BILL ANALYSIS
AB 1932
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Date of Hearing: April 20, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1932 (Hernandez) - As Amended: April 15, 2010
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. Establishes a
maximum Medi-Cal reimbursement rates for ambulance
transportation services. 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)Specifies the categories and maximum amount for reimbursement
rates for ambulance transportation services to be as follows:
Ground Mileage, Per Mile
$6.74
Advanced Life Support, Nonemergency Transport
$283.28
Emergency Transport, Level 1
$448.53
Basic Life Support, Nonemergency Transport
$236.07
Basic Life Support, Emergency Transport
$377.71
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Advanced Life Support, Level 2
$649.18
Specialty Care Transport
$767.21
4)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,
but not limited to, nursing, emergency medicine,
respiratory care, cardiovascular care, or a paramedic with
additional training.
EXISTING LAW :
AB 1932
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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 that 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; and,
b) Applying Medicare reimbursement formulas and payment
categories to Medi-Cal services to mitigate shortfalls.
CAA states that ambulance providers are an essential part of
California's health-care safety net and are unique Medi-Cal
providers: in that ambulance providers are required to
respond, treat and transport all emergency patients without
exception and without regard to a patient's ability to pay.
In most cases, ambulance providers are required to respond
within a mandated time period with fully equipped and
appropriately staffed ambulances.
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CAA states that while the costs to provide essential
ambulance services have significantly increased during the
past decade, reimbursement for these services by Medi-Cal
has not kept pace. 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. CAA estimates that
adjusted for 2010 and California cost of living, the
average cost in California is $586. 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
$118.20 paid per emergency transport, contrasted against
the actual cost of $586 to provide the service, the state
jeopardizes citizens' access to the benefit.
2)BACKGROUND . Medi-Cal provides ambulance and other medical
transportation only when ordinary public or private transport
is not appropriate 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 $118.02 for
daytime calls (7 a.m. to 7 p.m.) and $128.08 (for calls 7 p.m.
to 7 a.m.), plus $3.55 per mile. Current medical
transportation services reimbursement rates, including rates
for ambulance transportation are in state regulation.
Existing regulations prohibit rates from exceeding charges
made to the general public, and maximum rates for ambulance
transportation services are reimbursed using different
categories that this bill proposes, which is modeled on
Medicare. Existing Medi-Cal rates, effective March 1, 2010,
are as follows:
---------------------------------------------------------
|Ambulance service, basic life support (BLS) | $118.20|
|base rate, emergency transport, one way | |
|(includes allowance for emergency run) | |
|------------------------------------------------+--------|
|Non-emergency transportation, ambulance, base | 107.16|
|rate one way | |
|------------------------------------------------+--------|
|Response to call, 2 patients, each patient | 37.02|
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|(does not include an allowance for emergency | |
|run) | |
|------------------------------------------------+--------|
|Ambulance service, (BLS) per mile, transport | 3.55|
|one way | |
|------------------------------------------------+--------|
|Night call - 7:00 p.m. to 7:00 a.m. | 9.78|
|------------------------------------------------+--------|
|Emergency run | 9.88|
|------------------------------------------------+--------|
|Ambulance service, oxygen, administration and | 9.88|
|supplies, life sustaining situation | |
|------------------------------------------------+--------|
|Neonatal intensive care incubator | 51.49|
|------------------------------------------------+--------|
|Waiting time over 15 min. -each 15 min | 9.88|
|------------------------------------------------+--------|
|Compressed air for infant respirator | 10.23|
---------------------------------------------------------
---------------------------------------------------------
|Extra attendant -RN, EMT, or equivalent; (in addition to |
|normal crew of two): |
---------------------------------------------------------
---------------------------------------------------------
| First hour | 16.44|
---------------------------------------------------------
| Second and third hour, each hour | 11.51|
---------------------------------------------------------
| Each additional hour | 5.25|
---------------------------------------------------------
| Cost of IV fluids (invoice must be | By |
|attached) | Report|
---------------------------------------------------------
| ECG in ambulance | 16.07|
|------------------------------------------------+--------|
| Unlisted | By |
| |Report |
---------------------------------------------------------
3)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. It is also compared to the CAA estimated adjusted cost
for California in 2010.
Annual California Ambulance Services - By Source of Payment
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-------------------------------------------------------------
|Payment |% of |% of | 2005 Cost per |2005 |
|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 |
| | | | | |
-------------------------------------------------------------
4)PRUDENT PERSON STANDARD . Ambulance providers, unlike most
other Medi-Cal providers, are mandated to care for those who
require services. Providers such as physicians, dentists, and
surgeons may simply reject Medi-Cal patients. Ambulance
providers and hospital emergency departments are covered by
The Emergency Medical Treatment and Active Labor Act (EMTALA),
enacted in 1986, that prohibits the practice of patient
dumping, treatment denial, and patient discharge based on
anticipated high emergency treatment costs. Hospitals are
required to provide appropriate screening examinations to
determine whether emergency medical conditions exist,
regardless of patients' ability to pay. When emergency medical
needs are identified, EMTALA requires hospitals to stabilize
patients. This bill is proposing to apply the EMTALA standard
to Medi-Cal ambulance service, which is currently only
reimbursing when ordinary public or private conveyance is
medically contra-indicated and transportation is required for
obtaining needed medical care.
5)PREVIOUS AND RELATED LEGISLATION .
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a) AB 2173 (Beall) of 2010, establishes a $3 penalty on
every vehicle code violation to be matched in the Medi-Cal
Program and used to make supplemental payments for
emergency air medical transportation services in the
Medi-Cal. AB 2173 passed the Assembly Health Committee on
April 13, 2010.
b) AB 511 (De La Torre) of 2009, 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 matched with federal funds in the
Medi-Cal program and used for supplemental payments to
ambulance transportation services providers. AB 511 is
pending hearing in the Senate Health Committee.
c) AB 1174 ( Hernandez) of 2009, would have required
Medi-Cal to cover ambulance services when a patient
reasonably believes that without an ambulance a serious
health condition, as specified, might result, increased and
established in statute maximum Medi-Cal reimbursement rates
for ambulance transportation services, and required the
rates be adjusted per changes in the California Consumer
Price Index. AB 1174 died on the Assembly Appropriations
Committee Suspense File.
d) AB 2257 (Hernandez) of 2008 would have required Medi-Cal
to cover ambulance services when a patient reasonably
believes that without an ambulance a serious health
condition might result and established maximum Medi-Cal
reimbursement rates for ambulance transportation services.
AB 2257 on the Assembly Appropriations Committee Suspense
File.
e) AB 1153 (Beall) would have established a $3 penalty on
every vehicle code violation to be matched in the Medi-Cal
Program and used to make supplemental payments for
emergency air medical transportation services in the
Medi-Cal. AB 1153 died on the Assembly Appropriations
Committee Suspense File.
6)POLICY COMMENT .
a) REIMBURSEMENT FORMULA . This bill proposes to set the
Medi-Cal ambulance reimbursement rates at a specific dollar
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amount that is arrived at by a complex formula using a
weighted state average of Medicare rates and a relative
value unit factor. Medicare reimbursements are regionally
based, with rural and urban variations and there are
multiple regional rates for California. Medi-Cal uses a
statewide, uniform rate and under federal law, cannot
exceed Medicare. It is not easily ascertainable that the
proposed rate does not exceed Medicare. DHCS has stated
that the specific amount that was in AB 1174 exceeded
Medicare. This debate and calculation is more appropriate
in a budget committee or regulatory process than a policy
committee.
b) RATE INCREASE . 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 many provider
types are significantly less than Medicare rates. However,
given the state's current fiscal constraints and potential
cuts to existing health programs, should any Medi-Cal rate
increase for ambulance services be required at this time?
REGISTERED SUPPORT / OPPOSITION :
Support
California Ambulance Association (sponsor)
California Fire Chiefs Association
Fire Districts Association of California
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097