BILL ANALYSIS
AB 1599
Page 1
Date of Hearing: April 6, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1599 (Beall) - As Introduced: January 4, 2010
SUBJECT : Medi-Cal: alcohol and drug screening and brief
intervention services.
SUMMARY : Establishes the Medi-Cal Alcohol and Drug Screening
and Brief Intervention (SBI) Services Program for Medi-Cal
beneficiaries who are pregnant or women of childbearing age,
with county or local government entities paying the nonfederal
share of expenditures through certified public expenditures
(CPEs). Specifically, this bill :
1)Requires the Department of Health Care Services (DHCS), in
consultation with the Department of Alcohol and Drug Programs
(DADP), to administer the SBI services for the purpose of
increasing the state's ability to make available alcohol and
drug SBI services for Medi-Cal beneficiaries who are pregnant
or women of childbearing age.
2)Requires DHCS to administer SBI services in accordance with
federal regulations in certifying claimed expenditures in
order to be eligible for federal financial participation
(FFP).
3)Requires DHCS to do all of the following:
a) Provide evidence supporting the certification of CPEs;
b) Submit data to determine the appropriate amounts to
claim as expenditures qualifying for FFP;
c) Keep, maintain, and have readily retrievable any records
specified;
d) Fully disclose reimbursement amounts to which the
eligible public entity is entitled and any other records
required by the federal Centers for Medicare and Medicaid
Services (CMS);
e) Promptly seek any necessary federal approvals for the
implementation of this bill;
f) Submit claims for FFP for the expenditures for the
services that are allowable expenditures under federal law;
g) Submit, on an annual basis, any necessary materials to
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the federal government to provide assurances that claims
for FFP will include only those expenditures that are
allowable under federal law; and,
h) Create an appropriate mechanism to enable a public
entity to pay the nonfederal share of the cost of providing
services under this bill.
4)Requires the nonfederal share of expenditures submitted to CMS
for purposes of claiming FFP to be comprised of only those
funds that are paid by a public entity (county or other local
governmental entity) and certified in accordance with this
bill.
5)Requires DHCS, upon receipt of federal reimbursement for the
claim, including federal matching funds, to provide the
reimbursement to the public entity for which the claim was
submitted.
6)Permits DHCS to implement, interpret, and make specific this
bill by means of all county letters, provider bulletins, and
similar instructions.
7)Requires participation in the SBI Program to be voluntary for
a Medi-Cal beneficiary.
8)Requires participation in the SBI Program, and results of the
screening, to be maintained in the beneficiary's confidential
medical records, and subject to all confidentiality
requirements applicable to medical records.
9)Requires all participating public entities to enter into and
abide by an agreement with DHCS regarding the implementation
and reimbursement of the costs to DHCS.
10) States legislative intent of this bill to provide alcohol
and drug SBI services to Medi-Cal beneficiaries who are
pregnant or who are women of childbearing age without General
Fund expenditures.
11) Requires this bill to be implemented only to the extent
federal funds are available.
EXISTING LAW :
1)Establishes DADP to develop and implement a statewide plan to
alleviate problems related to inappropriate alcohol use, and
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to license alcoholism and drug abuse recovery or treatment
facilities that provide a broad range of services in a
supportive environment for adults who are addicted to alcohol
or drugs.
2)Establishes the Medicaid Program (Medi-Cal in California)
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.
3)Existing federal law requires a state that participates in the
Medicaid Program to offer certain benefits and allows states
the option of providing other specified benefits, including
alcohol and substance abuse screening and interventions
services.
4)Existing Federal law authorizes the use of CPEs as the
non-federal share of Medicaid spending. CPEs are funds
certified by counties, university teaching hospitals, or other
public entities within a state as having been spent on the
provision of covered services to Medicaid beneficiaries.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, fetal alcohol
syndrome is one of the leading known preventable causes of
birth defects and developmental disabilities. Prenatal
exposure to alcohol, tobacco, and other drugs have been proven
to severely damage the development, formation, and functioning
of the fetal brain. The author states, citing the U.S.
Centers for Disease Control and Prevention, that
approximately one in 12 pregnant women admit to consuming
alcohol and one in 30 pregnant women said they had engaged in
binge drinking. The author argues that effective prevention,
intervention, and screening such as the SBI services can
reduce the incidence of exposed infants while significantly
reducing long term health care costs. Despite evidence of the
benefits, the author continues, SBIs have not yet been widely
used in primary care settings, emergency rooms, state licensed
facilities and clinics.
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2)BACKGROUND . Effective January 2007, new billing codes were
approved by CMS to allow Medicaid reimbursement for SBI
services. Specifically, states may add, as an optional
Medi-Cal benefit, alcohol and/or substance abuse, brief
intervention (15 to 30 minutes) and a longer structured
intervention distinct from other clinic and emergency
department visit services performed during the same encounter
and bill for alcohol. According to the author, due to the
absence of state action, twenty counties have chosen to begin
their own county-funded prenatal SBI programs. This bill
would allow counties to obtain federal matching funds for
these services.
According to a recent report funded by the Department of Public
Health (DPH) Maternal, Child and Adolescent Health (MCAH)
Program, "Perinatal Substance Use Screening in California,
Screening and Assessment with the 4P's Plus, Screen for
Substance Use in Pregnancy," NTI Upstream, 2008 (MCAH Report),
16 California counties have established a comprehensive system
of screening, assessment, and brief intervention in pregnant
women. The MCAH Report issued in 2008 is based on data
provided by these counties. The counties collected almost
80,000 screens. The demographics represent the racial and
ethnic diversity of the state as well as a mix of income
levels. There is slight over representation of Medi-Cal due
to the additional participation of these providers.
3)EFFECTS OF ALCOHOL, TOBACCO, AND ILLICIT DRUGS ON PREGNANCY .
According to the 2008 MCAH Report, numerous studies have shown
unfavorable birth outcomes result from alcohol and illicit
drug exposure during pregnancy. Poor perinatal outcomes
include preterm labor, low birthweight, prematurity,
congenital anomalies, still births, and mental retardation.
Fetal Alcohol Spectrum Disorder describes a spectrum of
physical and nuerodevelopmental effects ranging from facial
dysmorpholgy to learning and behavioral difficulties.
Alcohol-exposed children have consistently lower IQ scores
than non-exposed children. Cocaine and methamphetamine use
may interfere with transplacental blood flow and result in
poor fetal growth and premature labor as well as long term
effects on the function of the central nervous system.
According to the MCAH Report, there is no information on the
long term impact of methamphetamine. However, the 2008 MCAH
Report cites a study that shows that ongoing maternal
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substance abuse exposes children to domestic violence and
physical abuse at home.
4)PREVALENCE OF SUBSTANCE USE DURING PREGNANCY . According to
the data collected in the 2008 MCAH Report, 23.7% of the women
screened were at risk for substance use during pregnancy. Of
the women screened, 12.8% admitted to tobacco use in the month
prior to knowledge of the pregnancy, 16% admitted to alcohol
use and 6.6% admitted to marijuana use. The MCAH Program has
recently estimated that approximately 15.8% of women reported
drinking during the first or third trimester of their
pregnancy.
5)SBI PROGRAM PROCEDURE . The SBI is a comprehensive system of
screening, assessment, and brief intervention. A validated
screening tool is used by a specified medical professional at
the first prenatal care visit. Any woman who admits to use of
any alcohol, any marijuana, or any tobacco in the month before
she knew she was pregnant underwent immediate assessment for
substance abuse. Based on the assessment, conducted in the
primary prenatal care setting, any women who had evidence of
use during pregnancy or the month prior was defined as a
substance abuser. All women with a positive assessment were
provided a brief intervention and education regarding
substance use and its impact on pregnancy and child outcome
and, if appropriate, were offered a referral to a perinatal
treatment program.
According to the 2008 MCAH Report, the screening tool is
specifically designed for pregnant women and that it is
successful at identifying pregnant women who use alcohol or
drugs heavily, but also those whose pregnancies are at risk
from relatively small amounts. It also has been evaluated
across a variety of populations and income levels and showed a
high level of predictive validity.
6)OUTCOMES .
a) The results reported in 2008 MCAH Report are as follows:
i) Among women with a positive screen, approximately
40% of those who were drinking prior to knowledge of
pregnancy admitted to continuing to drink after they
learned of their pregnancy, giving an overall prevalence
of 6.5% continuing alcohol use in the total population.
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ii) The rate of admitted marijuana use in the
month prior to knowledge of pregnancy among the total
population of women was 6.6%, and 2.5% of the total
population continued to use marijuana after knowledge of
pregnancy.
iii) The rate of use of cocaine, heroin, and/or
methamphetamines with or without alcohol and/or marijuana
in the month prior to knowledge of pregnancy was 1.8%.
This rate dropped to 0.8% after the women learned of the
pregnancy.
b) Additional Studies . The author also cites a Kaiser
Permanente Northern California Early Start Program with
similar protocols. According to the data supplied by
Kaiser, the benefit of intervention is $1,504 per baby.
Northern California Kaiser found a rate of perinatal
alcohol and drug exposure at two sites that was higher than
the statewide average of 11.35%. Kaiser also found that
the existing strategies were unsuccessful at linking women
to a follow-up visit.
After making changes and adopting the brief intervention
protocol Kaiser reported the following data that shows that
women who participated in SBI had outcomes were nearly
equal to women who has tested negative.
-----------------------------------------------------------------
|Outcome |% |% |% |% Tested |
| |Screened |Screened & |Screened Only|Negative |
| |Assessed |Assessed | | |
| |& | | | |
| |Treated | | | |
|-------------------------+---------+---------+---------+---------|
|Low Birthweight |4.7 |8.1 | 8.8 |3.7 |
|-------------------------+---------+---------+---------+---------|
|Rate of Delivery Prior |6.4 |8.9 |10.3 |5.7 |
|to 37 Weeks | | | | |
|-------------------------+---------+---------+---------+---------|
|Rate of Fetal Demise |0.5 |0.8 | 7.0 |0.6 |
-----------------------------------------------------------------
7)SUPPORT . California State Association of Counties (CSAC)
writes in support that currently counties that provide
substance and alcohol SBI services to Medi-Cal beneficiaries
must bear the full cost of such services. This bill would
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create voluntary and confidential program to provide the
non-federal match. This would enable the state to draw down
federal revenue for counties already providing the services.
Counties are seeking ways to make scarce intervention and
treatment dollars stretch even farther. CSAC further argues
in support that this bill provides counties with much-needed
federal revenue stream-at no cost to the state-for these
valuable services. The Drug Policy Alliance argues in
support, that this bill is a mechanism to allow counties to
choose to invest more in these critical screening and brief
interventions to help reduce the incidence of exposed
newborns.
8)PREVIOUS LEGISLATION .
a) AB 217 (Beall) of 2009 would have established the
Medi-Cal Alcohol and Drug SBI Program for Medi-Cal
beneficiaries who are pregnant or women of childbearing
age, with county or local government entities paying the
nonfederal share of expenditures CPEs. AB 217 was vetoed
by Governor Schwarzenegger. In his veto message, he stated
that he and the author shared the goal of improving
alcohol, drug screening, and brief intervention services in
the Medi-Cal population and had proposed to include
screening and brief intervention services in the 2008 May
Revision which was not adopted by the Legislature. He
agreed that clinical data shows that screening and brief
interventions reduce avoidable health problems associated
with alcohol and drug abuse, including emergency room
utilization as well as reducing substance use-related
arrests and traffic violations. However he stated that AB
217 contained several significant problems that prevent its
implementation and put the state General Fund at risk.
b) AB 2124 (Beall) of 2008 would have allowed counties to
set up a voluntary program to fund the states share of SBI
in draw down federal funds. AB 2124 was held on the Senate
Appropriations suspense file.
c) AB 2129 (Beall) also of 2008 would have required DPH to
collaborate with DADP in developing a model program for the
screening and treatment of pregnant women who are suffering
from drug and alcohol abuse. AB 2129 was held on the
Assembly Appropriations suspense file.
9)PROPOSED AMENDMENTS.
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a) Medi-Cal implementation as optional benefit . Under
federal Medicaid law states are required to provide
specified mandatory medical services. States are allowed
to provide certain "optional" benefits as long as they are
willing to pay for the non-federal share. The benefits are
required to be uniform and comparable, available
state-wide, and allow freedom of choice of providers.
Under this bill SBI services would be a county option and
would not be available statewide. These may be waived
either through either a Section 1915(b) or Section 1115
waiver or possibly as an administrative pilot project. To
avoid general fund costs, this bill provides that the
non-federal share be provided through CPEs. This is a
mechanism that is used in the Section 1115(b)
Hospital/Uninsured Waiver. It allows federal matching
funds for unreimbursed services provided by county and
University of California hospitals and eliminates general
funds as the non-federal share. Federal approval would
also be required to allow these costs to be counted as
CPEs.
b) Single Source . The 2008 MCAH Report was prepared by an
entity that owns the copyright on the screening instrument.
All the reported data is collected by means of strict
adherence to this particular screening tool and
accompanying protocol. Much of the 2008 MCAH Report is a
promotion of this methodology. The supporting data clearly
substantiates the premise that use of alcohol and/or
illicit drugs during pregnancy has financial costs to the
Medi-Cal Program as well as social and financial costs to
California generally. It does not however, clearly support
the premise that the SBI Program is the most or only
cost-effective method of reducing these costs and improving
outcomes.
This bill should be amended to clarify that DHCS has
authority to implement this bill by State Plan Amendment,
waiver or any other authority permitted by CMS and that any
SBI services that meet federal Medicaid standards for
reimbursement are allowable as follows:
On page 3, delete lines 18 to 40, inclusive and insert:
(b) The department, in consultation with the State
Department of Alcohol and Drug Programs, may establish
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alcohol and drug screening and brief intervention services
for Medi-cal beneficiaries who are pregnant women or women
of child bearing age in the Medi-Cal Program.
(c) The department, in implementing this article, shall do
all of the following:
(1)Create an appropriate mechanism to enable a public
entity to pay the nonfederal share of the cost of providing
services pursuant o this article.
(2) Submit claims for federal financial participation for
the expenditures for the services described in subdivision
(b) that are allowable expenditures under federal law.
(3) Establish standards. Billing codes, and reimbursement
rates for the services described in subdivision (b) that
are consistent with Title XIX of the feral Social Security
Act (42U.S.C Sec. 1396).
REGISTERED SUPPORT / OPPOSITION :
Support
California State Association of Counties
California State PTA
Drug Policy Alliance
March of Dimes Foundation
National Association of Social Workers, California Chapter
Sacramento County Board of Supervisors
Santa Clara County Board of Supervisors
The ARC of California
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097