BILL ANALYSIS
SB 1200
Page 1
Date of Hearing: June 22, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 1200 (Leno) - As Amended: June 1, 2010
SENATE VOTE : 22-10
SUBJECT : Health care coverage: timeliness of care.
SUMMARY : Requires the Department of Managed Health Care (DMHC)
and the California Department of Insurance (CDI) to update
timely access to care regulations, by January 1, 2012, to
include timeliness of care for school-age children who must
receive medically necessary services during school hours.
Specifically, this bill :
1)Requires DMHC and CDI to update regulations adopted to ensure
access to needed health care services in a timely manner, by
January 1, 2012, to include timeliness of care for school-age
children who must receive medically necessary services during
school hours.
2)Requires the updated regulations to:
a) Require health care service plans (health plans) and
insurers to work constructively with local education
agencies to provide reimbursement for covered health care
services provided to a child by the agency during school
hours.
b) Require health plans and insurers to ensure adequate
availability of licensed health care professionals to
accommodate the necessary medical needs of children during
school hours, including the administration of medically
necessary medications.
EXISTING LAW :
1)Provides for the licensure and regulation of health plans by
DMHC through the Knox-Keene Health Care Service Plan Act of
1975, and provides for the regulation of insurers by CDI.
2)Requires DMHC and CDI to develop regulations governing the
provision of timely access to health care for specified
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settings. Requires that services provided by health plans be
available to enrollees at reasonable times and makes a
violation of its provisions a crime.
3)Requires the governing board of a school district to give
diligent care to the health and physical development of
pupils, and permits employment of properly certified persons
for the work.
4)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.
FISCAL EFFECT : According to the Senate Appropriations
Committee:
Fiscal Impact (in thousands)
Major Provisions 2010-11 2011-12 2012-13 Fund
DMHC regulations $30 - $60
$115 - $175 $25 ongoing Special*
Potential increased CalPERS, likely low millions of dollars
annually General**
Medi-Cal, and Healthy commencing January 1, 2012,
uponFederal/
Families premiums completion of regulationsOther
*Managed Care Fund
**CalPERS: 55% General Fund and 45% other funds
Medi-Cal: 50% General Fund and 50% federal funds
Healthy Families: 65% General Funds and 35% federal funds
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, health insurers
currently do not assume financial responsibility for the provision
of covered health care services that are provided by school
districts, and the burden on school districts is rising much
faster than taxes are growing to finance the increase in needed
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services. Rising numbers of school age children suffer from
chronic or long term conditions such as asthma, diabetes, severe
allergies, mental health conditions, cardiac disease, epilepsy,
hemophilia, cancer, and other conditions. As a result, the scope
and acuity of medical care provided at school has dramatically
increased at the same time that schools have faced financial
challenges that have diminished the availability of licensed
school nurses. The author states that as school districts
increasingly are reducing or eliminating access to school nurses,
the burden has fallen on families to provide medical treatments
themselves, keep the child home from school, or change school
districts to one where a school nurse is available. The author
states that this bill seeks to clarify that it is the health plan
or insurers responsibility to ensure timely access to care to
school age children who require medically necessary health care
services during school hours. This requirement could be met
either by health 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.
2)TIMELY ACCESS REGULATIONS . According to the Institute of
Medicine, timely access to care is one of the principal indicators
for health care quality. Timely access is linked to significant
improvement in morbidity, mortality, and cost savings, according
to the Agency for Healthcare Research and Quality. AB 2179
(Cohn), Chapter 797, Statutes of 2002, requires DMHC to "develop
and adopt regulations to ensure that enrollees have access to
needed health care services in a timely manner." AB 2179 further
requires the development of indicators of timeliness of access to
care and specifies three indicators for DMHC to consider. The
author of AB 2179 contended that the law, at that time, permitted
plans to set their own standards for what constituted timely
access to medical care. Under AB 2179, the Legislature declared
that timely access to health care is essential to safe and
appropriate health care, and that lack of timely access to 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.
DMHC regulations regarding timely access went into effect January
17, 2010, and impact individual- or employer-based HMOs and the
handful of PPO plans regulated by DMHC. Under the DMHC
regulations, each health plan must submit a proposal to DMHC for
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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, seven days a week.
Similar, though less extensive, regulations were promulgated by
CDI in 2008.
3)PUPIL HEALTH . According to the Center for Health and Health Care
in Schools, a 2003 survey completed by 649 school nurses indicated
that 5.6% of children in grades K - 12 receive a medication at
school on a typical school day. Other chronic illnesses or health
conditions for which pupils in California may require medically
necessary care during school hours include epilepsy, asthma, and
diabetes. According to the American Diabetes Association (ADA),
there are nearly 15,000 school children with Type 1 diabetes. In
2007, the ADA sued the state of California because of insufficient
nurses to care for diabetic children who are too young to test
their own blood and inject insulin. On November 15, 2008, the
California Superior Court in Sacramento County overturned a
California Department of Education policy which allowed unlicensed
school personnel to administer insulin finding that it violated
the California Nursing Practice Act as well as the Americans with
Disabilities Act. The California Third District Court of Appeal
recently ruled that unlicensed school personnel are not authorized
by current law to administer prescribed injections of insulin to a
diabetic student. These court decisions and 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.
4)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,
preventative health 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
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mild to severe. SHCs are administered by a variety of
organizations, including school districts, Federally Qualified
Health Centers (FQHC), community health centers, hospitals, county
health departments, and private physician groups. As of February
2010, California had 153 school health centers: 42 in elementary
schools; 14 in middle schools; 58 in high schools; 16 on
mixed-grade campuses; and 23 "school linked" or mobile vans. In
school districts with school health centers, 21.5% of the children
live in families with incomes at or below the federal poverty in
contrast to 15.3% of the children in districts without health
centers. SHCs are financed through grants from state, local, and
private sources as well as reimbursements from the Child Health
and Disability Prevention Program, Medi-Cal, Family PACT, and
Healthy Families Program.
In June 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:
a) 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; and,
b) Facilitate outreach, enrollment and retention in health
insurance coverage programs for the school community.
5)FUNDING FOR SCHOOL HEALTH CENTERS . According to the
California School Health Centers Association (CSHC), more than
half of SHCs recover less than 50% of their operating costs
from billing sources. Until recently, SHCs 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 SHCs to rely on reimbursements
from third-party payers. Although there are a handful of
California SHCs 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 a FQHCs, the percentage of
services reimbursed by third-party sources varied from 25% to
80%.
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In counties with fee-for-service Medi-Cal, SHCs 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 SHCs 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 SHCs.
California's school-based health centers obtain Healthy Families
reimbursement only if they are a child's 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 2009 federal Children's Health Insurance
Program (CHIP) reauthorization bill clarifies that states can
provide benefits and services under CHIP through SHCs. This
is the first explicit recognition of SHCs as a potential
provider of CHIP services.
6)RELATED LEGISLATION . AB 1802 (Hall) would have authorized 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. AB 1802 failed
passage by a vote of 4-3 in the Assembly Business,
Professions, and Consumer Protection Committee.
AB 2454 (Torlakson) would have required the governing board of a
school district to employ at least one school nurse,
registered nurse, or licensed vocational nurse for every 750
pupils on and after July 1, 2020. AB 2454 would have required
registered nurses and licensed vocational nurses to provide
health care services to pupils under the supervision of a
school nurse. AB 2454 was held on suspense in the Assembly
Appropriations Committee.
SB 1051 (Huff) of 2010 would have authorized school districts to
provide school employees with voluntary emergency medical
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training to provide emergency medical assistance to pupils
with epilepsy suffering from seizures. SB 1051 was held on
suspense in the Senate Appropriations Committee.
7)SUPPORT . The California School Nurses Association (CNA)
states that the number of children with chronic illnesses,
specialized physical health care needs, and medication needs
attending our schools is constantly rising. CNA asserts that
some of these children are considered to be "special
education," some have individualized education programs, and
that other children in 504 plans, are in regular education,
and some just get sick at school. CNA states that 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 writes that that providing
timely access for students will ensure that children are ready
to learn, and will assist in providing mechanisms to better
assist children with health access. Health Access California
writes that managing diabetes is essential to minimizing
avoidable crippling complications and that this bill is an
effort to assure that children receive timely and appropriate
care for diabetes during the school day.
8)OPPOSITION . The Association of California Life and Health
Insurance Companies (ACLHIC) states that 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. ACLHIC further states that this bill would result
in an expensive cost shift to health insurers and would be
difficult to administer. The California Association of Health
Plans (CAHP) writes 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.
CAHP states that health plans can only ensure timely access to
providers who are under contract, therefore they believe it
would be impossible to ensure timely access to school-based
health care without requiring health plans to contract with
every school in California. Health Net states that this bill
will result in forced contracting as it would be impossible to
ensure timely access to school-based health care without
requiring health plans and insurers to contract with every
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school in California.
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees
American Nurses Association of California
Breathe California
California Nurses Association
California School Employees Association
California Teachers Association
Community Action to Fight Asthma
Health Access California
Opposition
Association of California Life and Health Insurance Companies
California Association of Health Plans
California Chamber of Commerce
California State Department of Finance
Health Net
Analysis Prepared by : Melanie Moreno / HEALTH / (916)
319-2097