BILL ANALYSIS Ó
AB 1863
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Date of Hearing: April 6, 2016
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez, Chair
AB
1863 (Wood) - As Introduced February 10, 2016
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Urgency: No State Mandated Local Program: NoReimbursable: No
SUMMARY:
This bill adds marriage and family therapists (MFTs) to the list
of health care professionals whose services are reimbursed
through Medi-Cal on a per-visit basis to federally qualified
health centers (FQHC) or rural health clinics (RHCs), and
specifies procedures for adjusting rates for clinics who elect
to bill Medi-Cal.
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FISCAL EFFECT:
1)One-time costs, potentially in the millions, to recalculate
the prospective payment system (PPS) rate for clinics that are
providing MFT services or wish to add those services
(GF/federal). The bill requires clinics that currently include
marriage and family therapist services in the costs used to
calculate their PPS rate to seek a recalculation of the rate
to allow the clinic to bill for visits. Recalculating a PPS
rate requires a detailed review of utilization and
expenditures by clinics. For example, assuming the cost per
review is about $10,000 and 500 clinics seek a recalculation,
the administrative costs to the Department of Health Care
Services (DHCS) would be about $5 million.
2)No significant increase in costs is expected for the current
level of MFT services in eligible clinics. A clinic employing
MFTs may be able to bill for more face-to-face encounters, but
the PPS rate will be adjusted to account for those visits such
that there is no projected net cost impact.
3)On the other hand, if this bill increases access to mental
health services in Medi-Cal by increasing the ability of
clinics to employ qualified mental health professionals where
the supply previously was constrained, it could result in
unknown cost pressure to Medi-Cal to fund additional visits.
There are nearly 40,000 licensed MFTs in the state, as
compared to 22,000 LCSWs and 21,000 psychologists, suggesting
increased flexibility to hire MFTs could lead to better access
to mental health visits.
COMMENTS:
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1)Purpose. According to the author, Medi-Cal reimbursement for
MFTs will allow clinics to see more low-income patients in
need of mental health services. The author states that under
existing law, psychologists and licensed clinical social
workers (LCSWs) are employed by RHCs and FQHCs to provide
mental health services, and receive reimbursement through
Medi-Cal for that care. However, the author points out that
while a RHC or FQHC can employ an MFT, the lack of
reimbursement for the care provided to Medi-Cal patients acts
as a disincentive for hiring. This bill is sponsored by the
California Primary Care Association (CPCA).
2)Clinic Reimbursement. Because of their unique role in
providing health care to underserved communities and the
uninsured, policymakers have historically attempted to ensure
that community clinics remain financially viable. Federal law
requires federally funded health programs, including Medicaid
and Children's Health Insurance Program (CHIP), to pay clinics
using a special reimbursement structure commonly called a
prospective payment system (PPS). According to DHCS Form
3090, the Freestanding FQHC Cost Report Form, PPS rates are a
clinic-specific per-visit rate, and are calculated by dividing
costs for Medi-Cal-reimbursable services by Medi-Cal
reimbursable visits. PPS rates are also adjusted by a growth
rate to account for inflation. In addition, clinics can
request a recalculation of their PPS rates based on a change
in their scope of services. All clinics must provide at least
a defined scope of primary care and mental health services,
but may provide additional services as well. If clinics are
paid by managed care plans in amounts less than their PPS
rates, there is a reconciliation performed to ensure clinics
get paid the full PPS rate through a wrap-around payment paid
by DCHS. For Medi-Cal, current PPS rates vary from around $80
to over $650 per visit, depending on the mix of services
provided at each clinic.
3)Costs for MFT Services May Already Be Reflected in Base PPS
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Rate. Under current state law, an FQHC or RHC "visit" means a
face-to-face encounter between a patient and certain type of
health care provider defined in state law. A visit must be
documented in order for a clinic to be reimbursed. According
to DHCS, for clinics that provide MFTs within their approved
scope of service, MFT services are included in the
all-inclusive calculation of the PPS rate, but are not
separately billable.
For example, a patient could visit a clinic to receive a
medical check-up and be referred directly to an MFT employed
by the clinic for mental health services. According to DHCS,
MFT services rendered are reflected in the baseline PPS
cost-based rate as long as they are within the approved clinic
scope of service. At this time, however, a facility could not
receive reimbursement for an MFT visit without receiving other
services. This bill would allow such reimbursement.
4)FQHC Payment Reform. The PPS system has been criticized as
encouraging a higher volume of services rather than rewarding
quality and efficiency, as well as limiting innovation by
restricting provider types and care delivery settings. DHCS
and the CPCA, the sponsor of this bill, have been discussing
reforming the PPS methodology for several years. Chapter 760,
Statutes of 2015 (SB 147, Hernández) authorizes a three-year
payment reform pilot project for federally qualified health
centers (FQHCs) using an alternative payment methodology (APM)
authorized under federal Medicaid law, but not all clinics
will participate. Theoretically, if clinic payment methodology
was reformed on a permanent and statewide basis in a way that
allowed clinics complete flexibility to choose provider types,
a bill like this, specifying payment for a certain provider
type, would not be necessary. But although this possibility is
on the horizon, such a comprehensive change does not appear
imminent.
5)Support and Opposition. The National Association of Social
Workers-California Chapter (NASW-CA) opposes the bill because
they believe there is a sufficient workforce of social
workers, and only social workers have the training and skills
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necessary to treat this community. The California
Psychological Association is also opposed.
The bill is supported by California Association of Marriage
and Family Therapists, AIDS Project Los Angeles, and the
County Health Executives Association of California, in
addition to CPCA and a number of clinic organizations.
6)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.
7)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." The
author believes the fiscal outlook for Medi-Cal has
stabilized due to recent state actions and the veto message
is thereby addressed.
b) AB 690 (Wood) of 2015 was substantially similar to the
provisions of this bill. It was held in the Assembly
Appropriations suspense file when its provisions were
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merged with those of AB 858.
c) AB 1785 (Lowenthal) of 2012 was similar to this bill and
was held on the Suspense File of this committee.
d) AB 1445 (Chesbro) of 2009 was similar to AB 848 (Wood),
and was held on the Suspense File in the Senate
Appropriations Committee.
e) SB 260 (Steinberg) of 2007 was similar to AB 1445 and
was vetoed by Governor Schwarzenegger on budgetary
concerns.
Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081