BILL ANALYSIS
AB 235
Page 1
Date of Hearing: March 31, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 235 (Hayashi) - As Introduced: February 6, 2009
SUBJECT : Emergency services and care.
SUMMARY : Defines a "psychiatric emergency medical condition"
for purposes of the obligation of hospitals with emergency
departments to provide emergency care and services for
psychiatric emergency medical conditions, and the obligations of
health plans in such cases, and by reference, makes changes to
provisions in the Knox-Keene Health Care Service Plan Act of
1975 (Knox-Keene) requiring health plans to reimburse for
emergency services under specified conditions. Specifically,
this bill :
1)Defines a "psychiatric emergency medical condition" as a
mental disorder that manifests itself by acute symptoms of
sufficient severity that renders the patient as being either
of the following:
a) An immediate danger to himself or herself, or to others;
or,
b) Immediately unable to provide for, or utilize, food,
shelter, or clothing, due to a mental disorder.
2)Clarifies that the definition in 1) above does not expand,
restrict, or otherwise affect the scope of licensure or
clinical privileges for clinical psychologists or medical
personnel.
3)Includes as what may be necessary to relieve a psychiatric
emergency medical condition, the admission or transfer of the
patient to a psychiatric unit within a general acute care
hospital or to an acute psychiatric hospital. The definitions
in this bill are applicable to the statutory obligation
imposed on Knox-Keene health plans to pay for emergency care
and services until the care results in stabilization of the
health plan's enrollee.
4)Allows the transfer of a patient to a psychiatric unit of a
hospital, or to an acute psychiatric hospital, where necessary
to relieve or eliminate the psychiatric emergency, to only
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occur if in the opinion of the treating provider, the
patient's psychiatric emergency is such that, within
reasonable medical probability, no material deterioration of
the patient's emergency condition is likely to result from, or
occur during the transfer.
5)Imposes specific obligations, and limitations, related to the
duties of a hospital transferring a patient pursuant to 3)
above, and to the duties of the hospital to which the patient
is transferred. Requires the initial treating hospital to
seek to obtain the name and contact information of the
patient's health plan, and notify the health plan or the
health plan's contracting medical provider (medical group) of
the transfer, as specified. Requires the receiving hospital
to notify the health plan or medical group if the hospital has
the name and contact information of the patient's health plan.
Specifies that a hospital is not required to make more than
one telephone call to the health plan, if the health plan can
reach a hospital representative should the health plan or its
contracting medical group need to return the call.
6)Requires health plans to provide all hospitals in the state to
which one of the health plan's members might be transferred
with specific health plan contract information needed to make
the contact required by this bill, and to update the
information as necessary, but at least once a year.
7)Clarifies that nothing in this bill would require providers to
seek authorization to provide emergency care and services to a
patient with a psychiatric medical emergency condition.
EXISTING LAW :
1)Establishes Knox-Keene for the licensure and regulation of
health care service plans and specialized health care service
plans, including specialized plans covering mental health
services, by the Department of Managed Health Care (DMHC).
2)Requires in federal law, under provisions of the federal
Emergency Medical Treatment and Active Labor Act (EMTALA),
hospital emergency departments to provide emergency screening
and stabilization services without regard to the patient's
insurance status or ability to pay. EMTALA requires hospitals
to maintain an on-call roster of specialists in a manner that
best meets the needs of its patients.
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3)Requires in state law, licensed hospitals which maintain and
operate an emergency department, to provide emergency care and
services to any person requesting the emergency services or
care, or for whom emergency services or care is requested, for
any life-threatening or serious injury or illness, including a
psychiatric emergency medical condition.
4)Prohibits a hospital from conditioning the provision of
emergency services required pursuant to 3) above, on the
person's ethnicity, citizenship, age, preexisting medical
condition, insurance status, economic status, ability to pay,
or other specified characteristics. Also requires a hospital
to render emergency care and services without first
questioning the patient's ability to pay.
5)Defines "emergency care and services" for purposes of 3)
above, to mean medical screening, examination, and evaluation
by a physician, or, other appropriate personnel under the
supervision of a physician, as permitted by law, to determine
if an emergency medical condition exists and, if it does, the
care, treatment, and surgery by a physician necessary to
relieve or eliminate the emergency medical condition, within
the capability of the facility.
6)Includes within the meaning of emergency care and services,
for purposes of 3) above, an evaluation to determine if a
psychiatric emergency medical condition exists and the care
and treatment necessary to relieve or eliminate that
psychiatric emergency medical condition. This bill would
further define psychiatric emergency medical condition for
purposes of this requirement.
7)Prohibits a health plan from requiring a provider to obtain
authorization prior to the provision of emergency services and
care. Authorizes a health plan to require prior authorization
as a prerequisite for payment for necessary medical care
following stabilization of an emergency medical condition.
8)Requires every health plan contract or health insurance policy
issued, amended, or renewed on or after July 1, 2000, that
provides hospital, medical, or surgical coverage to provide
coverage for the diagnosis and medically necessary treatment
of severe mental illnesses of a person of any age, and of
serious emotional disturbances of a child, under the same
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terms and conditions applied to other medical conditions, as
specified.
9)Requires mental health benefits provided pursuant to 8) above
to include outpatient services, inpatient hospital services,
partial hospital services, and prescription drugs, if the plan
contract includes coverage for prescription drugs.
10)Prohibits a non-contracting hospital from billing an enrollee
of a Knox-Keene licensed health plan for post-stabilization
care following an emergency, unless one of the following
apply: a) the hospital is unable to obtain the name and
contact information of the enrollee's health plan; or, b) if
the patient (or the spouse or legal guardian) refuses to
consent to transfer to a facility contracted with the health
plan after stabilization.
11)Establishes uniform and specific requirements governing
communications between health plans and non-contracting
hospitals related to post-stabilization care of the health
plan's enrollee following an emergency.
12)Requires a health plan or its contracting medical provider
contacted by a non-contracting hospital seeking authorization
for post-stabilization care to do either of the following
within 30 minutes of the contact:
a) Authorize post-stabilization care; or,
b) Inform the non-contracting hospital that the health plan
will arrange for the prompt transfer of the enrollee to
another hospital.
13)Requires the non-contracting hospital, in cases where the
patient, the patient's spouse or the patient's legal guardian
refuses to consent to the patient's transfer to a contracted
facility, to provide a written notice to the patient, spouse,
or guardian indicating that the patient will be financially
responsible for further post-stabilization care at the
hospital.
14)Authorizes under provisions of the Lanterman Petris Short
(LPS) Act the involuntary commitment of individuals who by
reason of a mental disorder are a danger to themselves or
others, or gravely disabled, under specified conditions, but
only if the individual cannot be served voluntarily.
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FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
needed to clarify that the treatment necessary to relieve or
eliminate a psychiatric emergency may include inpatient
admissions. The author states that hospitals have been denied
payment for claims by health plans in cases where the hospital
treated a mental health emergency with an inpatient admission.
The author states that there have been instances where a
health plan automatically denies a claim for a psychiatric
inpatient admission based on the fact that the patient did not
have prior authorization. The author points out that health
plans are already obligated to pay for the care and treatment
necessary to alleviate the emergency, which in the case of a
psychiatric emergency may include an inpatient psychiatric
admission. The author argues that this bill will prohibit
health plans from denying payment for appropriate treatment of
a psychiatric medical emergency. According to the sponsor,
the California Hospital Association, this bill addresses
drafting errors from similar legislation last year, AB 2861
(Hayashi), which was vetoed by Governor Schwarzenegger.
2)EMTALA . EMTALA governs when and how a patient may be: a)
refused treatment; or b) transferred from one hospital to
another when he is in an unstable medical condition. EMTALA
applies to "participating hospitals" -- i.e., to hospitals
which have entered into "provider agreements" under which they
will accept payment from the federal Department of Health and
Human Services, Centers for Medicare and Medicaid Services
under the Medicare program for services provided to
beneficiaries of that program. In practical terms, this means
that it applies to virtually all hospitals in the U.S., with
the exception of the Shriners' Hospital for Crippled Children
and many military hospitals.
The provisions of EMTALA apply to all patients, and not just to
Medicare patients. Under EMTALA, any patient who "comes to
the emergency department" requesting "examination or treatment
for a medical condition" must be provided with "an appropriate
medical screening examination" to determine if he is suffering
from an "emergency medical condition." If there is a medical
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emergency, then the hospital is obligated to either provide
the patient with treatment until the patient's condition is
stable, or to transfer him to another hospital in conformance
with the statute's directives. A transfer to another facility
before the patient has become stable can only take place if it
is an "appropriate transfer." A transfer after the patient
has become stable is permitted and is not restricted by EMTALA
in any way. EMTALA's restrictions apply only to transfers
before the patient has become stable, either on his own or as
a result of medical treatment. EMTALA also provides that a
pre-authorization requirement imposed by a managed care
organization or a health insurer may not be allowed to prevent
or delay the performance of a medical screening evaluation or
the institution of necessary stabilizing treatment once it is
determined that an emergency medical condition exists.
3)SUPPORT . The California Hospital Association (CHA), sponsor
of this bill, writes in support that this bill is in response
to a veto of a similar bill, AB 2861 (Hayashi) of last year.
CHA writes that the Governor's veto was based on a drafting
error and the veto message encouraged the author and
stakeholders to fix this error in future legislation. CHA
explains that some HMOs and other health plans have mistakenly
denied payment for rendering emergency care to individuals
with a psychiatric emergency on the basis that the hospital
did not receive prior authorization for admission to a
psychiatric unit within a general acute hospital. CHA argues
this bill will address this issue by clarifying that these
admissions are necessary to relieve or eliminate a psychiatric
emergency medical condition and therefore do not require prior
authorization. Health Net writes in support that this bill
provides an exception to the law that prohibits moving a
patient in an emergent state, where the patient is solely
suffering from a mental health emergency, to an acute care or
psychiatric care facility and that this bill recognizes that
the emergency department may not be the best location to
evaluate and treat emergency mental health conditions. The
American Federation of State, County and Municipal Employees
(AFSCME) writes in support that allowing the transfer of a
patient to a psychiatric unit for the purpose of providing
care and treatment solely necessary to relieve or eliminate a
psychiatric emergency medical condition would meet the needs
of those with mental health conditions within our health care
system. AFSCME states they support the regulation of health
facilities by requiring care to be provided to any person
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requesting the services or care for any condition that could
be life threatening.
4)SUPPORT IF AMENDED . Disability Rights California (DRC) writes
that they support the notification provision in this bill
because it will help patients avoid denials of service or
disputes with their health plans concerning the need for prior
authorization for an emergency transfer. DRC states, however,
that they are concerned that this bill may be unclear as to
the impact on existing legal requirements of the LPS Act
relating to voluntary and involuntary treatment of persons
with mental health emergency conditions, and seeks a
clarifying amendment.
5)RELATED LEGISLATION . AB 244 (Beall), pending in the
Assembly, would expand the existing requirements imposed
on health care service plan contracts and health
insurance policies to cover mental health conditions to
require coverage for the diagnosis and treatment of a
mental illness of a person of any age and would define
mental illness for this purpose as a mental disorder
defined in the Diagnostic and Statistical Manual IV.
The requirement in AB 244 would not apply to coverage
under the California Public Employees' Retirement System
unless the board elects to purchase a plan, contract, or
policy that provides mental health coverage. AB 244 is
substantially similar to AB 1887 of 2008 which was vetoed
by Governor Schwarzenegger.
6)PREVIOUS LEGISLATION .
a) AB 1203 (Salas), Chapter 603, Statutes of 2008,
establishes uniform requirements governing communications
between health plans and non-contracting hospitals related
to post-stabilization care following an emergency, and
prohibits a non-contracting hospital from billing a patient
who is a health plan enrollee for post-stabilization
services, except as specified.
b) AB 1887 (Beall) would have required full-service health
plans and health insurers to cover the diagnosis and
medically necessary treatment of a mental illness, as
defined, of a person of any age, including a child, not
limited to coverage for severe mental illness as in
existing law. AB 1887 was vetoed by Governor
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Schwarzenegger. The Governor's veto message read:
This bill is similar to a measure I vetoed last
year. Without comprehensive health care reform that
fully addresses prevention, affordability, cost
containment and shared responsibility, I cannot
support one-sided mandates that place additional
costs on our health care system. This mandate is
estimated to increase health care costs for the
insured population by over $110 million annually.
Mandates like these are a significant driver of cost
and mean some individuals may lose their coverage
and not receive health care at all.
Californians deserve better when it comes to the
health care they receive. They deserve
comprehensive health care reform that places a
priority on prevention and wellness, provides
coverage for all, promotes shared responsibility and
makes health care more affordable.
c) AB 2861 (Hayashi), substantially similar to this
bill, would have revised and made more specific the
obligation of hospitals with emergency departments to
provide emergency care and services for psychiatric
emergency medical conditions, and, by reference, the
obligations of health plans in such cases. AB 2861
was vetoed by Governor Schwarzenegger. The Governor's
veto message read:
This bill contains numerous drafting errors that
render its provisions confusing at best and
potentially harmful to patients at worst. I would
encourage the author and stakeholders to fix these
errors in future legislation. At that time, I will
consider this legislation again.
7)AUTHOR'S AMENDMENT . The author has agreed to accept the
following amendment to address concerns raised by DRC:
On page 3, line 16, insert:
Nothing in this section shall be construed to permit
any transfer in contravention of the requirements
contained in the Lanterman Petris Short Act, commencing
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with Section 5000 of the Welfare and Institutions Code.
REGISTERED SUPPORT / OPPOSITION :
Support
California Hospital Association (sponsor)
American Federation of State, County and Municipal Employees
California Psychiatric Association
Health Net
Psychiatric Solutions, Inc.
Support If Amended
Disability Rights California
Opposition
None on file.
Analysis Prepared by : Deborah Kelch / HEALTH / (916) 319-2097