BILL ANALYSIS �
AB 540
Page 1
Date of Hearing: April 5, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 540 (Beall) - As Introduced: February 16, 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)Authorizes the Department of Health Care Services (DHCS), in
consultation with the State Department of Alcohol and Drug
Programs (DADP), to establish alcohol and drug SBI services
for Medi-Cal beneficiaries who are pregnant women or women of
child bearing age in the Medi-Cal Program.
2)Requires DHCS, in implementing SBI, to do all of the
following:
a) Create an appropriate mechanism to enable a public
entity to pay the nonfederal share of the cost of providing
services;
b) Submit claims for federal financial participation for
the expenditures for the services as allowable under
federal law; and,
c) Establish standard, billing codes, and reimbursement
rates for the services
3)Requires the nonfederal share of expenditures submitted to
Centers for Medicare and Medicaid Services (CMS) for purposes
of claiming federal financial participation (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.
4)Requires DHCS, upon receipt of federal reimbursement for the
claim, including federal matching funds, to provide the
AB 540
Page 2
reimbursement to the public entity for which the claim was
submitted.
5)Permits DHCS to implement this bill by means of all county
letters, provider bulletins, and similar instructions.
6)Requires participation in the SBI Program to be voluntary for
a Medi-Cal beneficiary.
7)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.
8)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.
9)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.
10)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
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 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.
3)Requires, under federal law, a state that participates in the
Medicaid Program (Medi-Cal in California) to offer certain
benefits and allows states the option of providing other
specified benefits, including alcohol and substance abuse
AB 540
Page 3
screening and interventions services.
4)Authorizes, under federal law, the use of CPEs as the
nonfederal share of Medicaid spending.
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 provided 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. This bill would allow more counties
to provide these critical screenings and brief interventions
to help expectant mothers give birth to healthy babies.
2)BACKGROUND . Effective January 2007, CMS approved new billing
codes 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. 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. In 2008, Medicare also created parallel codes
to allow for similar services to persons over 65. Medicare
does not cover "screening" so the Medicare billing codes focus
on "assessment."
According to a recent report funded by the State Department of
AB 540
Page 4
Public Health (DPH), Maternal, Child and Adolescent Health
(MCAH) Program entitled, "Perinatal Substance Use Screening in
California: Screening and Assessment with the 4P's Plus Screen
for Substance Use in Pregnancy," published by 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 is based on
data provided by these counties and the almost 80,000 screens
on pregnant women they collected. The demographics represent
the racial and ethnic diversity of the state as well as a mix
of income levels. There is slight overrepresentation of
Medi-Cal due to the additional participation of these
providers. 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.
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 birth weight, prematurity,
congenital anomalies, still births, and mental retardation.
Fetal Alcohol Spectrum Disorder describes a spectrum of
physical and nuero-developmental effects ranging from facial
dysmorphology 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 use. However, the 2008
MCAH Report cites a study that shows that ongoing maternal
substance abuse exposes children to domestic violence and
physical abuse at home.
4)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
AB 540
Page 5
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 is successful at
identifying pregnant women who use alcohol or drugs heavily,
as well as 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.
5)OUTCOMES .
a) The 2008 MCAH Report .
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;
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; and,
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.
AB 540
Page 6
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 nearly
equal to women who has tested negative.
---------------------------------------------------------------
|Outcome |Screened,|Screened |Screened | Tested |
| | | & | only |Negative |
| |assessed |assessed | | |
| | & | only | | |
| | 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% |
---------------------------------------------------------------
6)MEDI-CAL IMPLEMENTATION . 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 nonfederal 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 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 nonfederal share be provided
through CPEs.
CPEs are one of several mechanisms that a state may employ to
obtain FFP in the Medicaid Program without cost to the state
General Fund. Under a CPE arrangement, government providers
certify their Medicaid expenditures to the state and the state
obtains federal reimbursement on the basis of these CPEs.
Medicaid law allows states to finance the nonfederal share of
AB 540
Page 7
payments with CPEs as long as the funds are derived from state
or local tax revenue and certified by units of local or state
government as eligible for federal reimbursement. States are
responsible for ensuring that expenditures are eligible for
federal reimbursement by reviewing standard cost reports filed
annually by each government provider. In no event may the
reimbursement rate exceed the equivalent Medicare rate.
According to a March 2007 U.S. Government Accountability
Office Report on Medicaid Financing, at least 10 out of 19
states that implemented new financing mechanisms as a result
of CMS restrictions on other mechanisms adopted this approach.
In 2005, the State of California sought a five year federal
waiver as a Medicaid demonstration project under the authority
of Section 1115(a) of the Social Security Act. The nonfederal
share of Medi-Cal funds for 22 county and University of
California (UC) hospitals known as designated public hospitals
was shifted from State General Funds to CPEs. This allowed
the state to reduce the General Fund contribution and allowed
designated public hospitals to be reimbursed up 100% of the
equivalent Medicare rates. This financing mechanism was
renewed in the 2010 successor demonstration waiver. In
addition, the waiver enacts a new Low Income Health Program
(LIHP) that allows counties to provide health care coverage to
childless indigent adults, under age 65. The nonfederal share
of the LIHP will be funded using CPEs. County participation
is voluntary; however any county that participates is required
to offer a uniform minimum benefit package which does not
include alcohol and substance abuse prevention services, which
may be provided at county option.
7)SUPPORT . The California Psychiatric Association (CPA) argues
in support that the 2008 study conducted by Kaiser
demonstrates the effectiveness of this model. CPA further
states in support that screening and brief intervention
services would be a valuable addition to the health care
safety net and is the right thing to do. According to the
County of Santa Clara, also in support, although the State has
not tapped the federal revenue source of these services, many
counties provide them for pregnant women and adversely
affected children and bear the full cost. According to Santa
Clara this bill would establish a voluntary program that
allows counties to provide the nonfederal share of cost and
obtain a one-for-one match.
AB 540
Page 8
8)SUPPORT IF AMENDED . The American Congress of Obstetricians
and Gynecologists, District IX (ACOG-IX) writes in support
that Kaiser Permanente Northern California conducted a pilot
project called "Early Start" at their Oakland Medical Facility
where they performed universal brief screening and treatment
of all pregnant women. The program included any and all
needed treatment and the majority of the women responded well
to brief intervention. ACOG-IX further states that even after
the costs of screening and treatment, Kaiser Permanente
Northern California reported a cost savings of $1,500 per
birth. ACOG-IX also states interest in working with the
author for an amendment to require any program to be medically
accurate and up-to-date.
9)RELATED LEGISLATION . AB 678 (Pan) would authorize local
public entities, including fire districts to use CPEs to match
unreimbursed costs for Medi-Cal emergency transportation
services in the form of supplemental payments. AB 678 is
pending in this committee.
10)PREVIOUS LEGISLATION .
a) AB 1599 (Beall) of 2010 would have established the
Medi-Cal Alcohol and Drug 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 CPEs. AB 1599
died on suspense in the Assembly Appropriations Committee.
b) 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
AB 540
Page 9
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.
c) AB 2124 (Beall) of 2008 would have allowed counties to
set up a voluntary program to fund the state's share of SBI
in draw down federal funds. AB 2124 was held on the Senate
Appropriations suspense file.
d) 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.
e) AB 959 (Frommer), Chapter 162, Statutes of 2006, allows
state facilities (hospitals, veterans' homes, and clinics)
and clinics owned or operated by the state, cities, and UC
and health care districts to use local funds to obtain FFP
for supplemental Medi-Cal reimbursements for hospital
outpatient services.
f) AB 915 (Frommer), Chapter 747, Statutes of 2002,
authorizes local public agencies and public health
facilities to use local funds to obtain FFP for
supplemental Medi-Cal reimbursements for hospital
outpatient services.
REGISTERED SUPPORT / OPPOSITION :
Support
The American Congress of Obstetricians and Gynecologists,
District IX
California Psychiatric Association
Santa Clara County Board of Supervisors
Opposition
None on file.
Analysis Prepared by: Marjorie Swartz / HEALTH / (916)
319-2097
AB 540
Page 10