BILL ANALYSIS                                                                                                                                                                                                    Ó






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                                   THIRD READING 


          Bill No:  AB 1231
          Author:   Wood (D)
          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: nonmedical transportation


          SOURCE:    Western Center on Law and Poverty

          DIGEST:   This bill adds nonmedical transportation as a Medi-Cal  
          benefit, subject to utilization controls and federally  
          permissible time and distance standards, for a beneficiary to  
          obtain covered Medi-Cal services.

          Senate Floor Amendments of 9/4/15 expand the scope of the  
          Medi-Cal nonmedical transportation (NMT) benefit in this bill by  
          eliminating the time and distance standards in this bill and  
          instead requiring the NMT benefit to be subject to federally  
          permissible time and distance standards. In addition, the  
          amendments expand the scope of the NMT benefit to beneficiaries  
          who need Medi-Cal services, instead of the NMT benefit being  
          limited to Medi-Cal beneficiaries who need specialty care  
          services in the current version of this bill. 








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          ANALYSIS:
          
          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 NMT as a Medi-Cal benefit, subject to utilization  
             controls and federally permissible time and distance  
             standards, for a Medi-Cal beneficiary to obtain covered  
             Medi-Cal services.

           2) Defines NMT to include, but not be limited to, roundtrip  
             transportation for a beneficiary to obtain covered 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, or  
             train tickets. 

           3) Requires the cost of NMT to be paid for a Medi-Cal  
             beneficiary who can attest in a manner to be specified by  
             DHCS that other available resources have been reasonably  
             exhausted.

           4) 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  







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             with state and local statutes, ordinances or regulations. 

           5) 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.

           6) 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. 

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

           8) Requires DHCS to seek any federal approvals necessary to  
             implement this bill that DHCS determines are necessary.  
             Prohibits this bill from being implemented until all  
             necessary federal approvals are obtained.

           9) Requires this bill to be implemented only to the extent that  
             federal financial participation is available and not  
             otherwise jeopardized and any necessary federal approvals  
             have been obtained.

           10)Permits DHCS without taking regulatory action, to implement,  
             interpret, or make specific this bill by means of all-county  
             letters, plan letters, plan or provider bulletins, or similar  
             instructions until the time regulations are adopted. Requires  
             DHCS to adopt regulations by July 1, 2017, and requires DHCS  
             to provide a status report to the Legislature on a semiannual  
             basis until regulations have been adopted.

          Comments
          
          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  







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          accessing this service due to wide variances in policies and  
          procedures. The Department of Managed Health Care (DMHC), which  
          licenses and oversees most health plans and requires licensed  
          health plans to comply with network adequacy requirements,  
          includes geographic access to care requirements. AB 1231 ensures  
          that low-income beneficiaries in rural areas have access to  
          transportation for their Medi-Cal care needs.  

          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. 

          DHCS indicates NMT is covered for children under age 21 through  
          the Early and Periodic Diagnosis and Treatment Program, 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  







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          vendor or were utilizing only qualified Medi-Cal providers.

          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No

          According to the Senate Appropriations Committee:

          1)One-time costs, likely about $150,000 to $300,000 for one to  
            two years to develop program requirements, amend the state's  
            Medicaid plan, and adopt regulations to implement this bill  
            (General Fund and federal funds).

          2)Ongoing costs of $1.5 million to $6.5 million to provide NMT  
            to Medi-Cal beneficiaries enrolled in Medi-Cal managed care  
            plans that do not already provide NMT as a covered benefit  
            (General Fund and federal funds). According to DHCS, 17 out of  
            21 Medi-Cal managed care plans already provide coverage for  
            NMT, covering between 50% and 70% of all existing Medi-Cal  
            managed care plan enrollees. DHCS estimates the annual cost  
            per member to provide NMT is between $0.50 and $2.00 per year.

          3)Ongoing costs of $1.5 million to $3.0 million per year to  
            provide coverage for NMT to Medi-Cal beneficiaries not  
            enrolled in Medi-Cal managed care. DHCS currently does not  
            provide coverage for NMT in the fee for service system (except  
            for children).

          4)Unknown impact on overall utilization of specialty health care  
            services in the Medi-Cal program (General Fund and federal  
            funds). By ensuring that Medi-Cal beneficiaries have access to  
            NMT to specialty care, this bill is likely to allow for  
            increased access to specialty care by Medi-Cal beneficiaries,  
            particularly those in rural areas of the state. This is likely  
            to increase utilization of those services. On the other hand,  
            timely access to specialty services may allow beneficiaries  
            and their providers to better manage serious medical  
            conditions, potentially reducing future needs for additional  
            specialty services or hospitalization. The net impact of these  
            factors is unknown.


          SUPPORT:   (Verified9/4/15)









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          Western Center on Law and Poverty (source)
          American Federation of State, County and Municipal Employees
          Asian Law Alliance
          California Academy of Family Physicians
          California Chapter of the National Association of Social Workers
          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
          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


          OPPOSITION:   (Verified9/4/15)


          Department of Finance


          ARGUMENTS IN SUPPORT:     This bill is sponsored by the Western  
          Center on Law and Poverty (WCLP), which writes that this bill  
          clarifies that accessible NMT is a covered Medi-Cal benefit.  
          WCLP argues access to transportation services is critical for  
          rural residents where distances to medical 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  







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          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.


          ARGUMENTS IN OPPOSITION:     The Department of Finance (DOF)  
          writes in opposition to a previous version of this bill as it  
          expands benefits in the Medi-Cal program and adds significant  
          additional General Fund costs that are not part of the 2015  
          Budget Act. DOF states this bill may also be unnecessary as many  
          Medi-Cal managed care plans already offer NMT to their enrolled  
          beneficiaries.

          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,  
            Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia,  
            Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray,  
            Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Kim,  
            Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,  
            Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte,  
            O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Rodriguez,  
            Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting,  
            Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins
          NO VOTE RECORDED:  Chávez, Grove, Jones-Sawyer, Ridley-Thomas

          Prepared by:Scott Bain / HEALTH / 
          9/8/15 15:00:01


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