BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K Alquist, Chair
BILL NO: AB 235
A
AUTHOR: Hayashi
B
AMENDED: June 11, 2009
HEARING DATE: June 17, 2009
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CONSULTANT:
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Tadeo/
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SUBJECT
Emergency services and care
SUMMARY
Extends the definition of emergency services and care to
include additional screening, examination, and evaluation
by appropriate medical professionals to determine if a
psychiatric emergency medical conditions exists. Clarifies
hospital and health plan responsibilities regarding
psychiatric emergencies.
CHANGES TO EXISTING LAW
Existing federal law:
Existing federal law, under the Emergency Medical Treatment
and Active Labor Act, requires hospital emergency
departments to provide emergency screening and
stabilization services without regard to the patient's
insurance status or ability to pay.
Existing state law:
Existing state law provides, under the Knox-Keene Act, 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).
Continued---
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Existing state law requires 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.
Existing state law prohibits a hospital from conditioning
the provision of emergency services on the person's
ethnicity, citizenship, age, pre-existing medical
condition, insurance status, economic status, ability to
pay, or other specified characteristics.
Existing state law establishes the obligation of health
plans and insurers to pay for emergency care and services,
including psychiatric emergencies.
Existing state law, for purposes of these requirements,
defines emergency care and services to mean medical
screening, examination and evaluation by a physician, or,
to the extent permitted by applicable law, by other
appropriate personnel under the supervision of a physician,
to determine if an emergency medical condition exists. The
definition also provides for treatment and surgery by a
physician, necessary to relieve or eliminate an emergency
medical condition, within the capability of the facility.
It also specifies those capabilities which the hospital is
required to have as a condition of its emergency medical
services permit.
Existing state law defines emergency care and services to
include screening, examination, and evaluation by a
physician or other personnel to the extent permitted by
applicable law, and within the scope of their licensure and
clinical privileges, to determine if a psychiatric
emergency medical condition exists. Existing state law
also defines emergency care and services to include care
and treatment necessary to relieve or eliminate that
psychiatric emergency medical condition, within the
capacity of the facility.
Existing law also defines a patient as stabilized, when, in
the opinion of the treating provider, the patient's medical
condition is such that, within reasonable medical
probability, no material deterioration of the patient's
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condition is likely to result from, or occur during, a
transfer of the patient, as specified.
This bill:
Defines a psychiatric emergency medical condition as a
mental disorder that manifests itself by acute symptoms of
sufficient severity that it renders the patient as being
either an immediate danger to himself or herself or to
others, or immediately unable to provide for, or utilize,
food, shelter, or clothing, due to the mental disorder.
Clarifies that the treatment necessary to relieve or
eliminate a psychiatric emergency medical condition may
require admission or transfer to a psychiatric unit within
a general acute care hospital or an acute care psychiatric
hospital.
Specifies that a patient with a psychiatric emergency
medical condition may be transferred for treatment provided
that the treating provider determines that there will not
be any risk to the patient's condition as a result of the
transfer.
Creates a process for the hospital to notify the health
plan of the need to transfer a patient with a psychiatric
medical condition and when a transfer has occurred.
Allows a health plan to further transfer the patient to a
contracting facility, if not initially transferred to such
a facility, provided that the treating provider determines
that there will not be any risk to the patient's condition
as a result of the transfer.
FISCAL IMPACT
According to the Assembly Appropriations Committee analysis
of AB 235, there is no direct fiscal impact as a result of
the clarifying changes in the bill.
BACKGROUND AND DISCUSSION
According to the author, AB 235 is needed to remedy the
problem of hospitals being denied payment for rendering
emergency care to individuals with a psychiatric emergency
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who are members of an HMO or another health plan regulated
by the Department of Managed Health Care. The author
maintains that AB 235 addresses the concerns that led to
the Governor veto of AB 2861 last year, which contained
similar provisions.
Emergency Medical Treatment and Active Labor Act (EMTALA)
The federal EMTALA governs when and how a patient may be
refused treatment or be transferred from one hospital to
another when he or she is in an unstable medical condition.
EMTALA applies to hospitals participating in the federal
Medicare program. In practical terms, this means that it
applies to all hospitals in the United States, with the
exception of the Shriners' Hospital for Crippled Children
and many military hospitals. 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 or she is suffering from an emergency medical condition.
If the person has an emergency medical condition, the
hospital is obligated to either provide the person with
treatment until stable, or to transfer the person to
another hospital in conformance with EMTALA provisions.
EMTALA prohibits the practice of patient dumping, treatment
denial, and patient discharge based on anticipated high
emergency treatment costs.
AB 2861 (Hayashi) of 2008, which was substantially similar
to AB 235, was vetoed by the Governor. AB 2861 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. In his veto message, the Governor
stated, "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."
Related legislation
AB 244 (Beall) requires health plans and health insurers to
provide coverage for mental health and substance abuse
treatment under the same terms and conditions as other
medical conditions, creating parity between these and other
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health conditions. Exempts CalPERS and Medi-Cal from
requirements established by the bill. This bill is
currently in the Senate Health Committee.
Previous legislation
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. Prohibits a
non-contracting hospital from billing a patient who is a
health plan enrollee for post-stabilization services,
except as specified.
AB 1553 (Lowenthal), Chapter 722, Statutes of 2008
prohibits a health care service plan from basing decisions
to deny requests by providers for authorization or to deny
claim reimbursement on whether admission was voluntary or
involuntary, or on the method of
transportation to the health care facility.
AB 1887 (Beall) of 2008 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. This bill was vetoed by the Governor.
Arguments in support
The California Hospital Association, sponsor of the bill,
states that oftentimes, in order to treat a patient with a
psychiatric emergency, a hospital may need to admit or
transfer the patient for admission to a psychiatric unit
within a general acute hospital or an acute psychiatric
hospital. The California Hospital Association further
states that some HMOs and other health plans have
mistakenly denied payment for these services on the basis
that the hospital did not have a prior authorization for
admission. The California Hospital Association contends
that since these services are for emergency care, prior
authorization is not required under current law.
The California Psychiatric Association states that AB 235
would reaffirm the obligations of health plans and insurers
to cover emergency mental health services and care, which
they are obliged to do within the Mental Health Insurance
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Parity article of the Knox-Keene Act.
PRIOR ACTIONS
Assembly Floor: 78-0
Assembly Appropriations: 16-0
Assembly Health: 19-0
POSITIONS
Support: California Hospital Association (sponsor)
American Federation of State, County and
Municipal Employees (AFSCME)
American Association for Marriage and Family
Therapy
Area Agency on Aging of Lake and Mendocino Counties
PSA 26
California Mental Health Directors Association
California Psychiatric Association
California Senior Legislature
Disability Rights California
Emergency Nurses Association
NAMI California
National Association of Social Workers
Oppose: None received
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