate, it
would take DHCS about $10 million (GF /federal funds) in staff
time to process the requests, likely over a period exceeding a
year or two. The average cost to do a rate recalculation is
$10,000. Currently, clinics can submit on a voluntary basis if
the cost or scope of services they offer changes
significantly.
3)Overall, there should not be a Medi-Cal cost impact to
allowing same-day mental health visits or visits with an MFT
to be separately billed, if rates are recalculated as
envisioned in this bill. However, the recalculation could have
unknown overall cost impacts on Medi-Cal, since additional,
unrelated factors may have changed from the last PPS rate
calculation.
PRIOR
VOTES :
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|Assembly Floor: |76 - 0 |
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|Assembly Appropriations Committee: |17 - 0 |
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|Assembly Health Committee: |16 - 0 |
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COMMENTS :
1)Author's statement. According to the author, currently one in
seven Californians receive care at a FQHC or a RHC. With the
increased number of Californians eligible for Medi-Cal, this
number is likely to increase. Within a primary care setting,
up to 26 percent of patients have some mental health disorder
(Kessler and Stafford, 2008, Primary Care is the De Facto
Mental Health System) and 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.
AB 858 (Wood) Page 5 of ?
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. There is clearly
a connection between chronic medical conditions and a
patient's mental health. All of these factors reinforce the
value of integrating mental health services into the primary
care settings and point to a growing need for qualified mental
health professionals.
California has recognized oral health services as a critical
part of overall health and has acknowledged this by adopting a
payment policy in clinics that allows for a dental visit to be
reimbursed in the same day as a medical visit. Given the
connection between physical health and mental health, a
similar payment policy should be adopted. Continuing to treat
various aspects of health care as if they exist in silos does
a disservice to patients who should be treated in a more
integrated, holistic manner. Community clinics are designed to
provide this type of integrated care. The ability to maximize
needed care in one visit alleviates transportation and other
barriers that may prevent people from seeking the care they
need."
2)Background on FQHCs and RHCs. FQHCs and RHCs are federal
designated clinics that are required to serve medically
underserved populations that provide primary care services.
FQHCs and RHCs provided over 10.5 million Medi-Cal visits in
2013. Demand for Medi-Cal services is expected to increase as
an estimated 1.4 million individuals will be newly Medi-Cal
eligible as a result of the Medicaid expansion under the
federal Affordable Care Act.
Medi-Cal reimbursement to FQHCs and RHCs is governed by state
and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on
a per-visit rate which is known as the PPS. For Medi-Cal
managed care plan patients, DHCS reimburses FQHCs and RHCs for
the difference between its per-visit PPS rate and the payment
made by the plan. This payment is known as a "wrap around"
payment. The Medi-Cal managed care wrap-around rate was
established to reimburse providers for the difference between
their PPS rate and their Medi-Cal managed care reimbursement
rate.
AB 858 (Wood) Page 6 of ?
FQHCs and Rural Health Clinics (RHCs) are both reimbursed under
the PPS system. The average ($178.14) and median ($157.24) PPS
rate paid to an FQHC and RHC in 2014-15 is considerably higher
than the most common primary care visit reimbursement rates in
Medi-Cal, but it also includes additional services not
included in a primary care visit. The rationale for the
enhanced reimbursement is to ensure that FQHCs and RHCs do not
use federal grant funds intended for uninsured and special
needs populations to back-fill for potentially below-cost
Medicare or Medi-Cal rates. Because FQHCs are required to
receive an MEI adjustment to their rates under federal law,
and because of their role in providing primary care access to
the Medi-Cal population, FQHCs have been exempted from the
Medi-Cal rate reductions enacted in prior budget years.
3)Billing for same day visits. DHCS policy in its State Plan
Amendment on same day visits at FQHCs and RHCs is that
encounters with more than one health professional and/or
multiple encounters with the same health professional, which
take place on the same day and at a single FQHC or RHC
location, constitute a single visit, except that more than one
visit may be counted on the same day:
a. When the clinic patient, after the first visit,
suffers illness or injury requiring another diagnosis or
treatment; or,
b. When the clinic patient has a face-to-face encounter
with a dentist or dental hygienist and then also has a
face-to-facet encounter with another health professional
or comprehensive perinatal services practitioner on the
same date.
Mental health visits are treated for Medi-Cal billing purposes
as a visit, and separate billing on the same day for a medical
visits and a mental health visit is not allowed.
4)Recent Changes in Medi-Cal Coverage for Mental Health and
Substance Use Services. Mental health and substance use
disorder services in Medi-Cal have been significantly changed
since the implementation of the Affordable Care Act.
SB X1 1 (Hernandez and Steinberg, Chapter 4, Statutes of 2013)
AB 858 (Wood) Page 7 of ?
required Medi-Cal to cover the additional mental and substance
use disorder benefits for both the newly eligible expansion
population and the current Medi-Cal population. SB X1 1
requires mental health services included in the essential
health benefit (EHB) package adopted by the state (the
Legislature adopted the Kaiser Small Group Product [Kaiser
Product] as the state's EHB for the individual and small group
health insurance market last session) to be covered under
Medi-Cal, to the extent those services are not covered
Medi-Cal benefits now. The additional mental health benefits
required to be provided include group therapy and psychology
(for non-specialty mental health program qualifying
individuals). In addition, SB X1 1 required Medi-Cal to
provide coverage for additional substance abuse disorder
services included in the EHB adopted by the state. The
additional substance use disorder services provided include:
a) Intensive Outpatient Treatment (Day Care Rehabilitation)
- For non-pregnant/postpartum beneficiaries (only pregnant
women were eligible for this service under Drug Medi-Cal
prior to this change);
b) Residential Substance Use Disorder Services - For
non-pregnant/postpartum beneficiaries (only pregnant women
were eligible for this service under Drug Medi-Cal prior to
this change); and,
c) Elective Inpatient Detox - This benefit was made broadly
available (prior to this change, individuals had to have an
underlying physical medical condition in order to receive
inpatient detoxification services).
SB X1 1 also required Medi-Cal managed care plans to provide
coverage for "mild to moderate" mental health benefits covered
in the state plan, except for those benefits provided by
county mental health plans under the Specialty Mental Health
Services Waiver. Under the previous system, Medi-Cal managed
care plans covered mental health services within the scope of
practice of a primary care physician under their contracts
with DHCS, while county specialty mental health plans provided
mental health services to individuals with severe mental
illness, and Medi-Cal fee-for-service provided services to
individuals who fell between those two plans. SB X1 1
effectively provided mid-level mental health services through
the Medi-Cal managed care plan, instead of in
AB 858 (Wood) Page 8 of ?
fee-for-services, resulting in more coordinated care and
better access to services.
In 2014, DHCS received federal approval of State Plan
Amendment 14-012, which allowed MFTs to be providers of
psychology services under Medi-Cal. In addition, registered
MFT interns, registered associate clinical social workers and
psychology assistants were added as providers of psychology
services under the direction of a licensed mental health
professional within their scope of services. The SPA was
approved May 2, 2014 with an effective date of January 1,
2014.
1)Governor's Budget proposal in 2012-13. DHCS proposed, as part
of last year's Governor's Budget, to change the Medi-Cal
payment methodology for FQHCs and RHCs. Under DHCS' proposal,
payments made to FQHCs and RHCs participating in Medi-Cal
managed care plan contracts would have changed from a cost and
volume-based payment to a fixed payment to provide a broad
range of services to its enrollees. A waiver of current
operating restrictions would allow FQHCs and RHCs to provide
group visits, telehealth, and telephonic disease management.
The waiver would also allow clinics to perform multiple
services on the same day. DHCS assumed an efficiency savings
of ten percent due to using the prospective payment reform and
would be removed from the funding provided to the plans. This
proposal was rejected by the Legislature.
2)Related legislation. AB 690 (Wood), would have added MFTs to
the list of health care providers whose services are
reimbursed through Medi-Cal on a per-visit basis by FQHCs and
RHCs. AB 690 was held on the Assembly Appropriations suspense
file and its provisions were amended into this bill when it
was amended off the Assembly Appropriations Committee suspense
file.
SB 147 (Hernandez), would require DHCS to authorize a
three-year payment reform pilot project for FQHCs using an
alternative payment methodology (APM) authorized under federal
Medicaid law. Requires a FQHC participating in the pilot to
receive a per member per month wrap-cap payment for each of
its APM enrollees from a Medi-Cal managed care health plan,
instead of the wrap around payment FQHCs currently receive
from DHCS. SB 147 is awaiting hearing in the Assembly Health
Committee.
AB 858 (Wood) Page 9 of ?
3)Prior legislation. SB 1081 (Hernandez, 2014), would have
required DHCS to authorize a 3-year APM pilot project for
FQHCs that would be implemented in any county and FQHC willing
to participate. Under the APM pilot project, participating
FQHCs would receive capitated monthly payments for each
Medi-Cal managed care enrollee assigned to the FQHC in place
of the wrap-around, fee-for-service per-visit payments made by
DHCS. SB 1081 was held on the Senate Appropriations suspense
file.
SB 1150 (Hueso & Correa, 2014), would have required Medi-Cal
reimbursement to FQHC and RHCs for two visits taking place on
the same day at a single location when the patient suffers
illness or injury requiring additional diagnosis or treatment
after the first visit, or when the patient has a medical visit
and another health visit with a mental health provider or
dental provider. SB 1150 was held on the Senate Appropriations
suspense file.
AB 1445 (Chesbro, 2009-10), was substantially similar to SB
1150. AB 1445 was held on the Senate Appropriations suspense
file.
SB 260 (Steinberg, 2007), was also similar to this bill. SB
260 was vetoed by Governor Schwarzenegger. In his veto
message, Governor Schwarzenegger argued the bill will increase
General Fund pressure at a time of continuing budget
challenges, and that allowing separate billing for mental
health services would lead to increased costs that our state
could not afford.
SB 36 (Chesbro, Chapter 527, Statutes of 2003), established a
statutory structure for Medi-Cal payments for services
provided by FQHCs and RHCs in compliance with federal law,
changing from fee-for-service to a per-visit basis.
AB 1785 (Lowenthal, 2012), would have added MFTs to the list
of health care providers whose services are reimbursed through
Medi-Cal on a per-visit basis by FQHCs and RHCs. AB 1785 was
held on the Assembly Appropriations suspense file.
4)Support. This bill is sponsored by the California Primary Care
Association (CPCA), which writes that this bill will help
FQHCs and RHCs better provide integrated behavioral health
AB 858 (Wood) Page 10 of ?
services to patients by allowing reimbursement for mental
health services provided on the same day as medical services.
CPCA states that, while California's State Plan and Medi-Cal
Provider Manual will permit FQHCs and RHCs to be reimbursed
for same-day medical and dental services, mental health
services are excluded. Federal Medicare law permits
reimbursement for same-day medical and mental health visits
and for federal matching funds to be provided for states that
choose to allow same-day visits. California, however, does not
take advantage of these federal funds. Changing the state
reimbursement system to allow for payment for same day medical
and mental health visits will increase the ability of FQHCs
and RHCs to provide the most effective services to patients.
CPCA argues that adding MFTs to the list of billable providers
will solve existing gaps in workforce capacity by providing
FQHCs with an adequate source of funding for their employment,
and would help to meet the demand for mental health services
in the public health care setting.
5)Support if amended. The National Association of Social
Workers-California Chapter (NASW-CA) writes it would support
this bill if it were amended as it opposes adding MFTs within
the list of billable providers. 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. In addition,
NASW-CA argues this change is unnecessary as there is a
sufficient workforce of unemployed social workers and LCSWs
that can fill positions if they become available, and through
existing new graduates of schools of social work. Finally,
NASW-CA argues this bill could be very costly for each FQHC to
recalculate their PPS rate and it believes this bill is
costly, unnecessary and ill-timed as DHCS and other interested
parties have proposed a different payment methodology for
clinics.
SUPPORT AND OPPOSITION :
Support: California Primary Care Association (sponsor)
AIDS Project Los Angeles Health and Wellness
Alameda Health Consortium
AltaMed Health Services
Arroyo Vista Family Health Center
Asian Pacific Health Care Venture, Inc.
Association of California Healthcare Districts
AB 858 (Wood) Page 11 of ?
California Association of Marriage and Family
Therapists
California Association of Rural Health Clinics
California Chapter of the American College of
Emergency Physicians
California Children's Hospital Association
California Consortium for Urban Indian Health
California Medical Association
California School-Based Health Alliance
California State Association of Counties
Clinica Sierra Vista
Clinica Sierra Vista - Elm Community Health Center
Coalition of Orange County Community Health Centers
Community Clinic Association of Los Angeles County
Community Clinic Consortium
Community Health Partnership
County Behavioral Health Directors Association
Family Health Centers of San Diego
Health Alliance of Northern California
Health Officers Association of California
Hill Country Community Clinic
Inland Behavioral and Health Services, Inc.
Kheir Center
L.A. Care Health Plan
Los Angeles LGBT Center
Mendocino Coast Clinics, Inc.
Mission Neighborhood Health Center
Mountain Valleys Health Centers
North County Health Services
North East Medical Services
North Orange County Regional Health Foundation
Northeast Valley Health Corporation
Omni Family Health
Pomona Community Health Center
Redwood Community Health Coalition
Saban Community Clinic
San Francisco Community Clinic Consortium
San Ysidro Health Center
Santa Clara County Board of Supervisors
Santa Cruz Community Health Centers
Shasta Community Health Center
T.H.E. Health and Wellness Center
The Children's Clinic
The Glide Foundation
Tiburcio Vasquez Health Center, Inc.
AB 858 (Wood) Page 12 of ?
Valley Community Healthcare
Watts Healthcare Corporation
Western Sierra Medical Clinic
White Memorial Community Health Center
Oppose: None received.
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