BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 1445
A
AUTHOR: Chesbro
B
AMENDED: June 1, 2009
HEARING DATE: July 8, 2009
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CONSULTANT:
4
Dunstan/sh
4
5
SUBJECT
Medi-Cal: federally qualified health centers and rural
health clinics
SUMMARY
Allows federally qualified health centers (FQHCs) and rural
health clinics (RHCs) to be reimbursed by Medi-Cal for
multiple visits by a patient with a single or different
health care professional on the same day at a single
location, when a patient has an appointment with a mental
health professional or has contracted an illness or been
injured and requires additional treatment.
CHANGES TO EXISTING LAW
Existing federal law:
Establishes the Medicaid program to provide comprehensive
health benefits to low-income persons. Requires the
Medicaid program to reimburse federally qualified health
centers (FQHCs) and rural health clinics (RHCs), at
enhanced rates of payment using a per-visit rate.
Existing state law:
Establishes the Medi-Cal program as California's Medicaid
program, administered by the Department of Health Care
Services (DHCS), which provides comprehensive health care
Continued---
STAFF ANALYSIS OF ASSEMBLY BILL 1445 (Chesbro) Page
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coverage for low-income individuals and their families;
pregnant women; elderly, blind, or disabled persons;
nursing home residents; and refugees who meet specified
eligibility criteria. Requires that Medi-Cal payments will
be made on a per-visit basis for services provided by FQHCs
and RHCs.
Establishes a statutory structure for Medi-Cal payments for
services provided by FQHCs on a per-visit basis.
Identifies those services that may be reimbursed as
services identified in federal law as covered benefits for
FQHCs and the types of health care providers whose services
may be reimbursed. Allows only one visit per day to be
reimbursed by Medi-Cal, except for a subsequent visit by a
patient to a dental professional with rates determined
prospectively.
This bill:
Allows FQHCs and RHCs to receive reimbursement for two
visits by a patient on the same day, provided the visits
are at a single location and either the patient suffers
illness or injury requiring additional diagnosis or
treatment after a medical visit, or the patient has made a
medical visit and subsequently visits a mental health
provider.
Requires DHCS to develop and adjust all appropriate forms
to determine which FQHC's and RHC's rates shall be adjusted
and to facilitate the calculation of the adjusted rates.
Requires DHCS to submit a state plan amendment to the
federal Centers for Medicare and Medicaid Services by
January 15, 2010, and by March 30, 2010 seek all necessary
federal approvals to implement this bill.
FISCAL IMPACT
According to the Assembly Appropriations Committee
analysis, this bill would result in annual costs of $1.7
million (50 percent General Fund) to provide an additional
11,500 same-day visits. This estimate assumes that less
than half of FQHCs and RHCs provide mental health services,
which is the most likely kind of visit to be added to an
existing visit for patients in need of additional care. In
addition, of those clinics providing mental health
STAFF ANALYSIS OF ASSEMBLY BILL 1445 (Chesbro) Page
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services, only a small proportion provides same day
appointments for mental health. Single patient visits are
reimbursed at a rate of $151 each.
BACKGROUND AND DISCUSSION
According to the author, in order to best provide
integrated behavioral health services to patients, many
community clinics and health centers provide medical and
mental health services on the same day. The author points
out that Medi-Cal does not provide reimbursement, however,
when a patient sees a primary care provider and a mental
health provider on the same day, even though federal law
allows two visits per day. The author argues that
California could take advantage of available federal funds.
The author also argues that primary care providers are
often the first line of defense for detection and treatment
of mental illness. According to the author, in
California's clinics, 95 percent of primary care providers
report providing mental health services and annually they
report over 800,000 mental health encounters of which
550,000 are by primary care physicians.
Clinics
FQHCs and RHCs serve a significant portion of the uninsured
and underinsured in California. They are open-door
providers that treat patients on a sliding fee scale basis
and make their services available regardless of a patient's
ability to pay. Currently, there are approximately 600
FQHCs and 350 RHCs in California. All FQHCs, and a
majority of the RHCs, are either non-profit community
clinics or government entities.
Because clinics are safety net providers, and care for a
significant number of the uninsured, their continued
survival depends heavily on the stability and adequacy of
revenues from the Medi-Cal program. To help preserve this
role, under federal law, FQHCs and designated RHCs are
eligible for enhanced Medicare and Medicaid (Medi-Cal in
California) reimbursement. The enhanced rate helps
compensate them for the uncompensated costs they occur in
caring for the uninsured. These FQHC and RHC services are
reimbursed in Medi-Cal on a fixed "per visit" rate rather
than by individual services.
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FQHC and RHC providers for which a visit can be billed in a
single day include: physician, physician assistant, nurse
practitioner, certified nurse midwife, clinical
psychologist, licensed clinical social worker, dental
hygienists or a visiting nurse. Current law only allows
multiple billable visits in a single day if they are for
dental services. Only mental health visits provided by a
clinical psychologist are separately billable FQHC visits,
but not for services provided on the same day as a medical
visit. Mental health visits are treated for Medi-Cal
billing purposes as a medical visit for which only one
visit per patient per day is allowed.
Prohibiting same-day services billing for separate
practitioners has been identified as a barrier to improved
access to mental health services for persons with public
insurance. This finding was contained in a July 2008
report by the federal Substance Abuse and Mental Health
Services Administration, which is titled "Reimbursement of
Mental Health Services in Primary Care Settings," The
report identified the limitation on same-day services
billing for separate practitioners as one of the seven
priority potential barriers and solutions for reimbursement
of mental health services in primary care settings.
Prior legislation
SB 260 (Steinberg) of 2007 was similar to this bill and
vetoed due to concerns about impacts of the bill on rate
calculations. This bill was vetoed by Governor
Schwarzenegger, who said in his veto message:
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.
Mental health services are already included in the
Medi-Cal rates for federally qualified health centers
and rural health clinics. Allowing separate billing
for mental health services would lead to increased
costs that our state cannot afford.
SB 36 (Chesbro), Chapter 527, Statutes of 2003, established
a statutory structure for Medi-Cal payments for services
provided by FQHCs and RHCs in compliance with federal law,
changing from fee-for-service to a per-visit basis.
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Arguments in support
The California Primary Care Association, the sponsor,
writes in support that this bill will allow FQHC clinics to
more effectively develop and implement integrated primary
and behavioral health services. They point out that
community based primary care is often the first line of
defense for detection and treatment of behavioral issues
and is often the first point of contact for identifying and
treating individuals who otherwise might face stigma,
cultural or other barriers to accessing traditional
behavioral and mental health services. Disability Rights
California supports this bill because the existing Medi-Cal
requirements create a burden for the individual who must
come back to the facility a second time and leaving the
individual untreated for one of the conditions in the
meantime.
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PRIOR ACTIONS
Assembly Floor: 78-0
Assembly Appropriations:17-0
Assembly Health: 17-0
POSITIONS
Support: California Primary Care Association (sponsor)
American College of Obstetricians and Gynecologists
California Hospital Association
California Mental Health Directors Association
California Psychological Association
California Psychiatric Association
Disability Rights California
National Association of Social Workers
San Bernardino County Board of Supervisors
Santa Clara County Board of Supervisors
Urban Counties Caucus
Oppose: None received
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