BILL ANALYSIS Ó
AB 1863
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CONCURRENCE IN SENATE AMENDMENTS
AB
1863 (Wood)
As Amended August 17, 2016
Majority vote
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|ASSEMBLY: |78-1 |(June 1, 2016) |SENATE: |39-0 |(August 22, |
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Original Committee Reference: HEALTH
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.
The Senate amendments make this bill operative only if SB 1335
(Mitchell) of the current legislative session and this bill are
both chaptered and become effective on or before January 1,
2017, and this bill is chaptered last.
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FISCAL EFFECT: 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 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 costs to the Department of
Health Care Services 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
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
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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.
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.
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.
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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.
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:
00045340003280
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