BILL ANALYSIS
AB 1174
Page 1
Date of Hearing: April 21, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 1174 (Hernandez) - As Amended: April 2, 2009
SUBJECT : Medi-Cal: ambulance transportation services.
SUMMARY : Requires Medi-Cal to cover ambulance services when a
patient reasonably believes that without an ambulance a serious
health condition, as specified, might result. Increases and
establishes in statute maximum Medi-Cal reimbursement rates for
ambulance transportation services, and requires the rates be
adjusted per changes in the California Consumer Price Index (CA
CPI). Specifically, this bill :
1)Requires, notwithstanding any other provision of law,
emergency basic life support and advanced life support
services to be covered under the Medi-Cal Program when, as
determined by the Department of Health Care Services (DHCS), a
patient could reasonably expect that an absence of immediate
medical attention would do at least one of the following:
a) Place the person's health in serious jeopardy;
b) Create a serious impairment to bodily function; or,
c) Result in a serious dysfunction in any bodily organ or
part.
2)Requires, notwithstanding any other provision of law,
reimbursement for emergency and nonemergency basic life and
advanced life support transportation to be made in accordance
with this bill, but prohibits rates from exceeding charges
made to the general public.
3)Requires maximum reimbursement rates for ambulance
transportation services to be as follows:
Ground Mileage, Per Mile
$7.00
Advanced Life Support, Nonemergency Transport
$369.15
Emergency Transport, Level 1
$584.49
Basic Life Support, Nonemergency Transport
$307.62
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Basic Life Support, Emergency Transport
$492.20
Advanced Life Support, Level 2
$845.97
Specialty Care Transport
$998.78
4)Requires DHCS to adjust the rates in 3) above each year in
accordance with the most recently determined annual change in
the CA CPI.
5)Defines, for purposes of this bill, the following:
a) "Advanced Life Support, Level 2" as either one of the
following:
i) Transportation by ground ambulance vehicle,
medically necessary supplies and services, and the
administration of at least three medications by
intravenous push/bolus or by continuous infusion,
excluding crystalloid, hypotonic, isotonic, and
hypertonic solutions such as dextrose, normal saline, and
Ringer's solution; or,
ii) Transportation, medically necessary supplies
and services, and the provision of at least one of the
following advanced life support procedures:
(1) Manual defibrillation/cardioversion;
(2) Endotracheal intubation;
(3) Central venous line;
(4) Cardiac pacing;
(5) Chest decompression;
(6) Surgical airway; and,
(7) Intraosseous line.
b) "Specialty Care Transport" as interfacility
transportation of a critically injured or ill beneficiary
by a ground ambulance vehicle, including medically
necessary supplies and services, at a level of service
beyond the scope of an emergency medical
technician-paramedic. Specialty Care Transport is
necessary when a beneficiary's condition requires ongoing
care that must be furnished by one or more health
professionals in an appropriate specialty area, including,
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but not limited to, nursing, emergency medicine,
respiratory care, cardiovascular care, or a paramedic with
additional training.
EXISTING LAW :
1)Establishes the Medi-Cal program, administered by DHCS, which
provides comprehensive health benefits to low-income children,
their parents or caretaker relatives, pregnant women, elderly,
blind or disabled persons, nursing home residents, and
refugees who meet specified eligibility criteria.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes emergency and nonemergency medical
transportation.
3)Establishes, through regulation, maximum reimbursement rates
for medical transportation services under Medi-Cal, and
prohibits billing from exceeding charges made to the general
public.
4)Defines, under Medi-Cal, a service as "medically necessary" or
a "medical necessity" when it is reasonable and necessary to
protect life, prevent significant illness or significant
disability, or alleviate severe pain.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . This bill is sponsored by the
California Ambulance Association (CAA), which argues this bill
would substantially alleviate the crisis the state's emergency
medical services systems faces by: a) Applying a "prudent
layperson" definition that establishes the medical necessity
for a patient's ambulance transport; b) Applying Medicare
reimbursement formulas and payment policies to Medi-Cal
services to mitigate the current shortfall; and, c)
Establishing an annual update to Medi-Cal payment rates based
on the CA CPI so that the crisis is addressed now and for the
future. CAA states ambulance providers are an essential part
of California's health-care safety net and are unique in two
ways when compared to other Medi-Cal providers: a) ambulance
providers are required to respond, treat and transport all
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emergency patients without exception and without regard to a
patient's ability to pay; and, b) in most cases, ambulance
providers are required to respond within a mandated time
period with fully equipped and appropriately staffed
ambulances.
CAA states that while the costs to provide essential ambulance
services have significantly increased during the past decade
including: escalating wages and benefits; increasing
insurance fees; and, newly-mandated equipment, including
vehicles and supplies; reimbursement for these services by
Medi-Cal has not kept pace with these increased costs. In a
recently-completed Governmental Accounting Office analysis of
ambulance costs, it was determined that the average cost of
providing ambulance service on a per trip basis was $583.
Medi-Cal beneficiaries comprised 21% of the total number of
patients in 2007. CAA states it is not difficult to conclude
that, if the state does not address the current inequity in
the Medi-Cal reimbursement rate of $117.02 paid per emergency
transport, contrasted against the actual cost of $496 to
provide the service, the state jeopardizes citizens' access to
the benefit. CAA states that increasingly, ambulance patients
are refused or diverted from the closest or most appropriate
receiving hospitals due to their funding shortfalls and the
lack of qualified personnel to treat the patient. These
ambulance diversions not only endanger the patient by
prolonging access to needed care, but also these diversions
result in increased emergency medical services system costs.
2)BACKGROUND . According to the Medi-Cal policy manual, Medi-Cal
covers ambulance and other medical transportation only when
ordinary public or private conveyance is medically
contra-indicated and transportation is required for obtaining
needed medical care. To receive reimbursement, a recipient
must be eligible for Medi-Cal on the date of service.
Ambulance providers are instructed to use the Basic Life
Support base rate, emergency transport, one way when billing
for responses to a 911 call. The maximum reimbursement rate
for this service is set at $117.02 for daytime calls (7 a.m.
to 7 p.m.) and $126.80 (for calls 7 p.m. to 7 a.m.), plus
$3.51 per mile. Current medical transportation services
reimbursement rates, including rates for ambulance
transportation are in state regulation, although the rates in
regulation are reduced by 1% to reflect last year's budget
action. Existing regulations prohibit rates from exceeding
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charges made to the general public, and maximum rates for
ambulance transportation services are reimbursed differently
than this bill proposes, which is modeled on Medicare.
Existing rates, effective March 1, 2009, are as follows:
---------------------------------------------------------
|Ambulance service, basic life support (BLS) | $117.02|
|base rate, emergency transport, one way | |
|(includes allowance for emergency run) | |
|------------------------------------------------+--------|
|Non-emergency transportation, ambulance, base | 106.01|
|rate one way | |
|------------------------------------------------+--------|
|Response to call, 2 patients, each patient | 36.65|
|(does not include an allowance for emergency | |
|run) | |
|------------------------------------------------+--------|
|Ambulance service, (BLS) per mile, transport | 3.51|
|one way | |
|------------------------------------------------+--------|
|Night call - 7:00 p.m. to 7:00 a.m. | 9.78|
|------------------------------------------------+--------|
|Emergency run | 9.78|
|------------------------------------------------+--------|
|Ambulance service, oxygen, administration and | 9.78|
|supplies, life sustaining situation | |
|------------------------------------------------+--------|
|Neonatal intensive care incubator | 50.98|
|------------------------------------------------+--------|
|Waiting time over 15 min. -each 15 min | 9.78|
|------------------------------------------------+--------|
|Compressed air for infant respirator | 10.13|
---------------------------------------------------------
---------------------------------------------------------
|Extra attendant -RN, EMT, or equivalent; (in addition to |
|normal crew of two): |
---------------------------------------------------------
---------------------------------------------------------
| First hour | 16.28|
---------------------------------------------------------
| Second and third hour, each hour | 11.39|
---------------------------------------------------------
| Each additional hour | 5.20|
---------------------------------------------------------
| Cost of IV fluids (invoice must be | By |
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|attached) | Report|
---------------------------------------------------------
| ECG in ambulance | 15.91|
|------------------------------------------------+--------|
| Unlisted | By |
| |Report |
---------------------------------------------------------
3)CA CPI . This bill requires Medi-Cal ambulance transportation
service rates to be adjusted annually in accordance with the
most recently determined annual change in the CA CPI. Current
state law/regulation does not require rates to be adjusted
annually. According to the Department of Finance's web site,
the annual percentage change in the CA CPI between 2003 and
2008 is as follows:
---------
|2003|2.3%|
| | |
|----+----|
|2004|2.6%|
| | |
|----+----|
|2005|3.7%|
| | |
|----+----|
|2006|3.9%|
| | |
|----+----|
|2007|3.3%|
| | |
|----+----|
|2008|3.4%|
| | |
| | |
---------
4)HOW DOES MEDI-CAL RATE COMPARES WITH OTHER PAYERS ? CAA
provides the following comparison, which CAA states is from an
"Industry Performance Survey" done by Hobbs & Ong on behalf of
CAA:
Annual California Ambulance Services - By Source of Payment
-------------------------------------------------------------
|Payment |% of |% of | 2005 Cost per |2005 |
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|Source |Transport |Revenue | Transport |Average |
| | | | |Reimbursemen|
| | | | |t Per |
| | | | |Transport |
|----------+----------+----------+---------------+------------|
|Medicare | 34.9% | 34.9% | $562 | $ 520 |
|----------+----------+----------+---------------+------------|
|Medi-Cal | 21% | 10.7% | $562 | $ 250 |
|----------+----------+----------+---------------+------------|
|Facility | 8.2% | 8.9% | $562 | $ 723 |
|----------+----------+----------+---------------+------------|
|Private | 17.9% | 6.3% | $562 | $ 201 |
|pay | | | | |
|----------+----------+----------+---------------+------------|
|Other | 17.7% | 38.7% | $562 | $1,100 |
|insurers | | | | |
|----------+----------+----------+---------------+------------|
|Other | 0.3% | 0.2% | $562 |$ |
| | | | |342 |
| | | | | |
-------------------------------------------------------------
5)PREVIOUS LEGISLATION . This bill is similar to AB 2257
(Hernandez) of 2008 except that AB 2257 also would have
increased Medi-Cal rates for air ambulance providers. AB 2257
was held on the Assembly Appropriations suspense file.
6)RELATED LEGISLATION .
a) AB 511 (De La Torre) imposes, as a condition of
participation in the Medi-Cal Program, a quality assurance
fee on certain ambulance transportation services providers,
to be administered by DHCS. The proceeds from the fee
would be required to be deposited into the Medi-Cal
Ambulance Transportation Services Providers Fund, and
moneys in the Fund would be required to be available
exclusively to enhance federal financial participation for
ambulance transportation services under the Medi-Cal
Program or to provide additional reimbursement to, and to
support quality improvement efforts of, ambulance
transportation services providers, including increased
reimbursement for and improvement of the quality of the
provision of advanced life support services, as defined.
AB 511 is scheduled to be heard in the Assembly Health
Committee on April 28, 2009.
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b) AB 1153 (Beall) levies an additional penalty of $3 upon
every fine, penalty, or forfeiture imposed and collected by
the courts for all offenses involving a vehicle violation,
except certain parking offenses, in each county. Counties
would be required to establish in the county treasury an
emergency air medical transportation act fund into which
the penalty collected would be deposited, and the county
treasurer would transfer moneys in the county's emergency
air medical transportation act fund to the Controller for
credit to the Emergency Air Medical Transportation Act Fund
created by the bill, which would be continuously
appropriated to DHCS solely for the purposes of augmenting
Medi-Cal reimbursement paid to emergency air medical
transportation services providers. DHCS would be required
to use the moneys in the Emergency Air Medical
Transportation Act Fund and federal matching funds to
increase the Medi-Cal reimbursement or supplemental
payments for emergency air medical transportation services
in an amount not to exceed normal and customary charges
charged by the emergency air ambulance transportation
services provider. AB 1153 is scheduled to be heard in the
Assembly Public Safety Committee on April 28, 2009.
7)POLICY QUESTION . This bill addresses an important issue in
that provider payment rates in public programs are a key
factor in beneficiaries' ability to access program services
and the ability of providers to continue to provide services.
Medi-Cal reimbursement rates for ambulances, as well as for
many other provider types, are significantly less than
Medicare rates, and rates were reduced last year as part of
the mid-year budget reduction. However, given the state's
current fiscal constraints and potential cuts to existing
health programs, should a Medi-Cal rate increase for ambulance
services be required at this time?
REGISTERED SUPPORT / OPPOSITION :
Support
California Ambulance Association (sponsor)
Opposition
None on file.
AB 1174
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Analysis Prepared by : Scott Bain / HEALTH / (916) 319-2097