BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1863
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|AUTHOR: |Wood |
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|VERSION: |May 27, 2016 |
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|HEARING DATE: |June 22, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medi-Cal: federally qualified health centers: rural
health centers
SUMMARY : Adds marriage and family therapists to the list of healthcare
professionals that qualify for a face-to-face encounter with a
patient at Federally Qualified Health Centers or Rural Health
Clinics for purposes of a per-visit Medi-Cal payment under the
prospective payment system.
Existing law:
1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health care coverage for low-income individuals.
Federally Qualified Health Center (FQHC) and Rural Health
Clinic (RHC) services are covered benefits under the Medi-Cal
program.
2)Requires FQHCs and RHCs to be reimbursed on a per-visit basis.
Defines a "visit" as a face-to-face encounter between an FQHC
or RHC patient and the following health care providers: a
physician, physician assistant, nurse practitioner, certified
nurse midwife, clinical psychologist, licensed clinical social
worker, visiting nurse, podiatrist, dentist, optometrist,
chiropractor, comprehensive perinatal services practitioner
providing comprehensive perinatal services, a four-hour day of
attendance at an Adult Day Health Care Center; and, any other
provider identified in the state plan's definition of an FQHC
or RHC visit. The reimbursement structure for FQHCs and RHCs
is known as the prospective payment system (PPS).
3)Requires FQHC and RHC per-visit rates to be increased by the
Medicare Economic Index (MEI) applicable to primary care
services in the manner provided for in federal law.
AB 1863 (Wood) Page 2 of ?
4)Permits FQHC or RHC to apply for an adjustment to its
per-visit rate based on a change in the scope of services
provided by the FQHC or RHC. Requires rate changes based on a
change in the scope of services provided by an FQHC or RHC to
be evaluated in accordance with Medicare reasonable cost
principles.
This bill:
1)Adds marriage and family therapists (MFTs) to the list of
health care professionals that qualify for a face-to-face
encounter with a patient at FQHCs or RHCs for purposes of a
per-visit Medi-Cal payment under the PPS.
2)Requires, if an FQHC or RHC that currently includes the cost
of the services of a MFT for the purposes of establishing its
FQHC or RHC rate and chooses to bill these services as a
separate visit, the FQHC or RHC to apply for an adjustment to
its per-visit PPS rate. Requires the FQHC or RHC, after the
rate adjustment has been approved by DHCS, to bill these
services as a separate visit.
3)Permits an FQHC or RHC that applies for an adjustment to its
PPS rate to continue to bill for all other FQHC or RHC visits
at its existing per-visit rate, subject to reconciliation,
until the rate adjustment for visits between an FQHC or RHC
patient and a MFT has been approved.
4)Requires any approved increase or decrease in the provider's
PPS rate to be made within six months after the date of
receipt of DHCS' rate adjustment forms and to be retroactive
to the beginning of the fiscal year in which the FQHC or RHC
submits the request, but in no case the effective date be
earlier than January 1, 2008.
5)Requires an FQHC or RHC that does not provide MFT services,
and later elects to add these services and to bill for these
services as a separate visit to process the addition of these
services as a change in scope of service.
6)Requires multiple encounters with MFTs that take place on the
same day to constitute a single visit.
7)Modifies existing law FQHC and RHC dental hygienist in
alterative practice provisions when the FQHC and RHC currently
AB 1863 (Wood) Page 3 of ?
includes the cost of the services of a dental hygienist in
alternative practice in its FQHC or RHC rate by requiring the
FQHC or RHC to apply for an adjustment to its per-visit rate
if the FQHC or RHC chooses to bill these services as a
separate visit.
8)Modifies existing law FQHC and RHC provisions that require an
FQHC or RHC that does not provide dental hygienist in
alternative practice services, and later elects to add these
services to process the addition of those services as a change
in scope of service if the FQHC and RHC bills these services
as a separate visit.
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 MFT 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 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.
AB 1863 (Wood) Page 4 of ?
PRIOR
VOTES :
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|Assembly Floor: |78 - 1 |
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|Assembly Appropriations Committee: |19 - 0 |
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|Assembly Health Committee: |18 - 0 |
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COMMENTS :
1)Author's statement. According to the author, as part of
California's implementation of the Affordable Care Act (ACA),
mental health and substance abuse disorder services were
deemed an essential health benefit for Medi-Cal managed care
plans. Along with the expansion of behavioral health benefits
for Medi-Cal beneficiaries, there has been an extensive
enrollment expansion as well. Within the primary care setting,
up to 26% of patients have some mental health disorder. One in
seven Californians are served by community clinics and health
centers (CCHCs) and behavioral health services are available
onsite at CCHCs in 50 of California's 58 counties. It is
essential we maximize availability to qualified mental health
providers and assure access is offered in key areas served
primarily by rural health clinics and FQHCs. As of February
2012, there were 31,865 licensed MFTs in California, and
19,009 LCSW and 16,228 licensed psychologists. Adding MFTs to
the list of PPS billable providers will solve existing gaps in
workforce capacity by providing clinics with an adequate
source of funding for their employment, which will also help
meet the demand for mental health services, particularly in
rural communities.
2)Background on FQHCs and RHCs. FQHCs and RHCs are federal
designated clinics that are required to serve medically
underserved populations that provide primary care services.
FQHCs and RHCs provided over 10.5 million Medi-Cal visits in
2013. Demand for Medi-Cal services is expected to increase due
to the expansion of Medi-Cal eligibility as a result of the
Medicaid expansion and the enrollment simplification
provisions of the federal ACA.
Medi-Cal reimbursement to FQHCs and RHCs is governed by state
AB 1863 (Wood) Page 5 of ?
and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on
a per-visit rate which is known as the PPS. Each FQHC and RHC
has a specific PPS Medi-Cal rate for each face-to-face
encounter, irrespective of the reason for the visit. 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.
FQHCs and RHCs are both reimbursed under the PPS system. The
average ($178.14) and median ($157.24) PPS rate paid to an
FQHC and RHC in 2014-15 is considerably higher than the most
common primary care visit reimbursement rates in Medi-Cal, but
it also includes additional services not included in a primary
care visit. The rationale for the enhanced reimbursement is to
ensure that FQHCs and RHCs do not use federal grant funds
intended for uninsured and special needs populations to
back-fill for potentially below-cost Medicare or Medi-Cal
rates. Because FQHCs are required to receive an MEI adjustment
to their rates under federal law, and because of their role in
providing primary care access to the Medi-Cal population,
FQHCs have been exempted from the Medi-Cal rate reductions
enacted in prior budget years.
3)Recent Changes in Medi-Cal Coverage for Mental Health and
Substance Use Services. Mental health and substance use
disorder services in Medi-Cal have been significantly changed
since the implementation of the ACA.
SB X1 1 (Hernandez and Steinberg, Chapter 4, Statutes of 2013)
required Medi-Cal to cover the additional mental and substance
use disorder benefits for both the newly eligible expansion
population and the current Medi-Cal population. SB X1 1
requires mental health services included in the essential
health benefit (EHB) package adopted by the state (the
Legislature adopted the Kaiser Small Group Product [Kaiser
Product] as the state's EHB for the individual and small group
health insurance market last session) to be covered under
Medi-Cal, to the extent those services are not covered Medi-Cal
benefits now. The additional mental health benefits required to
be provided include group therapy and psychology (for
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non-specialty mental health program qualifying individuals). In
addition, SB X1 1 required Medi-Cal to provide coverage for
additional substance abuse disorder services included in the
EHB adopted by the state. The additional substance use disorder
services provided include:
a) Intensive Outpatient Treatment (Day Care
Rehabilitation) - For non-pregnant/postpartum
beneficiaries (only pregnant women were eligible for this
service under Drug Medi-Cal prior to this change);
b) Residential Substance Use Disorder Services - For
non-pregnant/postpartum beneficiaries (only pregnant women
were eligible for this service under Drug Medi-Cal prior
to this change); and,
c) Elective Inpatient Detox - This benefit was made
broadly available (prior to this change, individuals had
to have an underlying physical medical condition in order
to receive inpatient detoxification services).
SB X1 1 also required Medi-Cal managed care plans to provide
coverage for "mild to moderate" mental health benefits covered
in the state plan, except for those benefits provided by county
mental health plans under the Specialty Mental Health Services
Waiver. Under the previous system, Medi-Cal managed care plans
covered mental health services within the scope of practice of
a primary care physician under their contracts with DHCS, while
county specialty mental health plans provided mental health
services to individuals with severe mental illness, and
Medi-Cal fee-for-service provided services to individuals who
fell between those two plans. SB X1 1 effectively provided
mid-level mental health services through the Medi-Cal managed
care plan, instead of in fee-for-services, resulting in more
coordinated care and better access to services.
In 2014, DHCS received federal approval of State Plan Amendment
(SPA) 14-012, which allowed MFTs to be providers of psychology
services under Medi-Cal. In addition, registered MFT interns,
registered associate clinical social workers and psychology
assistants were added as providers of psychology services under
the direction of a licensed mental health professional within
their scope of services. The SPA was approved May 2, 2014 with
an effective date of January 1, 2014.
AB 1863 (Wood) Page 7 of ?
1)Related legislation. SB 1335 (Mitchell), authorizes FQHCs and
RHCs to receive reimbursement from county specialty mental
health plans and through Drug Medi-Cal under the terms of a
contract between the FQHC and RHC and either the county or
DHCS outside of the regular Medi-Cal reimbursement structure
that applies to FQHCs and RHCs. SB 1335 is pending in the
Assembly Health Committee.
2)Prior legislation. 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:
These 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 co0nsiderable uncertainty in the funding of
this program.
Until the fiscal outlook for Medi-Cal is stabilized, I
cannot support any of these measures.
AB 690 (Wood of 2015), was substantially similar to the
provisions of this bill. AB 690 was held on the Assembly
Appropriations suspense file.
AB 1785 (Lowenthal of 2012), would have added MFTs to the list
of health care providers whose services are reimbursed through
Medi-Cal on a per-visit basis by FQHCs and RHCs. AB 1785 was
held on the Assembly Appropriations suspense file.
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.
3)Support. This bill is sponsored by CaliforniaHealth+ Advocates
(CH+A is also known as the California Primary Care Association
(CPCA), which writes that this bill will allow MFTs working in
FQHCs to become billable providers in Medi-Cal. CH+A) writes,
as part of California's implementation of the ACA, mental
AB 1863 (Wood) Page 8 of ?
health and substance use disorder services were deemed an
essential health benefit for Medi-Cal managed care health
plans. Recognizing the workforce shortage of personnel able
to meet the demand for mental health services created by
expanded insurance coverage, DHCS updated the Medicaid State
Plan to include MFTs as Medi-Cal mental health providers.
However, the State did not update FQHC statute to allow FQHCs
and RHCs to include MFTs as Medi-Cal billable providers. CPCA
writes that this bill will also lower the total cost of care
because these patients will be seeking preventive, primary
care services, in order to address their behavioral health
needs before they end up in crisis and access care through
much more expensive and less ineffective avenues such as an
emergency room.
The County Behavioral Health Directors Associations (CBHDA)
writes in support that the ACA expanded mental health and
substance use disorders and has resulted in a major expansion
in the number of Medi-Cal beneficiaries. CBHDA writes that it
is appropriate to maximize access to qualified mental health
providers and assure access is available in key areas
primarily served by RHCs and FQHCs. CBHDA concludes that
adding MFTs to the list of PPS billable providers will reduce
existing gaps in workforce capacity by providing clinics with
an adequate source of funding for their professionals and will
help meet the demand for mental health services.
4)Opposition. The National Association of Social
Workers-California Chapter (NASW-CA) writes in opposition that
this bill is unnecessary as there are sufficient numbers of
unemployed social workers that can fill these positions and
California schools of social work graduate approximately
10,000 bachelors and master's degree social workers each year,
and there are another 13,000 in the pipeline to receive their
full license. In addition, NASW-CA maintains these clinics
serve a population that is very diverse and in poverty, and
that while both MFT's and social workers have mental health
training, only social workers have extensive training in
providing culturally competent services to these disadvantaged
and impoverished communities. NASW-CA states a social worker
is trained to view clients from the
person-in-the-environment/whole person perspective, as opposed
to simply focusing on the pathology of a mental illness.
Finally, NASW-CA argues this bill could be very costly for
each FQHC to recalculate their PPS rate and it believes this
AB 1863 (Wood) Page 9 of ?
bill is costly, unnecessary and ill-timed as a recently
enacted law contains a pilot program for a different payment
methodology for FQHCs.
The California Psychological Association writes in opposition
that the long history of non-competitive salaries and
potentially remote work locations would seem to necessitate
this bill. However, there has been movement by the psychology
profession, resulting in increases of psychologists in these
settings. The move towards integrated health care model makes
psychologists poised to be the best trained clinicians to work
with a team of interdisciplinary clinicians in FQHCs and RHCs.
The Department of Finance is opposed to this measure, arguing
this bill is unnecessary and will result in unknown but
potentially significant General Fund costs in the Medi-Cal
program.
SUPPORT AND OPPOSITION :
Support: CaliforniaHealth+ Advocates (sponsor)
AIDS Project Los Angeles
Arroyo Vista Family Health Center
Association of California Healthcare Districts
Board of Behavioral Sciences
Borrego Health
California School-Based Health Alliance
California Academy of Family Physicians
California Association of Marriage and Family
Therapists
Clinicas De Salud Del Pueblo
Coalition of Orange County Community Health Centers
Community Clinic Association of Los Angeles County
Community Health Partnership
County Behavioral Health Directors Association
County Health Executives Association of California
County of Santa Clara
Family Health Centers of San Diego
Golden Valley Health Center
Health Alliance of Northern CA
L.A. Care Health Plan
La Maestra Community Health Centers
Northeast Valley Health Corporation
Omni Family Health
Operation Samahan
Santa Clara County Board of Supervisors
AB 1863 (Wood) Page 10 of ?
West County Health Centers
Westside Family Health Center
Oppose: California Psychological Association
Department of Finance
National Association of Social Workers, California
Chapter
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