BILL ANALYSIS Ó
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
AB 1863 (Wood) - Medi-Cal: federally qualified health centers:
rural health centers
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|Version: May 27, 2016 |Policy Vote: HEALTH 9 - 0 |
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|Urgency: No |Mandate: No |
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|Hearing Date: August 1, 2016 |Consultant: Brendan McCarthy |
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This bill meets the criteria for referral to the Suspense File.
Bill
Summary: AB 1863 would add marriage and family therapists
(MFTs) to the list of health care providers that qualify for
face-to-face encounter payments from the Medi-Cal program to
federally qualified health centers and rural health clinics.
Fiscal
Impact:
One-time costs, likely in the low millions to recalculate the
prospective payment system (PPS) rate for clinics that are
providing marriage and family therapist services or wish to
add those services (General Fund and federal funds). The bill
requires clinics that are currently including 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 face-to-face visits. The process for
recalculating a PPS rate requires a detailed review of
utilization and expenditures by clinics. For example, assuming
that the cost of performing such a review is about $10,000 and
that 500 clinics seek a recalculation, the administrative
AB 1863 (Wood) Page 1 of
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costs to the Department of Health Care Services would be about
$5 million.
No significant increase in costs is expected for MFT services
currently being provided in eligible clinics. Under the
current system for calculating the PPS rate paid by Medi-Cal
to federally qualified health centers and rural health
clinics, the total amount of eligible services (including
mental health services) provided to Medi-Cal beneficiaries is
divided by the number of eligible face-to-face visits (e.g. a
visit with a physician or clinical psychologist). Because the
bill requires a recalculation of the PPS to account for the
fact that MFTs would be eligible for face-to-face billing
before a clinic can bill for such an encounter, the Medi-Cal
program is not expected to pay more for services currently
being provided. (In other words, a clinic employing MFTs would
be able to bill for more face-to-face encounters, but the PPS
rate would be lower to account for those visits.)
Unknown potential increase in Medi-Cal paid visits to eligible
clinics. Under current law, a Medi-Cal beneficiary who visits
a federally qualified health center or rural health clinic
must be seen by certain types of providers (not including
MFTs) in order for the clinic to bill Medi-Cal for the visit.
In theory, the bill could allow clinics to bill Medi-Cal for
more overall visits, because it may be easier to hire MFTs
than other practitioners, such as physicians or psychologists.
However, under current practice, clinics can already qualify a
patient visit by having the patient see seven categories of
health care providers. The actual impact on overall
visitations to qualifying clinics may be small, given that
clinics can already use a variety of practitioners to qualify
the patient visit for payment from Medi-Cal.
Background: Under current law, the Medi-Cal program provides health care
coverage for certain low income and disabled individuals.
In the Medi-Cal fee-for-service system, federally qualified
health centers and rural health clinics are paid a per-visit
payment known as the prospective payment system (PPS). The PPS
rate is based on a baseline rate that reflects a federally
qualified health center's costs to provide services to in
1999-2000, adjusted for inflation. Those costs include the costs
AB 1863 (Wood) Page 2 of
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of eligible face-to-face visits (e.g. with a physician) and
other services provided to Medi-Cal beneficiaries that are not
eligible for billing as a face-to-face visit (e.g. visits with a
registered nurse). When a Medi-Cal beneficiary in the managed
care system receives care from a federally qualified health
center, the managed care plan makes a per-visit payment to the
center. Because the rates paid by managed care plans are
significantly below the PPS rate, the state makes a supplemental
"wrap-around" payment to the federally qualified health center
to bring the total payment up to the PPS rate.
Under current law, clinics may bill Medi-Cal for face-to-face
visits with several categories of health professionals,
including physicians, nurse practitioners, clinical social
workers, and others. Clinics cannot bill for face-to-face visits
with MFTs. However, the cost to provide services to Medi-Cal
beneficiaries by MFTs can be included in the calculation of the
PPS rate. (MFTs were added as eligible providers of psychology
services in the Medi-Cal program beginning in 2014.)
Proposed Law:
AB 1863 would add marriage and family therapists (MFTs) to the
list of health care providers that qualify for face-to-face
encounter payments from the Medi-Cal program to federally
qualified health centers and rural health clinics.
The bill would require a federally qualified health center or a
rural health clinic that currently includes the cost of MFT
services in its PPS rate to seek a recalculation of the PPS rate
by the Department of Health Care Services. Once the rate
adjustment has been approved, the bill would authorize an
eligible clinic to bill for those services as a separate visit.
The bill would require a federally qualified health center or a
rural health clinic that does not currently provide services by
MFTs that wants to add such services to do so by making a change
in scope of service (which requires a recalculation of the PPS
rate).
AB 1863 (Wood) Page 3 of
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Related
Legislation:
AB 1335 (Mitchell) authorizes federally qualified health
centers and rural health clinics to receive reimbursement for
services county specialty mental health plans and through the
Drug Medi-Cal program. That bill is pending in the Assembly.
AB 858 (Wood, 2015) was substantially similar to this bill.
That bill was vetoed by Governor Brown.
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