BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: SB 1200
S
AUTHOR: Leno
B
AMENDED: As Introduced
HEARING DATE: April 21, 2010
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CONSULTANT:
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Orr/cjt
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SUBJECT
Health care coverage: school-based health care
SUMMARY
Requires the Department of Managed Health Care (DMHC) and
the Insurance Commissioner to develop regulations to ensure
timeliness of care for school age children who must receive
medically necessary services during school hours.
CHANGES TO EXISTING LAW
Existing federal law:
Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.
Sec. 794) provides federal financial assistance to state
and local education agencies to guarantee special education
and related services to eligible children with
disabilities. It was intended to protect children and
adults with disabilities from exclusion, and unequal
treatment in schools, jobs and the community.
The Individuals with Disabilities Education Act (20 U.S.C.
Sec. 1400 et seq.) (IDEA) governs Individualized
Educational Programs (IEPs) and the special education
process. IDEA guarantees children with disabilities a 'free
appropriate public education" (FAPE) in the least
restrictive environment (LRE).
The Americans with Disabilities Act of 1990 prohibits
Continued---
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 2
discrimination on the basis of disability by employers,
public accommodations, state and local governments, public
and private transportation, and in telecommunications.
Existing state law:
Provides for the licensure and regulation of health care
service plans by the DMHC through the Knox-Keene Health
Care Service Plan Act of 1975, and provides for the
regulation of health insurers by the Insurance
Commissioner, (collectively referred to as health plans).
Requires DMHC and the Department of Insurance to develop
regulations governing the provision of timely access to
health care for specified settings.
Requires that the services provided by health care service
plans be available to enrollees at reasonable times and
makes a violation of its provisions a crime.
Requires the governing board of any school district to give
diligent care to the health and physical development of
pupils, and may employ properly certified persons for the
work.
Provides that each pupil who is required to take, during
the regular schoolday, medication prescribed for him or her
by a physician, may be assisted by the school nurse or
other designated school personnel if the school district
receives a written statement from the physician detailing
the method, amount, and time schedules by which the
medication is to be taken and a written statement from the
parent or guardian of the pupil indicating the desire that
the school district assist the pupil in the matters set
forth in the physician's statement.
Sets forth the scope of practice for nursing through the
Nursing Practice Act, which specifically includes the
administration of medication, and prohibits any person from
engaging in the practice of nursing without a license.
Existing regulations:
Establish standards for timely access to non-emergency
health care services the health plans have to follow, and
establishes additional metrics for measuring and monitoring
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 3
the adequacy of a plan's contracted provider network to
provide enrollees with timely access to needed health care
service.
Establishes standards for provider network access and
access to language assistance in obtaining health care
services.
This bill:
Requires DMHC and the Insurance Commissioner to develop
regulations that health plans must meet to ensure
timeliness of care for school age children who must receive
medically necessary services during school hours.
Deletes a requirement that DMHC and the Insurance
Commissioner report to specified committees of the
Legislature regarding their progress toward the
implementation of these regulations.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
T h is legislation seeks to clarify that existing law
requiring health plans and insurers to provide
beneficiaries with timely access to care, includes access
to medically necessary care for school age beneficiaries
that must be provided during school hours.
The author contends that, currently there are insufficient
numbers of school nurses to meet the needs of school
children who need care. Without access to licensed care
providers at school, children are forced to self administer
care inappropriately, and parents are forced to leave their
jobs or move their families to districts where the services
are available. The author notes that in 2007, the American
Diabetes Association sued the State of California because
of insufficient numbers of school nurses to care for
diabetic children who are too young to test their own blood
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 4
and inject insulin. The California Department of Education
(CDE) had entered into a settlement with the American
Diabetes Association, which allowed unlicensed school
personnel to administer insulin to students with diabetes
who have Section 504 or individual education plans (IEP).
The agreement was overturned by the California Supreme
Court in 2008, which found that it violated the California
Nurse Practice Act and the Americans with Disabilities Act.
As a result of the ruling, nurses must now be present on
campus to help monitor and administer insulin to diabetic
students who are unable to do it themselves.
This ruling also affects children suffering from seizures
and any other health condition that requires the
administration of medication. If the child has a 504 plan
or an I ndividualized Education Program (I EP ) indicating
that they must receive medical care at school , and the care
is a covered benefit , the author contends that the plan has
a responsibility to ensure that they have access to that
care at school. The author suggests that the requirements
in this bill could be met by plans and insurers contracting
directly with school districts to provide these services,
or by reimbursing for outside nurses to be available to
beneficiaries during school hours.
Timely access regulations
In 2002, the Legislature passed AB 2179 (Cohn), Chapter
797, Statutes of 2002, which required the DMHC to "develop
and adopt regulations to ensure that enrollees have access
to needed health care services in a timely manner." The
statute further required the department to develop
indicators of timeliness of access to care and specified
three indicators for the department to consider. The author
of the legislation contended that the law, at that time,
permitted plans to set their own standards for what
constituted timely access to medical care, and that neither
the previous Department of Corporations nor the current
DMHC had set such standards. The purpose of the bill was to
require DMHC to develop these standards.
Timely access to care is one of the principal indicators
for health care quality, according to the Institute of
Medicine, and is linked to significant improvement in
morbidity, mortality, and cost savings, according to the
Agency for Healthcare Research and Quality. The Legislature
declared that timely access to health care is essential to
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 5
safe and appropriate health care; and that, lack of timely
access to health care may be an indicator
of other systemic problems such as lack of adequate
provider panels, fiscal distress of a
health care service plan or a health care provider, or
shifts in the health needs of a covered population.
Status of the regulations
DMHC regulations regarding timely access recently went into
effect January 17, 2010, eight years after the original
legislation was passed. The regulations impact individual-
or employer-based HMOs and the handful of PPO plans
regulated by the Department of Managed Health Care.
Similar, though less extensive regulations were promulgated
by the Department of Insurance (DOI) in 2008 and apply to
insurers and contracted PPOs and IPAs in the state.
Under the DMHC regulations, each health plan must submit a
proposal to the DMHC for complying with the required time
standards, receive approval, and begin using the standards
within one year of the effective date of the regulation.
While these regulations set time standards, they also
provide doctors flexibility in scheduling appointments, as
long as doing so would not adversely affect the patient's
condition. Health plans must ensure that their contracted
provider network has adequate capacity and availability of
licensed health care providers to offer enrollees
appointments that meet specified timeframes, including 48
hours for urgent care appointments that do not require
prior authorization, 10 business days for non-urgent
primary care appointments, and triage or screening by
telephone 24 hours a day, 7 days a week.
Requirement to provide health care in schools
Numerous laws establish pupils' rights to receive health
care in a school setting. California statutes require the
governing board of any school district to give diligent
care to the health and physical development of pupils, and
may employ properly certified persons for the work. The
Americans with Disabilities Act of 1990 prohibits
discrimination on the basis of disability by a number of
entities, including schools.
The Individuals with Disabilities Education Act (20 U.S.C.
Sec. 1400 et seq.), and Section 504 of the Rehabilitation
Act of 1973 (29 U.S.C. Sec. 794) prohibit discrimination
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 6
against people with disabilities in programs that receive
federal financial assistance, in order to protect children
and adults with disabilities from exclusion, and unequal
treatment in schools, jobs and the community. Federal law
requires school districts to provide a "free appropriate
public education" (FAPE) to each qualified person with a
disability who is in the school district's jurisdiction,
regardless of the nature or severity of the person's
disability, under Section 504 regulations.
According to the Center for Health and Health Care in
Schools, a recent survey completed by 649 school nurses
indicated that 5.6 percent of children in grades K - 12
receive a medication at school on a typical school day. It
is estimated that there are at least 21,000 people with
diabetes under the age of 19 in California. Other chronic
illnesses or health conditions for which pupils in
California may require medically necessary care during
school hours in order to attend school include epilepsy and
asthma.
The larger number of children who now require medication
during the school day has prompted a focus on standards and
practices that guide student care. The potential for
continuous quality improvement (CQI) efforts to strengthen
school health is also being explored. A CQI tool for
school-based health centers has been developed; while
school nurses have piloted protocols for asthma and
diabetes management. Relevant school district and state
policies are also being reviewed.
School health centers
School health centers (SHC) provide a variety of diagnostic
and treatment services, including direct primary and mental
health care for acute and chronic illnesses, Child Health
and Disability Prevention (CHDP) exams, health education,
case management assistance and immunizations. They also
provide counseling for risk factors such as smoking,
substance abuse, teen sex, violence, and safety issues, as
well as behavioral problems ranging from mild to severe.
School boards have the final say over what services are
provided.
School health centers are administered by a variety of
organizations, including school districts, Federally
Qualified Health Centers (FQHC), community health centers,
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 7
hospitals, county health departments, and private physician
groups. A school health center will typically include
nurse practitioners, nurses, and mental health care
providers as well as part-time physicians and medical
students in training. Lab facilities for routine tests are
often located on the site. Some centers also offer dental
care. "School linked" health centers are located off campus
but have formal operating agreements with one or more
schools. In some cases, health services are provided on
campus by mobile vans.
As of February 2010, California has 153 school health
centers: 42 are in elementary schools (27 percent); 14 are
in middle schools (10 percent); 58 are in high schools (38
percent); 16 are on mixed-grade campuses (10 percent); and
23 are "school linked" or mobile vans (15 percent). During
a recent academic year, an estimated 262,000 students
received care from a school health center. In school
districts with school health centers, 21.5 percent of the
children live in families with incomes at or below the
federal poverty in contrast to 15.3 percent of the children
in districts without health centers. School health centers
are serving low-income students as well as immigrants still
learning English. These students are least likely to have
health insurance and more likely to experience difficulty
in school.
School health centers are financed through grants from
state, local, and private sources as well as reimbursements
from CHDP, Medi-Cal, Family PACT and Healthy Families.
According to the California School Health Centers
Association (CSHCA), more than half of SHCs recover less
than 50 percent of their operating costs from billing
sources.
In June of 2007, the Governor's Advisory Workgroup on
School-Based Health Centers developed several
recommendations in order to expand and sustain elementary
SHCs in the context of health care reform and universal
coverage for children, including:
increase access to primary care by serving as a primary
care or medical home, or providing services that extend
and complement a student's primary care home, including
promoting communication with the child's primary care
provider in order to avoid duplication and lack of
continuity.
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 8
facilitate outreach, enrollment and retention in health
insurance coverage programs for the school community.
Funding for school health centers
According to the California School Health Centers
Association (CSHC), school health centers currently expend
considerable effort to obtain a patchwork of funding from
local, state and federal sources, in-kind support from
schools and other sponsors, private donations and insurance
payments. Until recently, school health centers relied
heavily on local, state and federal grants and private
funding from foundations and hospitals. However,
uncertainty of these sources combined with a move toward
market-driven health care financing has increasingly led
school health centers to rely on reimbursements from
third-party payers. Although there are a handful of
California school health centers that are able to fund
themselves almost entirely through third-party billing,
there is a wide range in the amount of revenue centers
generate from billing. For example, 2004 data collected by
the CSHC found that among six school health centers run by
Federally Qualified Health Centers (FQHC), the percentage
of services reimbursed by third-party sources varied from
25 percent to 80 percent. Many school clinics recover less
than one-half of their costs.
In counties with fee-for-service Medi-Cal, school health
centers bill the state directly under the Local Educational
Agency (LEA) Medi-Cal Billing Option Program, established
in 1993. This LEA program provides the federal share of
reimbursement for health assessment and treatment for
Medi-Cal eligible children and family members within the
school environment. However, many counties have some form
of Medi-Cal managed care. This means that school health
centers cannot bill the state directly, but rather must
negotiate a contract with one or more health plans in order
to bill for the services they provide. Health plans serving
the Medi-Cal population vary in every county, and some have
been interested in working with school health centers. Note
that FQHCs enjoy a higher reimbursement rate that more
closely matches the cost of providing care.
California's school-based health centers obtain Healthy
Families reimbursement only if they are a child's
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 9
designated primary care provider under a contracted health
plan. Since the Healthy Families program operates through
contracts with managed care plans, school health centers
must negotiate contracts with each health plan to be able
to bill for Healthy Families.
The federal Children's Health Insurance Program (CHIP)
reauthorization bill - H.R. 2 (CHIPRA 2009) clarifies that
states can provide benefits and services under CHIP through
school-based health centers. This is the first explicit
recognition of SHCs as a potential provider of CHIP
services.
LA Care pilot project
L.A. Care Health Plan conducted a reimbursement pilot
project in 2005 to gain information on how school health
centers can better work with managed care organizations.
L.A. Care is the Local Initiative Medi-Cal managed care
organization for Los Angeles County and serves residents
through a variety of programs including Medi-Cal, Healthy
Families, Healthy Kids, and Medicare. The L.A. Care
reimbursement pilot found that although there was some
duplication of services between the school health centers
and PCPs, school health centers were an important site for
well care visits for students.
Related bills
SB 1051 (Huff) of 2010 would authorize school districts to
provide school employees with voluntary emergency medical
training to provide emergency medical assistance to pupils
with epilepsy suffering from seizures. Pending hearing in
Senate Health Committee.
AB 1802 (Hall) of 2010 would authorize a parent or guardian
of a pupil with diabetes
to designate one or more school employees as
parent-designated school employees for the purpose of
administering insulin to the pupil as necessary during the
regular schoolday when a credentialed school nurse or other
health care professional is not immediately available
onsite at the school. Pending in Assembly Business,
Professions, and Consumer Protection Committee.
AB 2454 (Torlakson) of 2010 would require the governing
board of a school district to employ at least one school
nurse, registered nurse, or licensed vocational nurse for
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 10
every 750 pupils on and after July 1, 2020. The bill would
require registered nurses and licensed vocational nurses to
provide health care services to pupils under the
supervision of a school nurse. Pending in Assembly
Education Committee.
Prior legislation
SB 564 (Ridley-Thomas), Chapter 381, Statutes of 2008,
expanded the definition of school health centers and
requires the State Department of Public Health (DPH), to
the extent funds are appropriated for implementation of the
Public School Health Center Support Program, to establish a
grant program to provide technical assistance and funding
for the expansion, renovation, and retrofitting of existing
school health centers and the development of new school
health centers, as specified.
AB 898 (Saldana) of 2007 would have required, until January
1, 2015, the Department of Public Health to establish and
administer a pilot grant program to award 3-year grants to
3-5 school health centers that use the "Promotores de
Salud" model, as defined, to administer a diet education
and obesity prevention program, as specified. Died on
suspense in Assembly Appropriations Committee.
SB 853 (Escutia), Chapter 713, Statutes of 2003, required
the DMHC and DOI to adopt regulations, by January 1, 2006,
to ensure that enrollees have access to language assistance
in obtaining health care services.
AB 2179 (Cohn), Chapter 797, Statutes of 2002, required the
Department of Managed Health Care and the Insurance
Commissioner to adopt, not later than January 1, 2004,
regulations to ensure access to needed health care services
in a timely manner. Required the department and the
commissioner to make specified reports to certain
committees of the Legislature on March 1, 2003, and March
1, 2004, regarding the progress towards the implementation
of these requirements. The bill also authorized the
Director of the Department of Managed Health Care to assess
an administrative penalty against a plan in specified
circumstances for its failure to comply with requirements
concerning timely access to care.
AB 1363 (Davis) of 1999 would have authorized the Managed
Risk Medical Insurance Board to include school-based health
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 11
centers as traditional and safety net providers that meet
certain requirements. The bill would have provided
guidelines for the creation of school-based and
school-linked health centers, established requirements and
guidelines for those providers, and would have set forth
student rights and responsibilities. Vetoed.
Arguments in support
The California School Nurses Association supports the bill,
and claims that the number of children with chronic
illnesses, specialized physical health care needs, and
medication needs attending our schools is constantly
rising. They claim that some of these children are
considered to be "special education" and some have IEPs.
Other children in 504 plans, are in regular education, and
some just get sick at school. As more of these children
need access to care during the school day, as ordered by
their physicians, it becomes a financial burden to the
school district and can prevent or limit access to the
multi facets of the educational day for many children.
The California Teachers Association supports this measure,
and claims that providing timely access for students will
ensure that children are ready to learn. This measure will
assist in providing mechanisms to better assist children
with health access.
Arguments in opposition
The Association of California Life and Health Insurance
Companies claims the bill will require health insurers to
contract with school districts to reimburse for services
provided by school nurses. They believe that the Department
of Insurance's "Provider Network Access Standards"
regulation already includes a requirement on insurers to
ensure that their network providers are duly licensed and
accredited, and that there are a sufficient number to
furnish health care services. They believe this bill would
result in an expensive cost shift to health insurers and
would be difficult to administer.
The California Association of Health Plans mentions that
California's timely access law applies to enrollees of
every age and without regard to whether they are at home,
at work, at school, or in between. They claim that health
plans can only ensure timely access to providers who are
under contract, therefore they believe it would be
STAFF ANALYSIS OF SENATE BILL 1200 (Leno) Page 12
impossible to ensure timely access to school-based health
care without requiring health plans to contract with every
school in California.
COMMENTS
1. Bill does not constitute a mandate as drafted.
According to the California Health Benefits Review Program,
this bill as written does not implement a provider
reimbursement mandate or a benefits mandate, and therefore
does not require a CHBRP analysis.
2. Bill represents a departure from previous timely access
standards. Current timely access standards and adequate
network standards do not require health plans to arrange
for or provide care using particular providers or in a
particular setting. The author has identified a conflict in
policies--between the policy that children with health care
needs be accommodated in order to attend school, and the
policy that health plans must ensure timely care is
provided, which is what the bill seeks to achieve by
extending the timely access standards.
3. Technical amendment. Change reference to the Senate
Committee on Insurance to the Senate Committee on Health.
Page 3, line 9, strike "Insurance" and insert "Health."
POSITIONS
Support: California School Nurses Organization
California Teachers Association (CTA)
Oppose: Association of California Life and Health
Insurance Companies
California Association of Health Plans
Health Net
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