Senate Bill No. 960

Introduced by Senators Hernandez and Leno

(Coauthor: Senator McGuire)

February 8, 2016

An act to amend Section 14132.725 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 960, as introduced, Hernandez. Medi-Cal: telehealth: reproductive health care.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, as specified. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for “teleophthalmology, teledermatology and teledentistry by store and forward,” as defined to mean the asynchronous transmission of medical information to be reviewed at a later time by a licensed physician or optometrist, as specified, at a distant site.

This bill would enact similar provisions relating to the use of reproductive health care under the Medi-Cal program. The bill would provide that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient shall not be required under the Medi-Cal program for “reproductive health care provided by store and forward.” The bill would define that term to mean an asynchronous transmission of medical information to be reviewed at a later time by a physician, nurse practitioner, certified nurse midwife, licensed midwife, physician assistant, or registered nurse at a distant site, where the provider at the distant site reviews the dental information without the patient being present in real time, as defined and as specified.

This bill would also provide that, to the extent federal financial participation is available and any necessary federal approvals are obtained, telephonic and electronic patient management services, as defined, provided by a physician or nonphysician health care provider acting within his or her scope of licensure shall be a benefit under the Medi-Cal program in fee-for-service and managed care delivery systems, as specified. The bill would authorize the department to seek approval of any state plan amendments necessary to implement these provisions.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

Section 14132.725 of the Welfare and Institutions
Code is amended to read:

14132.725.  

(a) To the extent that federal financial participation
is available, face-to-face contact between a health care provider
and a patient is not required under the Medi-Cal program for
teleophthalmology, teledermatology, and begin delete teledentistry end delete begin insert teledentistry,
and reproductive health care provided end insert by store and forward.
Services appropriately provided through the store and forward
process are subject to billing and reimbursement policies developed
by the department. begin insert A Medi-Cal managed care plan that contracts
with the department pursuant to this chapter and Chapter 8
(commencing with Section 14200) shall be required to cover the
services described in this section. end insert

(b) For purposes of this section, “teleophthalmology,
teledermatology, and begin delete teledentistry end delete begin insert teledentistry, and reproductive
health care provided end insert by store and forward” means an
asynchronous transmission of medical or dental information to be
reviewed at a later time by a physician at a distant site who is
trained in ophthalmology or dermatology or, for teleophthalmology,
by an optometrist who is licensed pursuant to Chapter 7
(commencing with Section 3000) of Division 2 of the Business
and Professions Code, or a dentist, begin insert or, for reproductive health
care, by a physician, nurse practitioner, certified nurse midwife,
licensed midwife, physician assistant, or registered nurse operating
within his or her scope of practice, end insert where the physician,
optometrist, begin delete or dentist end delete begin insert dentist, nurse practitioner, certified nurse
midwife, licensed midwife, physician assistant, or registered nurse end insert
at the distant site reviews the medical or dental information without
the patient being present in real time. A patient receiving
teleophthalmology, teledermatology, begin delete or teledentistry end delete begin insert teledentistry,
or reproductive health care end insert by store and forward shall be notified
of the right to receive interactive communication with the distant
specialist physician, optometrist, begin delete or dentist end delete begin insert dentist, end insert begin insert nurse
practitioner, certified nurse midwife, licensed midwife, physician
assistant, or registered nurse end insert and shall receive an interactive
communication with the distant specialist physician, optometrist,
begin delete or end delete dentist, begin insert nurse practitioner, certified nurse midwife, licensed
midwife, physician assistant, or registered nurse end insert upon request. If
requested, communication with the distant specialist physician,
optometrist, begin delete or dentist end delete begin insert dentist, nurse practitioner, certified nurse
midwife, licensed midwife, physician assistant, or registered nurse end insert
may occur either at the time of the consultation, or within 30 days
of the patient’s notification of the results of the consultation. If the
reviewing optometrist identifies a disease or condition requiring
consultation or referral pursuant to Section 3041 of the Business
and Professions Code, that consultation or referral shall be with
an ophthalmologist or other appropriate physician and surgeon, as
required.

begin insert

(c) (1) To the extent that federal financial participation is
available and any necessary federal approvals have been obtained,
telephonic and electronic patient management services provided
by a physician, or a nonphysician health care provider acting
within his or her scope of licensure is a benefit under the Medi-Cal
program, both in fee-for-service and managed care delivery
systems delivered by Medi-Cal managed care plans that contract
with the department pursuant to this chapter and Chapter 8
(commencing with Section 14200). Reimbursement for telephonic
and electronic patient management services shall be based on the
complexity of and time expended in rendering those services.

end insert begin insert

(2) This subdivision shall not be construed to authorize a
Medi-Cal managed care plan to require the use of telephonic and
electronic patient management services when the physician or
nonphysician health care provider has determined that those
services are not medically necessary.

end insert begin insert

(3) This subdivision shall not be construed to alter the scope of
practice of a health care provider or authorize the delivery of
health care services in a setting or in a manner than is not
otherwise authorized by law.

end insert begin insert

(4) All laws regarding the confidentiality of health information
and a patient’s right of access to his or her medical information
shall apply to telephonic and electronic patient management
services.

end insert begin insert

(5) This subdivision shall not apply to a patient in the custody
of the Department of Corrections and Rehabilitation or any other
correctional facility.

end insert begin insert

(d) Notwithstanding paragraph (1) of subdivision (b), separate
reimbursement of a physician or a nonphysician health care
provider shall not be required for any of the following:

end insert begin insert

(1) A telephonic or electronic visit that is related to a service
or procedure provided to an established patient within a
reasonable period of time prior to the telephonic or electronic
visit, as recognized by the Current Procedural Terminology codes
published by the American Medical Association.

end insert begin insert

(2) A telephonic or electronic visit that leads to a related service
or procedure provided to an established patient within a
reasonable period of time, or within an applicable postoperative
period, as recognized by the Current Procedural Terminology
codes published by the American Medical Association.

end insert begin insert

(3) A telephonic or electronic visit provided as part of a bundle
of services for which reimbursement is provided for on a prepaid
basis, including capitation, or which reimbursement is provided
for using an episode-based payment methodology.

end insert begin insert

(4) A telephonic or electronic visit that is not initiated by an
established patient, by the parents or guardians of a minor who
is an established patient, or by a person legally authorized to make
health care decisions on behalf of an established patient.

end insert begin insert

(e) Nothing in this section shall be construed to prohibit a
Medi-Cal managed care plan from requiring documentation
reasonably relevant to a telephonic or electronic visit, as
recognized by the Current Procedural Terminology codes
published by the American Medical Association.

end insert begin insert

(f) For purposes of this section, the following definitions apply:

end insert begin insert

(1) “Established patient” means a patient who, within three
years immediately preceding the telephonic or electronic visit, has
received professional services from the provider or another
provider of the same specialty or subspecialty who belongs to the
same group practice.

end insert begin insert

(2) “Nonphysician health care provider” means a provider,
other than a physician, who is licensed pursuant to Division 2
(commencing with Section 500) of the Business and Professions
Code.

end insert begin insert

(3) “Reproductive health care” means the general reproductive
health care services described in paragraph (8) of subdivision
(aa) of Section 14132.

end insert begin insert

(4) “Telephonic and electronic patient management service”
means the use of electronic communication tools to enable treating
physicians and nonphysician health care providers to evaluate
and manage established patients in a manner that meets all of the
following criteria:

end insert begin insert

(A) The service does not require an in-person visit with the
physician or nonphysician health care provider.

end insert begin insert

(B) The service is initiated by the established patient, the parents
or guardians of a minor who is an established patient, or a person
legally authorized to make health care decisions on behalf of an
established patient. “Initiated by an established patient” does not
include a visit for which a provider or a person employed by a
provider contacts a patient to initiate a service.

end insert begin insert

(C) The service is recognized by the Current Procedural
Terminology codes published by the American Medical Association.

end insert begin insert

(g) The department may seek approval of any state plan
amendments necessary to implement this section.

end insert begin delete

(c)

end delete

begin insert (h) end insert  Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, and make specific this
section by means of all-county letters, provider bulletins, and
similar instructions.