BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 960
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|AUTHOR: |Hernandez and Leno |
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|VERSION: |February 8, 2016 |
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|HEARING DATE: |April 20, 2016 | | |
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|CONSULTANT: |Melanie Moreno |
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SUBJECT : Medi-Cal: telehealth: reproductive health care
SUMMARY :1) Adds "reproductive health care" by store and forward provided
by a physician, nurse practitioner, certified nurse midwife,
licensed midwife, physician assistant, or registered nurse
operating within her scope of practice, to existing law that
prohibits face to face contact for teleophthalmology,
teledermatology and teledentisty from being required in the
Medi-Cal program. Requires Medi-Cal managed care plans to cover
reproductive health care, teleophthalmology, teledermatology,
and teledentistry.
Existing law:
1)Provides for the Medi-Cal program, which is administered by
the Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services,
as specified.
2)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.
3)States legislative intent to recognize the practice of
telehealth as a legitimate means by which an individual may
receive health care services from a health care provider
without in-person contact with the health care provider.
SB 960 (Hernandez) Page 2 of ?
4)Prohibits a health plan or health insurer from requiring
in-person contact between a health care provider and a patient
before payment is made for the covered services appropriately
provided through telehealth, subject to the terms and
conditions of the contract entered into between the enrollee
or subscriber and the health plan or the insured and health
insurer, and between the health plan or health insurer and its
participating providers or provider groups.
5)Prohibits a health plan or health insurer from limiting the
type of setting where services are provided for the patient or
by the health care provider before payment is made for the
covered services appropriately provided through telehealth,
subject to the terms and conditions of the contract entered
into between the enrollee or subscriber and the health plan or
the insured and the health insurer, and between the health
plan or health insurer and its participating providers or
provider groups.
6)Applies 4) and 5) above to health care and Medi-Cal managed
care plan contracts with the DHCS.
7)Prohibits existing law from being interpreted to authorize a
health plan or health insurer to require the use of telehealth
when the health care provider has determined that it is not
appropriate.
8)Establishes the Department of Managed Health Care (DMHC) to
regulate health plans and the California Department of
Insurance (CDI) to regulate health insurers, and other
insurance carriers and insurance agents.
This bill:
1)Adds "reproductive health care" by store and forward provided
by a physician, nurse practitioner, certified nurse midwife,
licensed midwife, physician assistant, or registered nurse
operating within her scope of practice, to existing law that
prohibits face to face contact for teleophthalmology,
teledermatology and teledentisty from being required in the
Medi-Cal program. Defines "reproductive health care" as the
general reproductive health care services described in
existing law related to FamilyPACT.
2)Requires Medi-Cal managed care plans to cover reproductive
health care, teleophthalmology, teledermatology, and
SB 960 (Hernandez) Page 3 of ?
teledentistry.
3)Makes, to the extent that federal financial participation is
available and any necessary federal approvals have been
obtained, for telephonic and electronic patient management
services provided by a physician, or a non-physician health
care provider acting within his or her scope of licensure, a
benefit under the Medi-Cal program, both in fee-for-service
and managed care delivery systems delivered by Medi-Cal
managed care plans.
4)Requires reimbursement for telephonic and electronic patient
management services to be based on the complexity of and time
expended in rendering those services.
5)Prohibits 4) above from being construed to authorize a
Medi-Cal managed care plan to require the use of telephonic
and electronic patient management services when the physician
or non-physician health care provider has determined that
those services are not medically necessary.
6)Prohibits this bill from being 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.
7)Requires all laws regarding the confidentiality of health
information and a patient's right of access to his or her
medical information to apply to telephonic and electronic
patient management services.
8)Specifies that this bill does not apply to a patient in the
custody of the Department of Corrections and Rehabilitation or
any other correctional facility.
9)Prohibits separate reimbursement of a physician or a
non-physician health care provider from being required for any
of the following:
a) 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 (CPT)
codes published by the American Medical Association
SB 960 (Hernandez) Page 4 of ?
(AMA);
b) 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 CPT codes published by the AMA.;
c) 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; and,
d) 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.
10)Prohibits anything in this bill from being construed to
prohibit a Medi-Cal managed care plan from requiring
documentation reasonably relevant to a telephonic or
electronic visit, as recognized by the CPT codes published by
the AMA.
11)Defines "telephonic and electronic patient management
service" as the use of electronic communication tools to
enable treating physicians and non-physician health care
providers to evaluate and manage established patients in a
manner that:
a) Does not require an in-person visit with the
physician or non-physician health care provider;
b) 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;
and,
c) Is recognized by the CPT codes published by
the AMA.
12)Permits DHCS to seek approval of any state plan amendments
necessary to implement this bill.
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FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, this bill will
expand access to reproductive health care services through the
use of existing and innovative technology that connects
patients with their health care provider more efficiently and
cost effectively. The use of telehealth is expanding, and is
a vital component of health care that increases access to
care, and lowers the cost of health care services. Planned
Parenthood developed a mobile app to facilitate the testing
and treatment of sexually transmitted infections (STIs) and
urinary tract infections (UTIs), and the provision of hormonal
birth control, without requiring an office visit. Using these
types of mobile, web-based technologies will increase access
to care in all communities -- rural, urban, and suburban
underserved areas. However, Medi-Cal reimbursement for
telehealth services is limited to only a few fields of
medicine. This bill will enable certain services that Planned
Parenthood provides to patients through health centers to also
be reimbursed when delivered through its mobile application.
At a time when we have increased insurance coverage for
millions of Californians, this bill ensures that low income
women seeking reproductive health care services, regardless of
location, can receive the care they need in the most efficient
way possible.
2)Impact of undiagnosed disease and unintended pregnancies.
About one in eight U.S. residents with HIV do not realize they
are infected, and they cause nearly one-third of HIV
transmissions, according to a CDC report released in June
2015. With regard to bacterial STIs, the Department of Public
Health reported that California ranked first among all states
in 2014 for the total number of cases of chlamydia, gonorrhea,
and syphilis. Additionally, disparities persist for STIs,
with the highest rates found among young people,
African-Americans, and gay and bisexual men. However,
according to the federal Department of Health and Human
Services, because many cases of STIs go undiagnosed, the
reported cases of chlamydia, gonorrhea, and syphilis represent
only a fraction of the true burden of STIs. Untreated STIs
can lead to serious long-term health consequences, especially
for adolescent girls and young women. Finally, in California,
about half of all pregnancies are unintended. Women with
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unintended pregnancies are less likely to receive prenatal
care, and health outcomes are worse for both mother and baby.
According to a 2015 study by the Guttmacher Institute, the
annual public cost of unintended pregnancies in California is
more than $1.75 billion.
3)Telehealth. Existing law defines "telehealth" as the mode of
delivering health care services and public health via
information and communication technologies to facilitate the
diagnosis, consultation, treatment, education, care
management, and self-management of a patient's health care
while the patient is at the originating site and the health
care provider is at a distant site. A 2014 report by the
California Health Benefits Review Program on AB 1771 (Perez of
2014), found these services, especially in underserved areas,
could substitute for 60% of current, more costly face-to-face
visits, while improving access by increasing capacity for more
patient visits to occur.
4)Planned Parenthood Direct. In June 2015, Planned Parenthood
Affiliates of California (PPAC) launched a mobile application
called Planned Parenthood Direct, which allows men and women
to order confidential STI testing kits through their mobile
phone and, if they test positive, receive treatment. It had
been available in Minnesota and Washington since the 2014 and
allows people to talk to a Planned Parenthood provider online
and face to face through a secure video consultation system,
and then receive birth control or an STI test kit and
treatment, if necessary, in the mail. According to Planned
Parenthood, these two apps build upon other resources that the
organization has introduced to the health care field to
increase access to reproductive health care services.
According to PPAC, Planned Parenthood Direct is only cash pay,
but they are working to accept insurance coverage. Under this
scenario, the interface will verify a patient's insurance to
see if the service is covered, and if it is, whether or not a
co-pay applies before the service is provided.
5)CPT codes. These codes are used to report episodes of patient
care initiated by an established patient or guardian of an
established patient. If the telephone service ends with a
decision to see the patient within 24 hours or next available
urgent visit appointment, the code is not reported; rather the
encounter is considered part of the preservice work of the
subsequent evaluation and management service, procedure, and
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visit. If the telephone call refers to an evaluation and
management service reported within the previous seven days or
within the postoperative period of the previously completed
procedure, then the service is not reported. There are also
CPT codes for telephone services provided by a qualified
non-physician who may report telephone assessment and
management services with similar criteria as described above.
While CPT codes exist, there is no Medi-Cal reimbursement for
telephone and email consultation for reproductive services,
and reimbursement for store and forward telehealth services is
limited to only a few fields of medicine. According to the
CHBRP analysis of AB 1771, with a few exceptions, the Centers
for Medicare and Medicaid Services (CMS) do not reimburse for
telephone (and email) communications, and most commercial
insurance carriers follow CMS reimbursement decisions.
6)Related legislation. AB 2507 (Gordon) expands the definition
of telehealth to also include telephone, email and synchronous
text, and chat conferencing as billable telehealth modalities
and requires health plans and insurers to reimburse telehealth
services to the same extent as services provided through in
person. AB 2507 is set to be heard in the Assembly Health
Committee on April 19, 2016.
7)Prior legislation. AB 1771 would have required health plans
and health insurers, with respect to plan contracts and
insurance policies issued, amended, or renewed on or after
January 1, 2016, to cover telephone visits provided by a
physician. AB 1771 was held on suspense in the Senate
Appropriations Committee.
AB 415 (Logue, Chapter 547, Statutes of 2011), among other
provisions, prohibits DHCS from requiring that a health care
provider document a barrier to an in-person visit prior to
paying for services provided via telehealth to a Medi-Cal
beneficiary. Repeals the prohibition of paying for a service
provided by telephone or facsimile and would instead prohibit
DHCS from limiting the type of setting where services are
provided for the patient. Prohibits health plans and insurers
from requiring that in-person contact occur between a health
care provider and a patient before payment is made for the
services appropriately provided through telehealth, subject to
the terms of the relevant contract. Repeals the prohibition
for paying for a service provided by telephone or facsimile
and would instead prohibit health plans and insurers from
SB 960 (Hernandez) Page 8 of ?
limiting the type of setting where services are provided for
the patient or by the health care provider.
SB 1665 (Thompson, Chapter 864, Statutes of 1996), establishes
the Telemedicine Development Act (TDA) to set standards for
the use of telemedicine by health care practitioners and
insurers. TDA specifies, in part, that face-to-face contact
between a health care provider and a patient is not required
under the Medi-Cal Program for services appropriately provided
through telemedicine, when those services are otherwise
covered by the Medi-Cal program, and requires a health care
practitioner to obtain verbal and written consent prior to
providing services through telemedicine.
8)Support. A number of Planned Parenthood affiliates write to
say that access to sensitive services, such as birth control
and STI testing, can be challenging for certain low-income
populations, particularly for those in rural and underserved
communities. Supporters state that payment for these
telehealth services should be expanded to include reproductive
health care in order to provide ease of access to reproductive
care, which will in turn minimize the spread of disease and
reduce the number of unintended pregnancies. The National
Health Law Program (NHeLP) states that there are many barriers
that interfere with a patient's ability to access care:
distance, lack of transportation, lack of child care, as well
as others. NHeLP states that timeliness is especially
important to the delivery of quality reproductive health care
services, in addition to other fields of medicine and that
telehealth plays a critical role in ensuring timely health
care delivery. The County Health Executives Association of
California writes that telemedicine has been a useful tool in
expanding services, especially to the more rural areas of
California where access to care can be difficult. The
California Family Health Council (CFHC) writes that women with
unintended pregnancies are less likely to receive prenatal
care, and health outcomes are worse for both mother and baby.
CFHC asserts that paying Medi-Cal providers to provide sexual
and reproductive health care via telehealth would ease access
to these services, which will in turn minimize the spread of
disease and reduce the number of unintended pregnancies and
could also expand the patient base who might be interested in
these services. The California Academy of Family Physicians
states that this bill empowers patients by allowing them more
control over their care, which leads to improved
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connectedness, continuity, and overall quality of the
patient-provider relationship. The California Medical
Association states that not only do telehealth services reduce
the use of expensive services, increase access, and improve
quality of care, but patients also feel more satisfaction with
their care. Stanford Health Care writes that efforts to
expand telehealth coverage and reimbursement are to be
supporter to better address the numerous health issues
Californians face. The American Civil Liberties Union writes
that this bill aligns with California's historic leadership in
establishing public policies that increase access to
reproductive health care, which in turn, minimizes the spread
of STIs and reduces the number of unintended pregnancies in
the state.
9)Oppose. The California Catholic Conference writes that
eliminating the requirement for a face-to-face visit with a
reproductive health care professional, alongside other types
of non-invasive medical care and in order to achieve
additional cost-savings to the state, is a potential direct
reduction in the standard of care for women on publicly
subsidized health care and bad public policy. CCC states that
because of the marvelous blessing bestowed upon women by our
ever-loving God, which allows for the miracle of life and is
intended for procreation for only part of their lives, women
should demand that the medical profession work with their
reproductive health, which must remain its own class of
medical care and deserves respect, understanding and
acceptance by all.
10)Oppose unless amended. The California Association of Health
Plans (CAHP) writes that they support the objectives of
telehealth in improving enrollee access to health care as a
means of controlling health care costs; however, they must
oppose this Medi-Cal coverage mandate. CAHP writes that this
bill does not add these telehealth services as a visit that is
counted as a patient encounter, and if telehealth visits are
not counted in the rate setting process then Medi-Cal managed
care plans will not be compensated for the provisions of these
services.
SUPPORT AND OPPOSITION :
Support: Planned Parenthood Affiliates of California (sponsor)
American Civil Liberties Union of California
American Congress of Obstetricians and Gynecologists,
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District IX (California)
California Academy of Family Physicians
California Family Health Council
California Medical Association
The Children's Partnership
Community Action Fund of Planned Parenthood of Orange
and San Bernardino Counties
County Health Executives Association of California
National Health Law Program
Planned Parenthood Action Fund of the Pacific
Southwest
Planned Parenthood Action Fund of Santa Barbara,
Ventura & San Luis Obispo
Planned Parenthood Advocacy Project Los Angeles County
Planned Parenthood Mar Monte
Planned Parenthood Northern California Action Fund
Stanford Health Care
Oppose: California Association of Health Plans (unless
amended)
California Catholic Conference
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