BILL ANALYSIS
AB 1445
Page 1
Date of Hearing: April 21, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 1445 (Chesbro) - As Amended: April 15, 2009
SUBJECT : Medi-Cal: federally qualified health centers and
rural health clinics.
SUMMARY : Authorizes Medi-Cal reimbursement to federally
qualified health centers (FQHCs) and rural health clinics (RHCs)
for a maximum of two visits for one patient on the same day, as
specified. Specifically, this bill :
1)Authorizes reimbursement for a maximum of two visits, as
specified, on the same day at a single location under the
following conditions:
a) After the first visit the patient suffers an illness or
injury requiring additional diagnosis or treatment; or,
b) The patient has a medical visit and another health
visit.
2)Defines "medical visit" as a face-to-face encounter between a
FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified midwife, visiting nurse, or
comprehensive perinatal services practitioner.
3)Defines "another health visit" as a face-to-face encounter
between a FQHC or RHC patient and a clinical psychologist,
licensed clinical social worker, dentist, or dental hygienist.
4)Specifies that this bill constitutes a change in the scope of
services and that FQHCs and RHCs must file a scope of service
change as required by law.
5)Requires the Department of Health Care Services, no later than
March 30, 2010, to seek all necessary federal approvals in
order to implement this bill.
EXISTING LAW :
1)Defines in federal law a "community health center" (CHC) as a
public or private nonprofit entity that serves a population
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that is medically underserved, or a special medically
underserved population, as defined, and provides that CHCs may
apply for and receive federal Public Health Service (PHS) Act
Section 330 grant funds to support health center planning and
operation.
2)Defines in federal law a FQHC as a CHC, as in 1) above,
receiving PHS grant funds, but also including certain tribal
organizations, and requires the Medicare and Medicaid programs
to reimburse FQHCs at enhanced rates of payment using a
prospective payment system (PPS) per visit rate.
3)Establishes a statutory structure for Medi-Cal PPS
reimbursement of FQHCs and RHCs, requires rates to be
increased by the Medicare Economic Index applicable to primary
care services and identifies services that may be reimbursed
at FQHC rates as those defined in federal law as covered
benefits for FQHCs.
4)Defines in federal law FQHC services to include the services
of a physician, physician assistant, nurse practitioner,
certified nurse midwife, clinical psychologist, licensed
clinical social worker, or visiting nurse, as well as any
other ambulatory services offered by an FQHC which are
otherwise included in the respective state's Medicaid plan.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
necessary to take advantage of the availability of federal
Medicaid funds to support mental health services for Medi-Cal
patients served by FQHCs. The author points out that federal
Medicaid law permits reimbursement for same-day FQHC visits
for mental health services. The author contends that this
bill will allow FQHCs to better integrate behavioral health
services with medical care services which is a best practice
for dealing with mental health issues. The author notes that
numerous studies over the last 30 years have found high rates
of physical health problems and death among individuals with
serious mental illness. In addition, studies also reveal that
less than 50% of those with mental illnesses actually seek
help for their mental health condition while 80% of those same
individuals had a primary care visit within the previous six
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months. The author cites these statistics to underscore the
importance of primary care providers as the first line of
defense for detection and treatment of mental illness.
However, the author also points out that one in four patients
referred to specialty mental health or substance abuse
services never make it to the first appointment. The author
argues that this bill will allow clinic primary care providers
to make same day referrals for mental health treatment thus
increasing the chances that patients will actually make the
appointments and get the services they need.
2)BACKGROUND . California licenses nonprofit community clinics
and many licensed community clinics are also federally
designated as FQHCs. Under federal law, FQHCs and designated
RHCs are eligible for enhanced Medicare and Medicaid (Medi-Cal
in California) reimbursement. The rationale for the enhanced
reimbursement is to ensure that FQHCs do not use federal grant
funds intended for uninsured and special needs populations to
back-fill for potentially below-cost Medicare or Medi-Cal
rates. FQHC services are reimbursed in Medi-Cal on a fixed
"per visit" rate rather than by individual services. FQHC
provider types are specified in existing statue as those for
which a visit can be billed in a single day: physician,
physician assistant, nurse practitioner, certified nurse
midwife, clinical psychologist, licensed clinical social
worker, or a visiting nurse. Current law only allows multiple
billable visits in a single day if they are for medical and
dental services. Only mental health visits provided by a
clinical psychologist are separately billable FQHC visits, but
not for services on the same day as a medical visit. Mental
health visits are currently coded for Medi-Cal billing
purposes as a medical visit for which only one visit per
patient per day is allowed. The federal Substance Abuse and
Mental Health Services Administration released a report in
July 2008, titled "Reimbursement of Mental Health Services in
Primary Care Settings," which identified potential barriers
and solutions for reimbursement of mental health services.
This report was developed to improve access to mental health
services for persons with public insurance and recommended
authorizing same-day services billing for separate
practitioners as proposed in this bill.
3)FQHCs . FQHCs are federally funded public or nonprofit
community clinics that serve a high number of both Medi-Cal
and uninsured patients. FQHCs are open door providers that
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treat patients on a sliding fee scale basis and make available
a comprehensive array of health and social services regardless
of the patient's ability to pay. FQHCs are CHCs, a federal
grant program established in the 1960s to improve access to
primary and preventive care for individuals in medically
underserved communities and special populations, such as the
medically uninsured, homeless persons, and migrant
farmworkers. In 1996, the health center programs (migrant
health centers, community health centers, health care for the
homeless, and health centers for residents of public housing)
were consolidated under Section 330 of the federal PHS Act.
All PHS grant recipients are nonprofit, public, or otherwise
tax-exempt entities. CHCs receiving PHS grant funds, and
meeting specific federal requirements, are FQHCs entitled to
higher reimbursement under Medicare and Medicaid.
4)PRIOR LEGISLATION .
a) SB 260 (Steinberg) of 2007, a substantially similar
bill, was also vetoed. In returning SB 260, the Governor
stated, "While I support improving access to health care
services, including mental health services, I cannot
support this bill as it would increase General Fund
pressure at a time of continuing budget challenges?separate
billing for mental health services would lead to increased
costs that our state cannot afford."
b) SB 36 (Chesbro), Chapter 527, Statutes of 2003, creates
a statutory structure for the implementation of a PPS for
Medi-Cal reimbursement of FQHCs, in response to the federal
Medicare, Medicaid, and State Children's Health Insurance
Program Benefits Improvement and Protection Act of 2000
(BIPA) which phased out cost-based reimbursement for
FQHC/RHCs and required states to implement a PPS or
federally-approved alternative.
c) SB 1413 (Chesbro) of 2002 would have restructured
Medi-Cal reimbursement for FQHCs in response to BIPA and
also contained a provision similar to the changes proposed
in this bill. Governor Gray Davis vetoed SB 1413.
5)SUPPORT . The sponsor of this bill, the California Primary
Care Association, writes in support that this bill will allow
FQHC clinics to more effectively develop and implement
integrated primary and behavioral health services, which, in
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the purest form, places the mental health professional into
the primary care setting as a team member working closely with
primary care providers. In these clinics, the primary care
provider may make a "warm handoff" to the on-site mental
health professional when they note the need for a further
mental health assessment, allowing the mental health
practitioner to promptly assess and treat the patient. The
California Mental Health Directors' Association (CMHDA)
supports this bill and believes that allowing billing for same
day medical and mental health visits will maximize federal
Medicaid funds and improve continuity of care for clinic
patients. CMHDA points out that same day services are the
hallmark of a fully integrated primary behavioral health care
model. The California Medical Association writes that medical
and mental health services are important components of an
integrated strategy for maintaining and improving health for
Medi-Cal beneficiaries and points out that mental health
treatment can improve patient compliance with chronic disease
management and treatment.
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REGISTERED SUPPORT / OPPOSITION :
Support
California Primary Care Association (Sponsor)
Alliance for Rural Health
AltaMed Health Services
American College of Obstetricians and Gynecologists
California Association of Marriage and Family Therapists
California Association of Rural Health Clinics
California Chiropractic Association
California Hospital Association
California Psychiatric Association
California Psychological Association
California School Centers Association
California School Health Centers Association
California Society for Clinical Social Work
California State Association of Counties
California State Rural Health Association
Community Clinic Association
County of San Bernardino
County of Santa Clara
Disability Rights California
Eisner Pediatric & Family Medical Center
North Coast Clinics Network
Six Rivers Planned Parenthood
Urban Counties Caucus
46 community clinics
Opposition
None on file.
Analysis Prepared by : John Miller / HEALTH / (916) 319-2097