BILL ANALYSIS Ó
AB 1863
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Date of Hearing: March 29, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 1863
(Wood) - As Introduced February 10, 2016
SUBJECT: Medi-Cal: federally qualified health centers: rural
health centers.
SUMMARY: Adds marriage and family therapists (MFTs) to the list
of healthcare professionals that qualify for a face-to-face
encounter with a patient at Federally Qualified Health Centers
(FQHCs) or Rural Health Clinics (RHCs) for purposes of a
per-visit Medi-Cal payment under the prospective payment system
(PPS). Makes conforming changes, including requiring an FQHC or
an RHC that includes the costs of the services of an MFT to
apply for an adjustment to its per-visit rate; that multiple
encounters with an MFT on the same day constitutes a single
visit; adjustment of rates; and, change in scope of service
requirements.
EXISTING LAW:
1)Establishes the Medi-Cal program to provide comprehensive
health benefits to low-income persons administered by the
Department of Health Care Services (DHCS).
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2)Establishes a statutory structure for Medi-Cal payments being
made under the PPS. These payments are for services provided
by FQHCs and RHCs on a per-visit basis with rates determined
prospectively. Federal law requires states to use a PPS
system to pay clinics.
3)Identifies those services that may be reimbursed as services
identified in federal law as covered benefits for FQHCs and
RHCs.
4)Defines visit as a face to face encounter with a physicians,
physician assistant, nurse practitioner, certified nurse
midwife, clinical psychologist, licensed clinical social
worker, visiting nurse, osteopath, podiatrist, dentist, dental
hygienists, optometrist, chiropractor, comprehensive perinatal
services practitioner, or adult day health care center.
Authorizes other providers if identified in the state plan.
5)Allows only one visit per day to be reimbursed by Medi-Cal,
except for a subsequent visit by a patient to a dental
provider.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
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COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, psychologists
and licensed clinical social workers are currently employed by
RHCs and FQHCs and these clinics receive reimbursement for
these providers. While clinics may employ an MFT, there is
not a reimbursement mechanism for these professionals, which
creates a disincentive to hire MFTs. MFTs are billable and
recognized providers under the Medi-Cal program but not in
community settings. Within the primary care setting, up to
26% of patients have some mental health disorder. This
measure brings parity throughout the Medi-Cal program and
allows for the utilization of all qualified mental health
providers, regardless of how or where the treatment is
provided.
2)BACKGROUND.
a) FQHCs and RHCs. FQHCs and RHCs serve a significant
portion of the uninsured and underinsured in California.
They are open-door providers that treat patients on a
sliding scale fee structure and make their services
available regardless of a patient's ability to pay. There
are approximately 600 FQHCs and 350 RHCs in California.
All FQHCs, and a majority of the RHCs, are either
non-profit community clinics or government entities.
Because clinics are safety net providers, their continued
survival depends heavily on the stability and adequacy of
revenues from the Medi-Cal program. FQHCs and RHCs are
paid by Medi-Cal on a "per visit" basis in an amount equal
to the clinic's cost of delivering services. Essentially,
DHCS calculates the annual cost of care provided by each
clinic and divides the total by the number of visits to
determine a per visit rate.
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Community clinics and health centers provide health care to
14% of Californians. This figure is even higher in rural
or remote areas that struggle to attract and retain health
care providers. Mental health and substance abuse services
are part of the essential health care benefits under the
Patient Protection and Affordable Care Act (ACA). As such
they are a part of Medi-Cal. Along with the expansion of
these benefits, the expansion of the Medi-Cal program
overall has increased the number of beneficiaries to over
12 million, placing even greater demands on Medi-Cal
providers.
b) Medi-Cal Reimbursement to FQHCs and RHCs. 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.
c) Same day visits. DHCS' policy on same day visits, as
stated in its in its State Plan Amendment, is that
encounters with more than one health professional and/or
multiple encounters with the same health professional,
which take place on the same day and at a single FQHC or
RHC location, constitute a single visit, except that more
than one visit may be counted on the same day: i) when the
clinic patient, after the first visit, suffers illness or
injury requiring another diagnosis or treatment; or, ii)
when the clinic patient has a face-to-face encounter with a
dentist or dental hygienist and then also has a
face-to-face encounter with another health professional or
comprehensive perinatal services practitioner on the same
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date. Mental health visits are treated for Medi-Cal
billing purposes as a same day visit, and separate billing
on the same day for a medical visits and a mental health
visit is not allowed.
3)SUPPORT. The California Primary Care Association, the sponsor
of this measure, and the Association of California Healthcare
Districts state that as part of the implementation of the ACA,
mental health and substance use disorder services were deemed
an essential health benefit for Medi-Cal managed care plans.
Recognizing the workforce shortage of personnel able to meet
the demand for mental health services created by expanded
health insurance coverage, California updated the State Plan
to include MFTs as Medi-Cal mental health providers. However,
existing law to allow FQHCs and RHCs to bill for the services
of MFTs was not changed. The inclusion of MFTs will address a
serious gap in behavioral health care access and increase
cultural competency and diversity of California's workforce.
The North Coast Clinics Network points out that investing in
preventive behavioral health services in the primary care
setting is essential in linking patients to services in a
timely manner while lowering the total cost of care.
4)OPPOSITION. The National Association of Social Workers,
California Chapter, believe this bill is unnecessary as there
are sufficient social workers to fill the positions needed and
only social workers have extensive training in providing
culturally competent services to disadvantaged and
impoverished communities.
5)RELATED LEGISLATION. SB 1335 (Mitchell), pending in Senate
Health Committee, authorizes FQHCs and RHCs to elect to have
Drug Medi-Cal and specialty mental health services to be
reimbursed on a fee-for-service basis, according to the same
criteria that applies to pharmacy and dental services.
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6)PREVIOUS LEGISLATION.
a) AB 858 (Wood) of 2015 included a similar provision
adding MFTs to the list of healthcare professionals that
could bill Medi-Cal for purposes of an FQHC or RHC visit.
SB 858 and five other bills were vetoed by Governor Brown
who indicated that
such "bills unnecessarily codify certain existing health care
benefits or require the expansion or development of new
benefits and procedures in the Medi-Cal program. Taken
together, these bills would require new spending at a time
when there is considerable uncertainty in the funding of
this program. Until the fiscal outlook for Medi-Cal is
stabilized, I cannot support any of these measures."
b) AB 690 (Wood) of 2015 was substantially similar to the
provisions of this bill but was held in the Assembly
Appropriations suspense file.
c) SB 260 (Steinberg) of 2007 was substantially similar to
this bill. SB 260 was vetoed by Governor Schwarzenegger
who cited concerns about the fiscal impact of the bill.
7)POLICY COMMENT. Last year, the Governor vetoed AB 858 (Wood)
which included similar provisions contained in this bill. The
author points out that the Governor's veto message of AB 858
cited the instability of the Medi-Cal Program last year.
Following the resolution of the Managed Care Organization tax
this year and the renewed stability of the Medi-Cal system,
the author believes that the Governor will accept the changes
that are being proposed in this measure.
REGISTERED SUPPORT / OPPOSITION:
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Support
California Primary Care Association (sponsor)
California Association of Marriage and Family Therapists
AIDS Project Los Angeles
Association of California Healthcare Districts
Community Clinic Association of Los Angeles County
County Health Executives Association of California
North Coast Clinic Network
Open Door Community Health Centers
Opposition
California Psychological Association
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National Association of Social Workers, California Chapter
Analysis Prepared by:Rosielyn Pulmano / HEALTH / (916) 319-2097