BILL ANALYSIS                                                                                                                                                                                                    Ó






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          |SENATE RULES COMMITTEE            |                       AB 2394|
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                                   THIRD READING 


          Bill No:  AB 2394
          Author:   Eduardo Garcia (D), et al.
          Amended:  8/16/16 in Senate
          Vote:     21 

           SENATE HEALTH COMMITTEE:  8-0, 6/22/16
           AYES:  Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,  
            Pan, Roth
           NO VOTE RECORDED:  Wolk

           SENATE APPROPRIATIONS COMMITTEE:  7-0, 8/11/16
           AYES:  Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen

           ASSEMBLY FLOOR:  78-0, 5/31/16 - See last page for vote

           SUBJECT:   Medi-Cal:  nonmedical transportation


          SOURCE:    Western Center on Law and Poverty

          DIGEST:   This bill requires Medi-Cal to provide coverage of  
          nonmedical transportation for a beneficiary to obtain covered  
          Medi-Cal services, subject to utilization controls and  
          permissible time and distance standards.


          ANALYSIS:  


          Existing law:


           1) Establishes the Medi-Cal program, administered by the  








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             Department of Health Care Services (DHCS), under which  
             qualified low-income individuals receive health care  
             services. 


           2) Establishes a schedule of benefits under the Medi-Cal  
             program, which includes medical transportation services,  
             subject to utilization controls, and in-home medical care  
             services when medically appropriate and subject to  
             utilization controls, for beneficiaries who would otherwise  
             require care for an extended period of time in an acute care  
             hospital at a cost higher than in-home medical care services.  
             Included within the definition of in-home medical care  
             services are emergency and non-emergency medical  
             transportation (NEMT).


           3) Requires, under federal Medicaid regulations, states'  
             Medicaid plans to:


              a)    Specify that the Medicaid agency will ensure necessary  
                transportation for recipients to and from providers; and, 


              b)    Describe the methods that the Medicaid agency will use  
                to meet this requirement. 


          This bill:


           1) Requires Medi-Cal to provide coverage for nonmedical  
             transportation (NMT) for a beneficiary to obtain covered  
             Medi-Cal services, subject to utilization controls and  
             permissible time and distance standards. Requires this bill  
             to take effect July 1, 2017 or the effective date of any  
             necessary federal approvals, whichever is later.


           2) Defines "NMT" to include, at a minimum, round trip  
             transportation for a beneficiary to obtain covered Medi-Cal  
             services by passenger car, taxicab, or any other form of  
             public or private conveyance, and mileage reimbursement when  







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             conveyance is in a private vehicle arranged by the  
             beneficiary and not through a transportation broker, bus  
             passes, taxi vouchers, or train tickets.


           3) Excludes from the definition of NMT the transportation of  
             sick, injured, invalid, convalescent, infirm, or otherwise  
             incapacitated beneficiaries by ambulances, litter vans, or  
             wheelchair vans licensed, operated, and equipped in  
             accordance with state and local statutes, ordinances, or  
             regulations.


           4) Requires NMT to be provided for a beneficiary who can attest  
             in a manner to be specified by DHCS that other currently  
             available resources have been reasonably exhausted. 


           5) Requires, for beneficiaries enrolled in a Medi-Cal managed  
             care plan, NMT to be provided by the beneficiary's Medi-Cal  
             managed care plan. 


           6) Requires DHCS, for Medi-Cal fee-for-service beneficiaries,  
             to provide NMT when those services are not available to the  
             beneficiary under specified provisions of existing law  
             providing federal Medicaid funding for targeted case  
             management and Medi-Cal administrative activities.


           7) Requires NMT to be provided in a form and manner that is  
             accessible, in terms of physical and geographic  
             accessibility, for the beneficiary and consistent with  
             applicable state and federal disability rights laws.


           8) Prohibits this bill from being interpreted to add a new  
             benefit to the Medi-Cal program.


           9) Requires DHCS to seek any federal approvals that may be  
             required to implement this bill, including, but not limited  
             to, approval of revisions to the existing Medicaid State Plan  
             that DHCS determines are necessary to implement this bill.







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           10)Implements this bill only to the extent that federal  
             financial participation is available and not otherwise  
             jeopardized and any necessary federal approvals have been  
             obtained.


           11)States that, prior to July 1, 2017 or the effective date of  
             any necessary federal approvals, NMT was not a Medi-Cal  
             managed care benefit with the exception of when provided as  
             an Early and Periodic Screening, Diagnosis, and Treatment  
             (EPSDT) service.


           12)Requires DHCS to implement, interpret or make specific this  
             bill by means of all-county letters, plan letters, plan or  
             provider bulletins, or similar instructions until regulations  
             are adopted. Requires DHCS, by July 1, 2018, to adopt  
             regulations in accordance with the Administrative Procedure  
             Act. Requires DHCS, commencing July 1, 2017, to provide a  
             status report to the Legislature on a semiannual basis until  
             regulations have been adopted.


           13) States legislative intent in enacting this bill to affirm  
             the requirement under federal Medicaid regulation, in which  
             DHCS is required to provide necessary transportation,  
             including NMT, for recipients to and from covered services. 


          Comments


          1)Author's statement.  According to the author, under federal  
            Medicaid law and California's State Medicaid Plan,  
            transportation of eligible recipients to and from health care  
            services is assured through a variety of methods.  However,  
            NMT, defined by DHCS as transportation of members to medical  
            services by passenger car, taxicabs, or other forms of public  
            or private conveyances provided by persons not registered as  
            Medi-Cal providers, is only provided directly as a Medi-Cal  
            benefit for children and CalMediConnect beneficiaries  
            (CalMediConnect beneficiaries are people who are dually  







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            eligible for Medi-Cal and Medicare).  Unfortunately, for all  
            other adults, questions remain regarding the basic  
            availability of NMT as a covered benefit.  Based on  
            information provided by DHCS in 2015, 17 of the 21 Medi-Cal  
            managed care plans purport that they provide NMT, but wide  
            variances in policies and procedures make it difficult for  
            beneficiaries to obtain NMT and there is no clear statewide  
            process for all other beneficiaries. This bill ensures that  
            low-income Medi-Cal beneficiaries throughout the state, but  
            particularly in rural areas, have access to transportation to  
            get to needed doctor appointments.


          2)Medi-Cal coverage of transportation. Medi-Cal coverage of  
            transportation services is governed by state and federal law.  
            Federal regulations require a state's Medicaid State Plan to  
            specify that the Medicaid agency will ensure necessary  
            transportation for recipients to and from providers, and to  
            describe the methods that the agency will use to meet this  
            requirement. California's Medicaid State Plan indicates  
            California provides both emergency and non-emergency medical  
            transportation. 


            DHCS distinguishes between NEMT and NMT. NEMT is transport by  
            ambulance, litter van, and wheelchair van medical  
            transportation when transport by ordinary means of public or  
            private conveyance is medically contraindicated, and  
            transportation is required for the purpose of obtaining needed  
            medical care. By contrast, NMT is transportation of members to  
            medical services by passenger car, taxicabs, or other forms of  
            public or private conveyances provided by persons not  
            registered as Medi-Cal providers. NMT does not include the  
            transportation of sick, injured, invalid, convalescent,  
            infirm, or otherwise incapacitated members by ambulances,  
            litter vans, or wheelchair vans licensed, operated and  
            equipped in accordance with state and local statutes,  
            ordinances or regulations. 


            DHCS indicates NMT is covered for children under age 21  
            through EPSDT, and for dually eligible beneficiaries enrolled  
            in CalMediConnect plans (plans that combine Medicare and  
            Medi-Cal benefits in one health plan, which operate in seven  







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            counties). CalMediConnect beneficiaries receive up to 30  
            one-way trips per year with no co-payment. For Medi-Cal  
            beneficiaries enrolled in Medi-Cal managed care plans, 17 out  
            of 21 plans DHCS surveyed reported having a contracted network  
            for NEMT, and the four health plans that did not have a  
            network were in the process of contracting with a vendor or  
            were utilizing only qualified Medi-Cal providers.




          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No

          According to the Senate Appropriations Committee:


          1)One-time costs of $120,000 and ongoing costs of $110,000 per  
            year to develop program requirements, amend the state's  
            Medicaid plan, adopt regulations to implement the bill, and  
            provide ongoing monitoring of benefit coverage (General Fund  
            and federal funds). 


          2)Ongoing costs of $3 million to $6 million per year to provide  
            NMT to Medi-Cal beneficiaries enrolled in Medi-Cal managed  
            care plans that do not already provide NMT as a covered  
            benefit and fee-for-service beneficiaries who do not already  
            qualify for NMT (General Fund and federal funds). According to  
            DHCS, 17 out of 21 Medi-Cal managed care plans already provide  
            coverage for NMT, covering between 50% and 70% of all existing  
            Medi-Cal managed care plan enrollees. DHCS currently does not  
            provide coverage for NMT in the fee-for-service system, except  
            for children and participants in the Coordinated Care  
            Initiative. DHCS estimates the annual cost per member to  
            provide NMT is between $0.50 and $2.00 per year. 


          3)Unknown impact on overall utilization of health care services  
            in the Medi-Cal program (General Fund and federal funds). By  
            ensuring that Medi-Cal beneficiaries have access to NMT to  
            covered services, this bill is likely to allow for increased  
            access to care by Medi-Cal beneficiaries, particularly  
            specialty care for beneficiaries in rural areas of the state.  







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            This is likely to increase utilization of those services. On  
            the other hand, timely access to specialty services may allow  
            beneficiaries and their providers to better manage serious  
            medical conditions, potentially reducing future needs for  
            additional specialty services or hospitalization. The net  
            impact of these factors is unknown. 




          SUPPORT:   (Verified8/15/16)


          Western Center on Law and Poverty (source)
          American Cancer Society Cancer Action Network
          Anthem Blue Cross
          Asian Americans Advancing Justice - Los Angeles
          Asian Law Alliance 
          Association of Regional Center Agencies 
          California Advocates for Nursing Home Reform 
          California Immigrant Policy Center 
          California Pan-Ethnic Health Network
          California Primary Care Association 
          California State Council of Services Employees International  
          Union
          Central California Legal Services, Inc. 
          Children Now 
          Children's Defense Fund - California 
          Coalition of California Welfare Rights Organizations, Inc. 
          Community Action Fund of Planned Parenthood of Orange and San  
            Bernardino Counties 
          Community Health Councils, Inc. 
          County Health Executives Association of California 
          Disability Rights California
          Disability Rights Education and Defense Fund 
          Health Access California 
          Justice in Aging 
          LeadingAge California 
          Legal Services of Northern California 
          Local Health Plans of California
          Maternal and Child Health Access 
          NAMI California 
          National Association of Social Workers, California Chapter
          National Health Law Program 







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          Planned Parenthood Action Fund of Santa Barbara, Ventura and San  
            Luis Obispo Counties 
          Planned Parenthood Action Fund of the Pacific Southwest 
          Planned Parenthood Advocacy Project Los Angeles County
          Planned Parenthood Advocates Pasadena and San Gabriel Valley
          Planned Parenthood Affiliates of California
          Planned Parenthood Mar Monte
          Planned Parenthood Northern California Action Fund 
          Project Inform


          OPPOSITION:   (Verified8/15/16)


          California Ambulance Association 


          ARGUMENTS IN SUPPORT:     This bill is sponsored by the Western  
          Center on Law and Poverty (WCLP), which writes that this bill  
          ensures Medi-Cal members have access to medical care by  
          clarifying that NMT is a Medi-Cal benefit and includes roundtrip  
          transportation for members to obtain covered Medi-Cal services.  
          WCLP argues access to transportation services is critical for  
          rural residents where distances to health providers are  
          significant, public transport is scarce, and low-income  
          beneficiaries cannot afford the limited transportation options  
          available. According to the state's Medicaid State Plan,  
          California "assures" transportation to and from Medi-Cal  
          services, but WCLP argues the implementation of the  
          transportation benefit varies widely across the state. As a  
          result, Medi-Cal beneficiaries are either unaware that they may  
          get assistance to go to their appointments or must fight through  
          nearly impossible administrative hurdles to access the benefit.  
          WCLP states that, for many rural Medi-Cal beneficiaries seeing a  
          specialist is not a one-time trip, but multiple trips where time  
          off work must be requested, childcare needs to be arranged,  
          rides from relatives and friends must be scrounged, and  
          financial tradeoffs must be made. WCLP concludes that this issue  
          is exacerbated by the mandatory transition into managed care for  
          Medi-Cal consumers in 28 mostly rural counties who are reporting  
          farther travel distances to access medically needed specialty  
          services. 









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          ARGUMENTS IN OPPOSITION:     The California Ambulance  
          Association states that the Medi-Cal Program severely underpays  
          ambulance providers and that Medi-Cal should not be expanded to  
          include new services until the Medi-Cal program properly funds  
          emergency ambulance services. 


          ASSEMBLY FLOOR:  78-0, 5/31/16
          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, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto,  
            Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper,  
            Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim,  
            Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,  
            Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, O'Donnell,  
            Olsen, Quirk, Ridley-Thomas, Rodriguez, Salas, Santiago,  
            Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,  
            Wilk, Williams, Wood, Rendon
          NO VOTE RECORDED:  Obernolte, Patterson

          Prepared by:Scott Bain / HEALTH / (916) 651-4111
          8/16/16 18:21:26


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