BILL ANALYSIS Ó
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
SB 960 (Hernandez) - Medi-Cal: telehealth: reproductive health
care
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|Version: April 26, 2016 |Policy Vote: HEALTH 6 - 0 |
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|Urgency: No |Mandate: No |
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|Hearing Date: May 23, 2016 |Consultant: Brendan McCarthy |
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This bill meets the criteria for referral to the Suspense File.
Bill
Summary: SB 960 would require reproductive health care services
provided through telehealth to be covered by the Medi-Cal
program. The bill would require telephonic and electronic
patient management services to be covered by the Medi-Cal
program.
Fiscal
Impact:
Likely one-time costs in the low hundreds of thousands for the
Department of Health Care Services to gain federal approvals,
adopt regulations, and make any necessary system changes to
allow for the provision of services under the bill (General
Fund and federal funds).
Unknown impact on Medi-Cal spending for reproductive health
care services (General Fund and federal funds). By allowing
reproductive services to be provided through telehealth, the
bill is likely to make it easier for Medi-Cal beneficiaries to
SB 960 (Hernandez) Page 1 of
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access such services. Whether this will actually increase the
utilization of services is uncertain. To a large extent, the
authority to use telehealth to access such services will make
ordering such services more convenient for beneficiaries, but
will not increase overall utilization (since a beneficiary
would most likely have sought out services in another manner
without the bill). There also may be some increase in
utilization of services. For example a beneficiary may request
a test for a sexually transmitted infection for symptoms that
would have resolved on their own before the beneficiary sought
a test through traditional health care settings. The extent to
which that would happen is unknown.
Increased costs in the tens of millions per year for Medi-Cal
coverage of telephonic and electronic patient management
services (General Fund and federal funds). The requirement in
the bill for Medi-Cal coverage of telephonic and electronic
patient management services goes beyond reproductive health
care and would be available for all appropriate health care
services. Based to an analysis of a similar requirement in
another bill by the California Health Benefits Review Program,
staff estimates that the overall increase in Medi-Cal spending
from this requirement could be between $10 million and $40
million per year.
Background: Under state and federal law, the Department of Health Care
Services operates the Medi-Cal program, which provides health
care coverage to low income individuals, families, and children.
Medi-Cal provides coverage to childless adults and parents with
household income up to 138% of the federal poverty level and to
children with household income up to 266% of the federal poverty
level. The federal government provides matching funds that vary
from 50% to 90% of expenditures depending on the category of
beneficiary.
Current law provides that a face-to-face visit is not required
between a patient and a provider for Medi-Cal coverage of
teleopthamology, teledermatology, and teledentistry by store and
forward. In this case, store and forward means technologies that
capture information from a patient and send it to a provider at
a different location, for example an x-ray image taken in a
clinic and then sent to a dentist in another location for
examination. To date, the use of store and forward telehealth
technology in Medi-Cal does not allow patients to directly
SB 960 (Hernandez) Page 2 of
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request services or send information about symptoms directly to
health care providers (for example using a smart phone).
Proposed Law:
SB 960 would require reproductive health care services
provided through telehealth to be covered by the Medi-Cal
program The bill would require telephonic and electronic patient
management services to be covered by the Medi-Cal program.
Specific provisions of the bill would:
Add reproductive health care services to those
telehealth services that are covered under the Medi-Cal
program without the need for a face-to-face visit;
Require Medi-Cal managed care plans to cover
reproductive health care provided by telehealth store and
forward;
Specify the medical provider types that can provide
reproductive health care by telehealth store and forward;
Require telephonic and electronic patient management
services to be a benefit in the Medi-Cal program, in both
fee-for-service and managed care;
Limit the required reimbursement for services when the
telephonic or electronic patient management service is
related to another service or procedure provided to the
patient, when the telephonic or electronic patient
management service leads to a related service or visit,
when the health care provider receives a bundled or
capitated payment, or when the telephonic or electronic
patient management service is not initiated by the patient;
Define reproductive health care, by reference to another
statute.
Related
Legislation:
AB 2507 (Gordon) would expand the definition of
telehealth to include telephone, email, and synchronous
text. That bill is pending in the Assembly Appropriations
Committee.
SB 289 (Mitchell, 2015) would have mandated that health
insurers and health plans provide coverage for telephonic
and electronic patient management services provided by a
SB 960 (Hernandez) Page 3 of
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contracted physician or non-physician health care provider.
That bill was held on this committee's Suspense File.
Staff
Comments: SB 289 (Mitchell, 2015) would have mandated the
coverage of telephonic and electronic patient management
services for all health plans and insurers. According to the
analysis of that bill by the California Health Benefits Review
Program, the requirements to cover those service modalities
would have had an overall effect of increasing utilization of
health care services. As is described in the analysis of that
bill provided by Program, there is a good deal of uncertainty
about how the behavior of patients and providers would change
under that bill. By requiring reimbursement to providers for
telephonic and electronic patient management services, that bill
was very likely have to increased providers' willingness to use
such services with their patients, increasing utilization. Some
of the increased utilization of telephonic and electronic
patient management services would have reduced in person visits
with providers. For example, a patient may have found it more
convenient to call or email a provider with a question about an
ongoing health issue, rather than making an in person
appointment. In that case, the bill would not have reduced
overall utilization of services: it would have resulted in a
substitute visit. On the other hand, the ability to communicate
with a provider on the phone or through electronic means would
also have resulted in supplemental visits (i.e. more utilization
than would occur under current law). For example, a patient with
a minor question or who is experiencing a minor illness that
would not necessarily have led to an in person visit with a
provider would have been more likely to make a phone call or use
an electronic means to communicate with a provider. In those
cases, the bill would have resulted in an increase in overall
utilization of health care services.
The California Health Benefits Review Program modelled a variety
of scenarios for utilization under SB 289. Under all scenarios,
there would have been both substitution and supplementation of
in person visits. In all scenarios, however, the supplementation
would have resulted in an overall increase of utilization of
services and therefore an increase of health care costs.
The California Health Benefits Review Program analysis for SB
SB 960 (Hernandez) Page 4 of
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289 assumed that Medi-Cal managed care plans would not have been
able to pass the cost of the benefit mandate along to the state,
due to the state's bargaining power. However, the requirement in
this bill is specific to the Medi-Cal program and explicitly
includes both fee-for-service and managed care. Because Medi-Cal
managed care rates are required to be actuarially sound, staff
anticipates that Medi-Cal managed care plans would be able to
pass along increased costs to the state, once they were able to
demonstrate that utilization was occurring.
Current law are regulation allows Medi-Cal managed care plans to
provide services to enrollees not specifically required under
law. Therefore, Medi-Cal managed care plans can already contract
with providers to allow the use of telehealth for reproductive
health care services, provided that the Medi-Cal managed care
plan and the provider can agree on the rates and terms that
would apply to those services.
Current federal law and state regulation provides that Medi-Cal
enrollees can access family planning (including reproductive
health care) from any Medi-Cal provider, even when the provider
is not in the enrollee's Medi-Cal managed care plan network. By
authorizing the use of telehealth for reproductive health care
services, the bill will make it easier for Medi-Cal
beneficiaries to seek services outside of their managed care
plan network. To the extent that providers and Medi-Cal managed
care plans cannot agree on the rates and terms for providing
reproductive health care services through telehealth, the bill
is likely to result in a shift in the provision of health care
services from Medi-Cal managed care plan networks to
out-of-network providers.
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