BILL ANALYSIS Ó
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 |
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|Assembly Appropriations Committee: |17 - 0 |
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|Assembly Health Committee: |18 - 0 |
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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.
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