BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 2394| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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 AB 2394 Page 2 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 AB 2394 Page 3 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. AB 2394 Page 4 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 AB 2394 Page 5 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 AB 2394 Page 6 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. AB 2394 Page 7 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 AB 2394 Page 8 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. AB 2394 Page 9 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 **** END ****