BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1335
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|AUTHOR: |Mitchell |
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|VERSION: |April 5, 2016 |
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|HEARING DATE: |April 13, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Med-Cal benefits: federally qualified health centers
and rural health centers: Drug Medi-Cal and specialty mental
health services
SUMMARY : Authorizes federally qualified health centers (FQHCs) and
rural health clinics (RHCs) to receive reimbursement from county
specialty mental health plans and through Drug Medi-Cal under
the terms of a contract between the FQHC and RHC and either the
county or the Department of Health Care Services outside of the
regular Medi-Cal reimbursement structure that applies to FQHCs
and RHCs.
Existing law:
1)Establishes the Medi-Cal program as California's Medicaid
program, administered by the Department of Health Care
Services (DHCS), which provides comprehensive health care
coverage for low-income individuals. FQHC and RHC services are
covered benefits under the Medi-Cal program.
2)Requires FQHCs and RHCs to be reimbursed on a per-visit basis.
Defines a "visit" as a face-to-face encounter between an FQHC
or RHC patient and specified health care providers. The
Medi-Cal reimbursement to FQHCs and RHCs on a per-visit rate
is known as the Prospective Payment System (PPS).
3)Permits an FQHC or RHC to elect to have pharmacy or dental
services reimbursed on a fee-for-service (FFS) basis,
utilizing the current fee schedules established for those
services. Requires these costs to be adjusted out of the
FQHC's or RHC's clinic base rate as scope-of-service change.
4)Establishes the Drug Medi-Cal program, under which the DHCS is
authorized to enter into contracts with each county for
SB 1335 (Mitchell) Page 2 of ?
various alcohol and drug treatment services for Medi-Cal
beneficiaries.
5)Requires DHCS to implement managed mental health care for
Medi-Cal beneficiaries through contracts with mental health
plans. Mental health plans may include individual counties,
counties acting jointly, or an organization or nongovernmental
entity determined by DHCS to meet mental health plan
standards.
6)Requires mental health plans to provide specialty mental
health services to eligible Medi-Cal beneficiaries, including
both adults and children.
This bill:
1)Requires, if an FQHC or RHC and a county specialty mental
health plan mutually agree to enter into a contract to have
the FQHC or RHC provide specialty mental health services to
Medi-Cal beneficiaries as part of the mental health plan's
network, the FQHC or RHC to elect to have specialty mental
health services reimbursed pursuant to the terms of the
contract or contracts and outside of the per-visit PPS rate.
2)Permits an FQHC or RHC to elect to become certified to provide
services in the Drug Medi-Cal program. Requires reimbursement
for Drug Medi-Cal program services to be reimbursed pursuant
to the terms of the contract or contracts and outside of the
per-visit PPS rate.
3)Permits, if the FQHC or RHC is located in a county that has
elected to participate in the Drug Medi-Cal Organized Delivery
System (ODS), the FQHC or RHC to elect to receive
reimbursement pursuant to a mutually agreed upon contract
between the county and the FQHC or RHC.
4)Permits, if the county does not elect to participate in the
Drug Medi-Cal ODS, an FQHC or RHC to elect to contract through
DHCS as a Drug Medi-Cal provider.
5)Requires, if an FQHC or RHC elects to receive from a county
specialty mental health plan or from Drug Medi-Cal, the
reimbursement the FQHC or RHC receives to be adjusted out of
the FQHC's or RHC's clinic base rate as scope-of-service
changes, and the PPS payment would not apply.
6)Implements this bill only to the extent that federal financial
participation is available and any necessary federal approvals
SB 1335 (Mitchell) Page 3 of ?
have been obtained.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, as the growing
need for behavioral health care services continues to go
unmet, barriers that impair the ability of community clinics
and health centers to participate as providers in the Drug
Medi-Cal Program and as providers contracted with county
specialty mental health plans should be eliminated. This bill
will help community clinics more easily provide substance use
disorder treatment and medically necessary specialty mental
health services to our most vulnerable communities by allowing
FQHCs and RHCs to elect reimbursement on a FFS basis instead
of the PPS basis, thereby expanding the services offered and
provider types available at FQHCs and RHCs.
2)Background on FQHCs and RHCs. FQHCs and RHCs are federal
designated clinics that are required to serve medically
underserved populations that provide primary care services.
FQHCs and RHCs provided over 10.5 million Medi-Cal visits in
2013. Medi-Cal reimbursement to FQHCs and RHCs is governed by
state and federal law. FQHCs and RHCs are reimbursed by
Medi-Cal on a per-visit rate which is known as the PPS. For
Medi-Cal managed care plan patients, DHCS reimburses FQHCs and
RHCs for the difference between its per-visit PPS rate and the
payment made by the plan. This payment is known as a "wrap
around" payment. The Medi-Cal managed care wrap-around rate
was established to reimburse providers for the difference
between their PPS rate and their Medi-Cal managed care
reimbursement rate.
3)Specialty mental health and Drug Medi-Cal "carve out" and
contracting with FQHCs. The Medi-Cal Specialty Mental Health
Services Program and Drug Medi-Cal are "carved-out" of the
broader Medi-Cal program and is administered by DHCS and
operated under federal waivers approved by the Centers for
Medicare and Medicaid Services (CMS). DHCS contracts with a
MHP in each county to provide or arrange for the provision of
Medi-Cal specialty mental health services. Under the terms of
the specialty mental health waiver and state regulation, FQHC
services are not covered by county mental health plans.
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DHCS is in the process of implementing the new Drug Medi-Cal
waiver referred to as the Drug Medi-Cal ODS, under which
counties can elect to opt-in to administering the benefit, and
Medi-Cal beneficiaries will receive a richer drug treatment
benefit package than in counties that do not opt-in. As
counties have begun planning to implement the new Drug
Medi-Cal ODS, at least one county counsel in Los Angeles
County has questioned whether county specialty mental health
plans can claim FFP if they contract with FQHCs. This bill
would clarify that contracting with county specialty mental
health plans and county and state Drug Medi-Cal programs is
allowed, and that contracting would be through contract and
outside the normal PPS Medi-Cal rate paid to FQHCs and RHCs.
4)Support. This bill is jointly sponsored by the California
Primary Care Association (CPCA), the Los Angeles County Board
of Supervisors, and the Community Clinic Association of Los
Angeles County. CPCA writes that this bill will improve
Californian's access to substance use disorder treatment by
eliminating a barrier which prevents community health centers
from participating in Drug Medi-Cal and county specialty
mental health programs by allowing FQHCs the option to
contract with their counties for these services and be
reimbursed on par with other health care providers. CPCA
states that, under the Medi-Cal expansion and new DMC-ODS
waiver, FQHCs are critically needed in the behavioral health
continuum of care, but find it difficult to contract with
counties, even when the counties want to contract with health
centers. This contracting is important to better integrate
FQHCs into the county specialty mental health plan or Drug
Medi-Cal System. Such contracting also allows FQHCs to provide
different types of services with different types of providers
(i.e. peer support specialists, group counseling, drug abuse
counselors) which may be more limited under the current FQHC
PPS payment system. CPCA concludes that this bill will improve
access to behavioral health service by providing legal
certainty and clarify that FQHCs and RHCs can provide these
important behavioral health services outside of the PPS rate.
5)Drafting issue. FQHCs currently contract in some counties for
specialty mental health and Drug Medi-Cal services. While this
bill would clarify in the FQHC/RHC statute that FQHCs and RHCs
can contract for these services, the Los Angeles county
counsel memo that raised the contracting issue discusses a
different area in state county mental health plan regulation
as a barrier to contracting with FQHCs. The memo cites the
SB 1335 (Mitchell) Page 5 of ?
exclusion of FQHC services from county specialty mental health
plans in regulation, and a regulation that makes county
specialty mental health plans ineligible for federal financial
participation (FFP) for excluded services as barriers to
contracting with FQHCs under specialty mental health. The
author may wish to consider a clarifying amendment to the body
of law dealing with county specialty mental health plans that
clarifies their ability to contract with FQHC and RHCs and be
eligible for FFP.
SUPPORT AND OPPOSITION :
Support: Community Clinic Association of Los Angeles County
(co-sponsor)
California Primary Care Association (co-sponsor)
Los Angeles County Board of Supervisors (co-sponsor)
AIDS Project Los Angeles
Alliance for Rural Community Health
AltaMed Health Services Corporation
Asian Health Services
California Pan-Ethnic Health Network
Community Clinic Consortium
East Valley Community Health Center
Health and Life Organization, Inc.
Health Center Partners of Southern California
Kheir Center
La Clinica de La Raza
Los Angeles LGBT Center
Mountain Valleys Health Centers
Neighborhood Healthcare
North East Medical Services
Northeast Valley Health Corporation
Sacramento Native American Health Center, Inc.
San Ysidro Health Center
South Central Family Health Center
The Coalition of Orange County
Oppose: None received
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