BILL ANALYSIS Ó
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
AB 858 (Wood) - Medi-Cal: federally qualified health centers
and rural health clinics
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|Version: July 1, 2015 |Policy Vote: HEALTH 9 - 0 |
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|Urgency: No |Mandate: No |
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|Hearing Date: July 6, 2015 |Consultant: Brendan McCarthy |
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This bill meets the criteria for referral to the Suspense File.
Bill
Summary: AB 858 would add marriage and family therapists (MFTs)
to the list of health care providers that qualify for
face-to-face encounter payments from the Medi-Cal program to
federally qualified health centers and rural health clinics.
Fiscal
Impact:
One-time costs, likely in the low millions to recalculate the
prospective payment system (PPS) rate for clinics that are
providing marriage and family therapist services or wish to
add those services (General Fund and federal funds). The bill
requires clinics that are currently including marriage and
family therapist services in the costs used to calculate their
PPS rate to seek a recalculation of the rate to allow the
clinic to bill for face-to-face visits. The process for
recalculating a PPS rate requires a detailed review of
utilization and expenditures by clinics. For example, assuming
that the cost of performing such a review is about $10,000 and
that 500 clinics seek a recalculation, the administrative
AB 858 (Wood) Page 1 of
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costs to the Department of Health Care Services would be about
$5 million.
No significant increase in costs is expected for MFT services
in eligible clinics. Under the current system for calculating
the PPS rate paid by Medi-Cal to federally qualified health
centers and rural health clinics, the total amount of eligible
services (including mental health services) provided to
Medi-Cal beneficiaries is divided by the number of eligible
face-to-face visits (e.g. a visit with a physician or clinical
psychologist). Because the bill requires a recalculation of
the PPS to account for the fact that MFTs would be eligible
for face-to-face billing before a clinic can bill for such an
encounter, the Medi-Cal program is not expected to pay more
for services currently being provided. (In other words, a
clinic employing MFTs would be able to bill for more
face-to-face encounters, but the PPS rate would be lower to
account for those visits.)
Background: Under current law, the Medi-Cal program provides health care
coverage for certain low income and disabled individuals.
In the Medi-Cal fee-for-service system, federally qualified
health centers and rural health clinics are paid a per-visit
payment known as the prospective payment system (PPS). The PPS
rate is based on a baseline rate that reflects a federally
qualified health center's costs to provide services to in
1999-2000, adjusted for inflation. Those costs include the costs
of eligible face-to-face visits (e.g. with a physician) and
other services provided to Medi-Cal beneficiaries that are not
eligible for billing as a face-to-face visit (e.g. visits with a
registered nurse). When a Medi-Cal beneficiary in the managed
care system receives care from a federally qualified health
center, the managed care plan makes a per-visit payment to the
center. Because the rates paid by managed care plans are
significantly below the PPS rate, the state makes a supplemental
"wrap-around" payment to the federally qualified health center
to bring the total payment up to the PPS rate.
Under current law, clinics may bill Medi-Cal for face-to-face
visits with several categories of health professionals,
including physicians, nurse practitioners, clinical social
workers, and others. Clinics cannot bill for face-to-face visits
AB 858 (Wood) Page 2 of
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with MFTs. However, the cost to provide services to Medi-Cal
beneficiaries by MFTs can be included in the calculation of the
PPS rate. (MFTs were added as eligible providers of psychology
services in the Medi-Cal program beginning in 2014.)
Proposed Law:
AB 858 would add marriage and family therapists (MFTs) to the
list of health care providers that qualify for face-to-face
encounter payments from the Medi-Cal program to federally
qualified health centers and rural health clinics.
The bill would require a federally qualified health center or a
rural health clinic that currently includes the cost of MFT
services in its PPS rate to seek a recalculation of the PPS rate
by the Department of Health Care Services. Once the rate
adjustment has been approved, the bill would authorize an
eligible clinic to bill for those services as a separate visit.
The bill would require a federally qualified health center or a
rural health clinic that does not currently provide services by
MFTs that wants to add such services to do so by making a change
in scope of service (which requires a recalculation of the PPS
rate).
Related
Legislation:
AB 690 (Wood) was substantially similar to this bill in its
current form. The provisions of that bill were amended into
this bill and AB 690 was held on the Assembly Appropriations
Committee's Suspense File.
SB 147 (Hernandez) would authorize a pilot project under which
participating federally qualified health centers and rural
health clinics would be paid a capitated, per member per month
payment rather than encounter based PPS rate payments. That
bill is pending in the Assembly.
Staff
AB 858 (Wood) Page 3 of
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Comments: This bill formerly included provisions authorizing a
federally qualified health center or a rural health clinic to
bill for a mental health visit on the same day as another visit.
Those provisions of the bill were removed in the recently
adopted amendments.
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