BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 858|
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THIRD READING
Bill No: AB 858
Author: Wood (D), et al.
Amended: 9/4/15 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 9-0, 6/17/15
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,
Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/27/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
ASSEMBLY FLOOR: 76-0, 6/2/15 - See last page for vote
SUBJECT: Medi-Cal: federally qualified health centers and
rural health clinicsMedi-Cal: federally qualified
health centers and rural health clinics.
SOURCE: California Primary Care Association
California Association of Marriage and Family
Therapists
DIGEST: This bill 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 Federally Qualified Health Center
(FQHC) or Rural Health Clinic (RHC) for purposes of the per
visit Medi-Cal payment billed by FQHCs and RHCs.
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Senate Floor Amendments of 9/4/15 are "chaptering-out"
amendments, to ensure that the provisions of this bill, and the
provisions of SB 610 (Pan), in the case that both bills are
signed into law, do not chapter each other out.
ANALYSIS:
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. FQHC and 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
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
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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 multiple encounters with an MFT on the same day to
constitute a single visit.
4)Permits an FQHC or RHC that applies for a rate adjustment to
bill at its existing per visit rate until the rate adjustment
has been approved.
5)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.
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.
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. Continuing to treat various aspects of
health care as if they exist in silos does a disservice to
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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.
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)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.
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SB X1 1 (Hernandez and Steinberg, Chapter 4, Statutes of 2013)
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
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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 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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
1)One-time costs, likely in the low millions to recalculate the
prospective payment system (PPS) rate for clinics that are
providing MFT services or wish to add those services (General
Fund and federal funds). The bill requires clinics that are
currently including MFT 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 costs
to DHCS would be about $5 million.
2)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 FQHC and RHCs, 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.
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(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.)
SUPPORT: (Verified9/4/15)
AIDS Project Los Angeles Health and Wellness
Alameda Health Consortium
Alliance for Rural Community Health
AltaMed Health Services
Arroyo Vista Family Health Center
Asian Pacific Health Care Venture, Inc.
Association of California Healthcare Districts
Avenal Community Health Center
California Academy of Family Physicians
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 Division of the American Association for Marriage and
Family Therapy
California Medical Association
California School-Based Health Alliance
California State Association of Counties
Chapcare
Chinatown Service Center
Clinica Sierra Vista
Clinica Sierra Vista - Elm Community Health Center
Clinicas De Salud Del Pueblo
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
Harbor Community Clinic
Health Alliance of Northern California
Health Officers Association of California
Hill Country Community Clinic
Imperial Beach Community Clinic
Inland Behavioral and Health Services, Inc.
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Kheir Center
L.A. Care Health Plan
Los Angeles LGBT Center
Marin City Health and Wellness Clinic
Mendocino Coast Clinics, Inc.
Mission Neighborhood Health Center
Mountain Valleys Health Centers
Neighborhood Healthcare
North Coast Clinics Network
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
Sacramento Native American Health Center
San Diego American Indian Health Center
San Francisco Community Clinic Consortium
San Ysidro Health Center
Santa Clara County Board of Supervisors
Santa Cruz Community Health Centers
Santa Rosa Community Health Centers
Shasta Community Health Center
South of Market Health Center
St. John's Well Child and Family Center
T.H.E. Health and Wellness Center
The Children's Clinic
The Glide Foundation
Tiburcio Vasquez Health Center, Inc.
UMMA Community Clinic
Valley Community Healthcare
Venice Family Clinic
Watts Healthcare Corporation
Western Sierra Medical Clinic
White Memorial Community Health Center
OPPOSITION: (Verified9/4/15)
California Chapter of the National Association of Social Workers
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ARGUMENTS IN 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 services to patients by 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.
ARGUMENTS IN OPPOSITION: The National Association of Social
Workers-California Chapter (NASW-CA) writes in opposition that
this bill is unnecessary as there are sufficient numbers of
unemployed social workers that can fill these positions and
California schools of social work graduate approximately 10,000
bachelors and master's degree social workers each year. In
addition, 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. 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.
ASSEMBLY FLOOR: 76-0, 6/2/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd,
Frazier, Beth Gaines, Gallagher, Cristina Garcia, Gatto,
Gipson, Gomez, Gonzalez, Gordon, Gray, Hadley, Harper, Roger
Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey,
Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes,
McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte,
O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon,
Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark
Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams,
Wood, Atkins
NO VOTE RECORDED: Chávez, Eggman, Eduardo Garcia, Grove
Prepared by:Scott Bain / HEALTH /
9/8/15 17:19:43
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