BILL ANALYSIS Ó
AB 1485
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Date of Hearing: April 28, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 1485
(Patterson) - As Amended April 21, 2015
SUBJECT: Medi-Cal: radiology.
SUMMARY: Prohibits the Department of Health Care Services
(DHCS) from using the location of a radiologist as a condition
of approving Medi-Cal provider enrollment or reimbursement for
radiology services provided to Medi-Cal beneficiaries undergoing
imaging procedures, if the radiologist meets requirements, as
specified. Specifically, this bill:
1)Makes the declaration this bill must not be considered a
precedent for other types of health care service providers
because the services performed by radiologists are provided to
attending physicians and not to patients, therefore they do
not supplant work performed by other California health care
providers.
2)Requires a radiologist to meet the following conditions for
Medi-Cal enrollment and reimbursement for radiology services,
when located outside of California:
a) Must be licensed in California;
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b) Must be enrolled and in good standing in the Medicaid
program for the state where the radiologist is located, in
Medicare, or in both programs;
c) The radiologist must be located in the United States;
d) The radiologist must satisfy all requirements for
enrollment and participation in the Medi-Cal program;
e) The radiologist must consent to Medi-Cal acting through
the state Medicaid program where the radiologist is located
and the Medicare program with respect to any issues
concerning the radiologist's enrollment or participation in
Medi-Cal; and,
f) The radiologist must consent to enrollment in Medi-Cal,
including, but not limited to, formal or informal
proceedings, as well as administrative, civil, and criminal
proceedings.
EXISTING LAW:
1)Establishes the Medi-Cal program under the direction of DHCS,
as California's Medicaid program, to provide qualifying
low-income individuals health care and a uniform schedule of
benefits.
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2)Allows DHCS to establish regulations, consistent with federal
Medicaid law, to provide for the care and treatment of persons
eligible for medical assistance by providers in another state
in those cases in which the out-of-state care or treatment is
rendered on an emergency case or is otherwise in the best
interests of the person.
3)Authorizes services to be provided to Medi-Cal beneficiaries
through telehealth and does not require in-person contact
between a provider and a beneficiary if the service is
appropriately provided through telehealth.
4)Prohibits a health insurer or health care service plan from
limiting the type of setting where services are provided for
the patient or by the health care provider before payment is
made for the covered services appropriately provided through
telehealth.
FISCAL EFFECT: This bill has not yet been analyzed by the
fiscal committee.
COMMENTS:
1)PURPOSE OF THIS BILL. The author states that high speed
broadband and the Internet are providing patients unparalleled
access to radiology subspecialists through national radiology
networks, which can within minutes provide expert analyses to
attending physicians, regardless of the location of the
patient or radiologist; however existing law governing
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Medi-Cal provider enrollment and reimbursement have not kept
pace with these innovations. The author argues that privately
insured and Medi-Cal managed care patients already benefit
from this unparalleled access to subspecialists and timely
accurate diagnoses and that Medi-Cal fee-for-service patients
should also have the opportunity to access this type of care.
The author concludes this bill will clarify existing law to
provide necessary statutory guidance for DHCS regarding
Medi-Cal provider enrollment and reimbursements for
radiologists.
2)BACKGROUND.
a) Telehealth. "Telehealth" is defined as the mode of
delivering health care services and public health via
information and communication technologies to facilitate
the diagnosis, consultation, treatment, education, care
management, and self-management of a patient's health care
while the patient is at the originating site and the health
care provider is at a distant site.
As California continues with full implementation of the
Patient Protection and Affordable Care Act, there has been
great concern from stakeholders throughout the state about
provider access to services. In an effort to ensure
quality services are provided to patients, health reform
policies have focused on innovative methods to adjust the
way delivery systems contract and pay for services.
Telehealth has received increased attention as it may serve
to improve access to care for the increasing number of
newly insured individuals. The California HealthCare
Foundation reports that health plans, providers, and
information technology vendors are currently effectively
using telehealth applications to increase quality of care,
reduce costs, and increase access for the underserved.
Studies have demonstrated telehealth services have improved
outcomes and continuity of care for patients, particularly
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in rural settings.
b) Examples of Medi-Cal coverage of telehealth include the
following:
i) Selected psychiatric diagnostic interview
examination and selected psychiatric therapeutic
services;
ii) Store and forward teledermatology and
teleophthalmology by "store and forward" (the
transmission of medical information to be reviewed at a
later time by a physician/optometrist at a distant site
who is trained in ophthalmology, optometry or dermatology
where the physician or optometrist at the distant site
reviews the medical information without the patient being
present in real time);
iii) Interpretation and report of X-rays and
electrocardiograms performed after telehealth
transmission.
While existing Medi-Cal law provides coverage for
telehealth services, another provision of Medi-Cal law and
regulation limits Medi-Cal coverage of out-of-state medical
care. Specifically, Medi-Cal covers necessary out-of-state
medical care only under the following conditions:
i) When an emergency arises from accident, injury, or
illness;
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ii) Where the health of the individual would be
endangered if care and services are postponed until it is
feasible that he or she return to California;
iii) Where the health of the individual would be
endangered if he or she undertook travel to return to
California;
iv) When it is customary practice in border communities
for residents to use medical resources in adjacent areas
outside of California; or,
v) When an out-of-state treatment plan has been
proposed by the beneficiary's attending physician, and
the proposed plan has been received, reviewed, and
authorized by DHCS before the services are provided.
DHCS can authorize such out-of-state treatment plans only
when the proposed treatment is not available from
resources and facilities within California.
Prior authorization is required for all out-of-state
services, except for emergency services and services
provided in border areas adjacent to California where it is
customary practice for California residents to avail
themselves of such services. No services are covered by
Medi-Cal outside the United States, except for emergency
services requiring hospitalization in Canada or Mexico.
California will not reimburse California licensed
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out-of-state physicians who seek to bill Medi-Cal for
telehealth services for fee-for-service beneficiaries.
These providers cannot be enrolled in Medi-Cal using their
out-of-state location practice location, or DHCS will deny
their applications. DHCS' denial letters state that
out-of-state medical care for Medi-Cal beneficiaries is
covered only when emergency services have been provided to
a Medi-Cal beneficiary traveling out-of-state. This
argument seems contrary to existing law which states a
health insurer or health care service plan is prohibited
from limiting the type of setting where services are
provided for the patient or by the health care provider
before payment is made for the covered services
appropriately provided through telehealth.
c) Standards of care. According to the Medical Board of
California (MBC), telehealth is seen as a tool in medical
practice, not a separate form of medicine. There are no
legal prohibitions to using technology in the practice of
medicine, as long as the practice is done by a California
licensed physician. The MBC specifies that telehealth is
not a telephone conversation, email/instant messaging
conversation, or fax; it typically involves the application
of videoconferencing or store and forward technology to
provide or support health care delivery. The MBC is also
clear that the standard of care is the same whether the
patient is seen in-person, through telehealth or other
methods of electronically enabled health care.
3)SUPPORT. Virtual Radiologic, the sponsor of the bill, states
that the bill is necessary to provide statutory guidance to
DHCS. The sponsor points to its experience working with DHCS;
in particular that DHCS has switched its position several
times in the last few years, making clear legislative guidance
necessary. Virtual Radiologic reports during some periods,
after receiving denial letters for Medi-Cal reimbursement and
provider enrollment, DHCS has subsequently rescinded denials,
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agreeing that technological advances in the delivery of
radiology services are consistent with existing law. Other
times, DHCS has denied such provider enrollment and
reimbursement requests.
4)OPPOSITION. The Union of American Physicians and
Dentists/AFSCME-Local 206 states this bill will allow
radiology services through the Medi-Cal program to patients
who live across state lines. The opposition states that this
practice would allow Medi-Cal dollars to be contracted to
out-of-state for-profit corporations, and will take away
employment opportunities and Medi-Cal dollars from state and
local economies.
5)RELATED LEGISLATION. AB 250 (Obernolte) clarifies that
Marriage and Family Therapist interns and trainees may provide
services via telehealth, under specified supervision, to gain
supervised hours required for licensure. AB 250 was heard by
the Assembly Business and Professions Committee on April 7,
2015 and passed out with a vote of 14-0. AB 250 is currently
in the Assembly Health Committee.
6)PREVIOUS LEGISLATION.
a) AB 1310 (Bonta) of 2014would have required a health care
provider located outside of California to meet specified
requirements as a condition for enrolling in the Medi-Cal
program for the purpose of providing telehealth services to
Medi-Cal beneficiaries receiving care in California. AB
1310 died in the Assembly Health Committee.
b) AB 415 (Logue), Chapter 547, Statutes of 2011,
establishes the Telehealth Advancement Act of 2011 to
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revise and update existing law to facilitate the
advancement of telehealth as a service delivery mode in
managed care and the Medi-Cal program.
c) AB 175 (Galgiani), Chapter 419, Statutes of 2010, for
the purposes of Medi-Cal reimbursement, expanded, until
January 1, 2013, the definition of "teleophthalmology and
teledermatology by store and forward" to include services
of an optometrist who is trained to diagnose and treat eye
diseases.
d) AB 1733 (Logue), Chapter 782, Statutes of 2012, updated
several code sections to replace the term "telemedicine"
with "telehealth" and expanded the potential for the use of
telehealth in additional health care programs administered
by DHCS, such as the Program of All-Inclusive Care for the
Elderly.
7)POLICY CONSIDERATIONS. The author and sponsor emphasize the
need for DHCS provider enrollment procedures to keep pace with
recent innovations within medical technology. Although the
language of this bill highlights increased access to provider
enrollment, regardless of location, for radiologists, this
bill is silent on other innovative forms of technology, which
include hospital-based telehealth (e.g. stroke care and care
in the intensive care unit), home and community-based care
(e.g. management of chronic care), and other ancillary
services (e.g. telepathology, telepharmacology,
teledermatology, etc.). The Committee may wish to consider
whether this bill is too narrow in scope by excluding all
forms of telehealth but teleradiology, and therefore requiring
future legislation to allow for new innovations in technology.
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8)TECHNICAL AMENDMENT. The intent language of the bill states
that this bill shall not be considered a precedent for other
types of health care service providers, because the services
performed by radiologists are provided to attending physicians
and not patients, and therefore they do not supplant the
employment of other California health care providers. This
language could be interpreted to suggest radiologists do not
currently provide services to patients at all, which is not
the intent of the author. The author's intent is to state
that these provisions will not lead to the supplanting of
in-state radiologists. The Committee may suggest the
following technical amendment to clarify the intent language:
a) Strike Section 14132.735(a).
b) Insert the following language:
(a) It is the intent of the Legislature that:
(1) This section shall not be a precedent for other
health care providers.
(2) Remotely located radiologists supplement, and do
not supplant, on-site radiologists as an integral part
of providing a high level of care in local
communities.
REGISTERED SUPPORT / OPPOSITION:
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Support
Virtual Radiologic (sponsor)
Association of California Healthcare Districts
Opposition
Union of American Physicians and Dentists/AFSCME-Local 206
Analysis Prepared by:An-Chi Tsou / HEALTH / (916) 319-2097