BILL ANALYSIS                                                                                                                                                                                                    



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 1231             
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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: nonmedical transportation.

         SUMMARY  :1. Adds nonmedical transportation as a Medi-Cal benefit for a  
          beneficiary to obtain covered specialty care Medi-Cal services,  
          if those services are more than 60 minutes or 30 miles from the  
          beneficiary's place of residence.
        
          Existing law:
          1)Establishes the Medi-Cal program, administered by the  
            Department of Health Care Services (DHCS), under which  
            qualified low-income individuals receive health care services.

          2)Establishes a schedule of benefits under the Medi-Cal program,  
            which includes medical transportation services, subject to  
            utilization controls, and in-home medical care services when  
            medically appropriate and subject to utilization controls, for  
            beneficiaries who would otherwise require care for an extended  
            period of time in an acute care hospital at a cost higher than  
            in-home medical care services. Included within the definition  
            of in-home medical care services are emergency and  
            nonemergency medical transportation
          
          This bill:
          1)Adds nonmedical transportation (NMT) as a Medi-Cal benefit for  
            a beneficiary to obtain covered specialty care Medi-Cal  
            services, if those services are more than 60 minutes or 30  
            miles from the beneficiary's place of residence.

          2)Defines NMT to include, but not be limited to, roundtrip  
            transportation for a beneficiary to obtain covered specialty  
            care Medi-Cal services by passenger car, taxicab, or any other  
            form of public or private conveyance, mileage reimbursement  
            for conveyance by private vehicle, bus passes, taxi vouchers,  







          AB 1231 (Wood)                                      Page 2 of ?
          
          
            or train tickets. 

          3)Excludes from the definition of NMT the transportation of  
            sick, injured, invalid, convalescent, infirm, or otherwise  
            incapacitated beneficiaries by ambulances, litter vans, or  
            wheelchair vans licensed, operated and equipped in accordance  
            with state and local statutes, ordinances or regulations. 

          4)Requires NMT to be provided in a form and manner that is  
            accessible, in terms of physical and geographic accessibility,  
            for the beneficiary, and consistent with policies and  
            procedures established for a beneficiary with a disability.

          5)States legislative intent in enacting this bill to affirm the  
            requirement under a specified provision of federal regulation  
            in which DHCS is required to ensure necessary transportation  
            for recipients to and from providers. 

          6)Prohibits this bill from being interpreted to add a new  
            benefit to the Medi-Cal program.

          7)Permits DHCS to seek approval of any necessary state plan  
            amendments to implement this bill.

          8)Requires this bill to be implemented only to the extent that  
            federal financial participation is available and any necessary  
            federal approvals have been obtained.

           FISCAL  
          EFFECT  :  According to the Assembly Appropriations Committee,  
          unknown cost pressure, potentially in the range of $1 million in  
          Medi-Cal managed care, and low hundreds of thousands in direct  
          costs in fee-for-service (FFS) Medi-Cal annually (General  
          Fund/majority federal). Due to data limitations this estimate is  
          fairly rough, it assumes a small percentage of rural Medi-Cal  
          enrollees receives transportation services each year for a  
          single specialty visit; is based on 20,000 additional transports  
          in managed care, and 5,000 in FFS annually at a cost of $50 per  
          transport.  The cost of mandating NMT as a covered benefit in  
          Medi-Cal depends on several factors, which are in turn subject  
          to significant uncertainty and change. Some additional cost  
          dynamics and cost offsets are described below:

          1)To the extent better access to transportation increases  
            utilization of specialty care services, additional unknown  








          AB 1231 (Wood)                                      Page 3 of ?
          
          
            costs in FFS and cost pressure on managed care rates for more  
            specialty care visits. These increased costs for specialty  
            care would be offset to some extent by cost savings from  
            better management of chronic conditions, fewer complications,  
            and reduced emergency room use.


          2)Managed care plans, as well as the DHCS, are likely to  
            experience some administrative costs to institute policies and  
            procedures to ensure coverage complies with the defined  
            standards.


          3)The actual impact on managed care rates from the potential  
            increased cost pressure identified here is unknown and may  
            depend in part on how it compares to what plans currently  
            provide.


          4)Since the coverage of NMT is only available for visits that  
            meet a certain time/distance standard, to the extent provider  
            networks in both managed care plans and FFS Medi-Cal grow more  
            robust, the demand for transportation services would decrease.  
            The inverse is also true; if networks grew more sparse, demand  
            for transportation would increase based on a higher likelihood  
            that visits meet the defined standard.


          5)Utilization of transportation services for specialty visits,  
            and corresponding costs, could also vary dramatically based on  
            whether beneficiaries and providers know it is a covered  
            benefit, and how easy it is to access.



           PRIOR  
          VOTES  :  
          
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          |Assembly Floor:                     |76 - 0                      |
          |------------------------------------+----------------------------|
          |Assembly Appropriations Committee:  |17 - 0                      |
          |------------------------------------+----------------------------|
          |Assembly Health Committee:          |18 - 0                      |
          |                                    |                            |








          AB 1231 (Wood)                                      Page 4 of ?
          
          
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          COMMENTS  :
          1)Author's statement. According to the author, NMT, defined as  
            transportation of members to medical services by passenger car,  
            taxicabs, or other forms of public or private conveyances provided  
            by persons not registered as Medi-Cal providers, is only a covered  
            Medi-Cal benefit for children and Cal MediConnect beneficiaries.  
            Unfortunately, for all other beneficiaries, NMT is an optional  
            benefit that plans may provide. Although plans provide for this  
            service, beneficiaries report difficulty accessing this service  
            due to wide variances in policies and procedures. The Department  
            of Managed Health Care (DMHC), which licenses and oversees most  
            health plan and requires licensed health plans to comply with  
            network adequacy requirements, includes geographic access to care  
            requirements. DMHC has no geographic or timely access standards  
            for specialty care. AB 1231 ensures that low-income beneficiaries  
            in rural areas have access to transportation for their specialty  
            care needs.  The bill requires that NMT will be provided to  
            specialty care beneficiaries if those services are more than 60  
            minutes or 30 miles from the beneficiary's place of residence. 

          2)Background on Medi-Cal coverage of transportation. Medi-Cal  
            coverage of transportation services is governed by state and  
            federal law. Federal regulations require a state's Medicaid State  
            Plan to specify that the Medicaid agency will ensure necessary  
            transportation for recipients to and from providers, and to  
            describe the methods that the agency will use to meet this  
            requirement. California's Medicaid State Plan indicates California  
            provides both emergency and non-emergency medical transportation.  
            DHCS distinguishes between non-emergency medical transportation  
            (NEMT) and NMT. 

          NEMT is transport by ambulance, litter van, and wheelchair van  
            medical transportation when transport by ordinary means of public  
            or private conveyance is medically contraindicated, and  
            transportation is required for the purpose of obtaining needed  
            medical care. By contrast, NMT is transportation of members to  
            medical services by passenger car, taxicabs, or other forms of  
            public or private conveyances provided by persons not registered  
            as Medi-Cal providers. NMT does not include the transportation of  
            sick, injured, invalid, convalescent, infirm, or otherwise  
            incapacitated members by ambulances, litter vans, or wheelchair  
            vans licensed, operated and equipped in accordance with state and  
            local statutes, ordinances or regulations. 








          AB 1231 (Wood)                                      Page 5 of ?
          
          

            DHCS indicates NMT is covered for children under age 21  
            through the Early and Periodic Diagnosis and Treatment Program  
            (EPSDT), and for dually eligible beneficiaries enrolled in  
            CalMediConnect plans (plans that combine Medicare and Medi-Cal  
            benefits in one health plan, which operate in seven counties).  
            CalMediConnect beneficiaries receive up to 30 one-way trips  
            per year with no co-payment. 

            For Medi-Cal beneficiaries enrolled in Medi-Cal managed care  
            plans, 17 out of 21 plans DHCS surveyed reported having a  
            contracted network for NEMT, and the four health plans that  
            did not have a network were in the process of contracting with  
            a vendor or were utilizing only qualified Medi-Cal providers.

          3)Support. This bill is sponsored by the Western Center on Law  
            and Poverty (WCLP), which writes that this measure would   
            clarify that accessible nonmedical transportation is a covered  
            Medi-Cal benefit, including roundtrip transportation for  
            beneficiaries who must travel more than 60 minutes or 30 miles  
            from his/her residence to access specialty care. The time and  
            distance standard is based on the Department of Insurance's  
            specialty care service standards and is double the standards  
            DMHC has for primary care providers of 30 minutes or 15 miles.  


          WCLP argues access to transportation services is critical for  
            rural residents where distances to specialty care are  
            significant, public transport is scarce, and low-income  
            beneficiaries cannot afford the limited transportation options  
            available. Although transportation to and from health care  
            services is "assured" through California's Medicaid State  
            Plan, variation in implementation of this benefit leaves many  
            remaining questions regarding the basic availability and  
            criteria for getting such benefits. WCLP states that, for many  
            rural Medi-Cal beneficiaries seeing a specialist is not a  
            one-time trip, but multiple trips where time off work must be  
            requested, childcare needs to be arranged, rides from  
            relatives and friends must be scrounged, and financial  
            tradeoffs must be made. WCLP concludes that this issue is  
            exacerbated by the mandatory transition into managed care for  
            Medi-Cal consumers in 28 mostly rural counties who are  
            reporting farther travel distances to access medically needed  
            specialty services.
          








          AB 1231 (Wood)                                      Page 6 of ?
          
          
          4)Policy issues. 
             a)   Current utilization review requirements and this bill.  
               Current Medi-Cal coverage of transportation in Medi-Cal  
               statute is subject to utilization controls. Regulations  
               implementing utilization controls place greater requirement  
               on that benefit than the NMT required to be covered under  
               this bill. For example, ambulance, litter van and  
               wheelchair van medical transportation services are covered  
               only when the beneficiary's medical and physical condition  
               is such that transport by ordinary means of public or  
               private conveyance is medically contraindicated, and  
               transportation is required for the purpose of obtaining  
               needed medical care. In addition, Medi-Cal reimbursement is  
               required to be approved only for the lowest cost type of  
               medical transportation that is adequate for the patient's  
               medical needs, and all NEMT requires a physician's,  
               dentist's or podiatrist's prescription and prior  
               authorization (except for transfers from a hospital to a  
               skilled nursing facility). Finally, transportation is  
               required only to the nearest facility capable of meeting  
               the patient's medical needs. The requirement that NMT be  
               subject to utilization controls is not made explicit in  
               this bill. The author may wish to consider making this  
               benefit subject to utilization controls in the same way as  
               the existing Medi-Cal transportation benefit.

             b)   Implementation of benefit. The author may wish to  
               consider how DHCS would implement the benefit required by  
               this bill as regulations or a provider bulletin/all plan  
               letter would likely be needed to spell out the details of  
               the NMT benefit.

           SUPPORT AND OPPOSITION  :
          Support:  Western Center on Law and Poverty (sponsor)
                    American Federation of State, County and Municipal  
                    Employees
                    Asian Law Alliance
                    California Academy of Family Physicians
                    California Coverage and Health Initiatives, 
                    California Pan-Ethnic Health Network
                    California Primary Care Association
                    Children Now
                    Children's Defense Fund of California
                    Disability Rights California
                    Disability Rights Education & Defense Fund








          AB 1231 (Wood)                                      Page 7 of ?
          
          
                    First 5 Mendocino 
                    Health Access California
                    Justice in Aging
                    Legal Aid Society of San Diego, Inc.
                    Legal Services of Northern California
                    National Alliance on Mental Illness California
                    National Health Law Program
                    Project Inform
          
          Oppose:   None received.
                                      -- END --