BILL ANALYSIS Ó
AB 1863
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ASSEMBLY THIRD READING
AB
1863 (Wood)
As Amended May 27, 2016
Majority vote
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|Committee |Votes|Ayes |Noes |
| | | | |
| | | | |
| | | | |
|----------------+-----+----------------------+--------------------|
|Health |18-0 |Wood, Maienschein, | |
| | |Bonilla, Burke, | |
| | |Campos, Chiu, | |
| | |Dababneh, Gomez, | |
| | | | |
| | | | |
| | |Roger Hernández, | |
| | |Lackey, Olsen, | |
| | |Patterson, | |
| | | | |
| | | | |
| | |Ridley-Thomas, | |
| | |Rodriguez, Santiago, | |
| | |Steinorth, Thurmond, | |
| | |Waldron | |
| | | | |
|----------------+-----+----------------------+--------------------|
|Appropriations |19-0 |Gonzalez, Bigelow, | |
| | |Bloom, Bonilla, | |
| | |Bonta, Calderon, | |
AB 1863
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| | |Chang, Daly, Eggman, | |
| | | | |
| | | | |
| | |Eduardo Garcia, | |
| | | | |
| | | | |
| | |Roger Hernández, | |
| | |Holden, Jones, | |
| | |Obernolte, Quirk, | |
| | |Santiago, Wagner, | |
| | |Weber, Wood | |
| | | | |
| | | | |
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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 that
chooses to bill these services as a separate visit, 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.
FISCAL EFFECT: According to the Assembly Appropriations
Committee:
1)One-time costs, potentially in the millions, to recalculate
the 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
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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: 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.
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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.
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.
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.
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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: 1) when the
clinic patient, after the first visit, suffers illness or injury
requiring another diagnosis or treatment; or, 2) 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 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.
Analysis Prepared by:
Rosielyn Pulmano / HEALTH / (916) 319-2097 FN:
0003280