BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 1863|
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THIRD READING
Bill No: AB 1863
Author: Wood (D)
Amended: 5/27/16 in Assembly
Vote: 21
SENATE HEALTH COMMITTEE: 9-0, 6/22/16
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,
Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/11/16
AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen
ASSEMBLY FLOOR: 78-1, 6/1/16 - See last page for vote
SUBJECT: Medi-Cal: federally qualified health centers:
rural health centers
SOURCE: California Primary Care Association
California Association of Marriage and Family
Therapists
DIGEST: This bill 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.
ANALYSIS:
Existing law:
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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.
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
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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
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.
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
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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
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
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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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
1)One-time costs, likely in the low millions to recalculate the
PPS rate for clinics that are providing MFT 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
costs to DHCS would be about $5 million.
2)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
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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.)
3)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.
SUPPORT: (Verified 8/9/16)
California Primary Care Association (co-source)
California Association of Marriage and Family Therapists
(co-source)
AIDS Project Los Angeles
Arroyo Vista Family Health Center
Association of California Healthcare Districts
Borrego Health
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 Assoc.
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
La Maestra Community Health Centers
Northeast Valley Health Corporation
Omni Family Health
Operation Samahan
San Joaquin County
Westside Family Health Center
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West County Health Centers
OPPOSITION: (Verified8/9/16)
California Psychological Association
Department of Finance
National Association of Social Workers, California Chapter
ARGUMENTS IN 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. CPCA writes, as part of California's
implementation of the ACA, mental 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.
ARGUMENTS IN OPPOSITION: The National Association of Social
Workers-California Chapter (NASW-CA) writes in opposition that
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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 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.
ASSEMBLY FLOOR: 78-1, 6/1/16
AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker,
Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke,
Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley,
Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth
Gaines, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez,
Gonzalez, Gordon, Gray, Grove, Hadley, Roger Hernández,
Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine,
Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty,
Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell,
Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez, Salas,
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Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner,
Waldron, Weber, Wilk, Williams, Wood, Rendon
NOES: Harper
NO VOTE RECORDED: Gallagher
Prepared by:Scott Bain / HEALTH / (916) 651-4111
8/15/16 19:36:08
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