BILL ANALYSIS �
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 540
A
AUTHOR: Beall
B
AMENDED: April 7, 2011
HEARING DATE: June 29, 2011
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CONSULTANT:
4
Bain
0
SUBJECT
Medi-Cal: alcohol and drug screening and brief intervention
services
SUMMARY
Establishes the Medi-Cal Alcohol and Drug Screening and
Brief Intervention Services Program, to provide Medi-Cal
reimbursement for alcohol and drug screening and brief
intervention services provided to Medi-Cal beneficiaries
who are pregnant or women of childbearing age. Requires
the nonfederal share to be paid for by counties or other
governmental entities designated by the Department of
Health Care Services (DHCS) through certified public
expenditures (CPEs).
CHANGES TO EXISTING LAW
Existing law:
Establishes the Medi-Cal program, which is administered by
DHCS, under which qualified low-income individuals receive
health care services. The Medi-Cal program is, in part,
governed and funded by federal Medicaid program provisions.
This bill:
Requires DHCS, in consultation with the Department of
Continued---
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Alcohol and Drug Programs (DADP), to provide Medi-Cal
reimbursement for alcohol and drug screening and brief
intervention (SBI) services provided to Medi-Cal
beneficiaries who are pregnant women or women of
childbearing age.
Requires DHCS, in implementing this bill, to do all of the
following:
� Create an appropriate mechanism to enable a public entity
(county or other local governmental entity designated by
DHCS) to pay the nonfederal share of the cost of
providing services under this bill.
� Submit claims for federal financial participation (FFP)
for the expenditures for the services that are allowable
expenditures under federal law.
� Establish standards, billing codes, and reimbursement
rates for the SBI services that are consistent with
federal Medicaid law. Requires the SBI model used to be
the most medically appropriate and within current
standards of practice.
Requires the nonfederal share of expenditures submitted to
the federal Centers for Medicare and Medicaid Services
(CMS) for purposes of claiming FFP to be comprised of only
those funds that are paid by a public entity, as defined.
Requires DHCS to seek all necessary federal approvals in
order to implement this bill, including any amendments to
the state plan. Requires DHCS, to the extent that any
element or requirement of this bill is not approved, to
submit a request to CMS for any waivers necessary to
implement this bill.
Requires DHCS, upon receipt of federal reimbursement for
the claim, including FFP, to provide the reimbursement to
the public entity for which the claim was submitted.
Permits DHCS to implement, interpret, and make specific
this bill by means of all-county letters, provider
bulletins, and similar instructions without adopting
regulations pursuant to the Administrative Procedure Act.
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Makes participation in the SBI program voluntary for a
Medi-Cal beneficiary. Requires participation in the
program and results of the screening to be maintained in
the beneficiary's confidential medical records and to be
subject to all confidentiality requirements applicable to
medical records.
Requires a public entity that participates in the program
established under this bill, upon receiving FFP for CPEs
made for alcohol and drug SBI services, to reimburse the
state for any costs of creating and administering the
program.
Requires a public entity, as a condition of receiving FFP
for CPEs made for alcohol and drug SBI services under this
bill to enter into and abide by an agreement with DHCS for
the implementation of this bill, and to provide
reimbursement to DHCS for DHCS' administrative costs.
Implements this bill only if, and to the extent that,
federal funds are available for the purposes of this bill.
FISCAL IMPACT
According to the Assembly Appropriations Committee
analysis:
1)One-time state administrative costs of $200,000 to
$300,000 to DHCS to develop and manage a federal waiver
to qualify local SBI expenditures for matched funding.
On-going annual state administrative costs in the range
of $50,000. This bill requires local programs to pay the
state costs associated with the program, but the
mechanisms of payment would need to be established by
DHCS.
2)DHCS submitted a budget change proposal on a similar
subject in 2008 that included $1.6 million General Fund
(GF) and was rejected by the Legislature.
3)Although this bill expresses legislative intent to not
use any GF to support the activities in the bill, it
unclear the workload to garner federal support and
document local expenditures can be accomplished without
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an initial GF investment.
4)Potentially significant savings to the extent SBI reduces
or prevents substance abuse or results in improved birth
outcomes.
BACKGROUND AND DISCUSSION
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 cites data from the Centers for
Disease Control and Prevention that approximately 1 in 12
pregnant women admit to consuming alcohol and 1 in 30
pregnant women said they had engaged in binge drinking.
The author argues that effective prevention, intervention,
and screening services, such as the SBI services provided
under this bill, 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, and state licensed
facilities and clinics. This bill would allow more
counties to provide these critical SBI services to help
expectant mothers give birth to healthy babies.
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 interventions
(15 to 30 minutes), and longer structured interventions
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, 20 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."
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According to a 2008 report funded by the Department of
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 (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 screenings on pregnant women they
collected.
Effects of alcohol, tobacco and illicit drugs on pregnancy
According to the 2008 MCAH Report, numerous studies have
shown unfavorable birth outcomes resulting 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 neuro-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 MCAH Report
cites a study that shows that ongoing maternal substance
abuse exposes children to domestic violence and physical
abuse at home.
According to the data collected in the 2008 MCAH Report,
23.7 percent of the women screened were at risk for
substance use during pregnancy. Of the women screened,
12.8 percent admitted to tobacco use in the month prior to
knowledge of the pregnancy, 16 percent admitted to alcohol
use, and 6.6 percent admitted to marijuana use. The MCAH
Program has recently estimated that approximately 15.8
percent of women reported drinking during the first or
third trimester of their pregnancy.
According to the 2008 MCAH Report, the screening tool is
specifically designed for
pregnant women, and is successful at identifying pregnant
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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. Findings from the 2008 MCAH Report
are as follows:
� Among women with a positive screening, approximately 40
percent 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 percent continuing alcohol use in the total
population;
� The rate of admitted marijuana use in the month prior to
knowledge of pregnancy among the total population of
women was 6.6 percent, and 2.5 percent of the total
population continued to use marijuana after knowledge of
pregnancy; and
� 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
percent. This rate dropped to 0.8 percent after the
women learned of the pregnancy.
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 undergoes an immediate assessment for
substance abuse. Conducted in the primary prenatal care
setting, any woman who had evidence of use during pregnancy
or the month prior is defined as a substance abuser. All
women with a positive assessment are 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.
Additional studies
The author also cites a Kaiser Permanente Northern
California Early Start Program (Kaiser) with similar
protocols. According to the data supplied by Kaiser, the
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benefit of intervention is $1,504 per baby. Kaiser found a
rate of perinatal alcohol and drug exposure at two sites
that was higher than the statewide average of 11.35
percent. 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% |
---------------------------------------------------------------
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 statewide,
and allow freedom of choice of providers. Under this bill,
SBI services would be a county option, would not be
available statewide, and thus may require a federal waiver.
To avoid GF costs, this bill provides that the nonfederal
share be provided through CPEs.
Federal Medicaid regulations establish requirements on the
public funds that can be used as the state share to draw
down FFP in Medicaid. CPEs are one of several mechanisms
that a state may employ to obtain FFP and to make
supplemental payments to Medi-Cal providers without cost to
the GF. Under a CPE arrangement, government providers
certify their Medicaid expenditures to the state, and the
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state then obtains federal reimbursement on the basis of
these CPEs. Medicaid law allows states to finance the
nonfederal share of payments with CPEs as long as the funds
are derived from state or local tax revenue and are
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. The reimbursement
rate cannot exceed the equivalent Medicare rate.
Previous budget proposal
As part of the May Revise to the 2008-09 DHCS budget, DHCS
proposed adding new procedure codes to allow medical
providers to routinely screen at-risk patients and provide
appropriate SBI services at a cost of $1.6 million ($800,00
General Fund) in 2008-09. SBI services would have been
provided under the Medi-Cal to individuals ages 18 through
64 in hospital emergency departments. This proposal was
rejected by the Legislature and has not been proposed
again.
Related bills
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 was heard in in this
committee on June 22, 2011, and passed on an 8-0 vote.
Prior legislation
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.
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
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
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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 GF at
risk.
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.
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.
AB 959 (Frommer), Chapter 162, Statutes of 2006, allows
facilities (hospitals, veterans' homes, and clinics) and
clinics owned or operated by the state, cities, UC, and
health care districts to use local funds to obtain FFP for
supplemental Medi-Cal reimbursements for hospital
outpatient services.
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.
Arguments in support
The California Psychiatric Association (CPA) argues that
the 2008 study conducted by Kaiser demonstrates the
effectiveness of this model. CPA further states in support
that SBI services would be a valuable addition to the
health care safety net and is the right thing to do. Santa
Clara County states that, although the state has not tapped
federal revenues for these services, many counties provide
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them for pregnant women and adversely affected children and
bear the full cost. According to Santa Clara County, this
bill would establish a voluntary program that allows
counties to provide the nonfederal share of cost and obtain
a one-for-one match.
PRIOR ACTIONS
Assembly Health: 17- 0
Assembly Appropriations:17- 0
Assembly Floor: 78- 0
POSITIONS
Support: American Congress of Obstetricians and
Gynecologists
California Association of Alcohol and Drug
Program Executives
California Council of Community Mental Health
Agencies
California Maternal, Child and Adolescent Health
Directors
California Medical Association
California Psychiatric Association
California State Association of Counties
California State Association of Counties
California State PTA
City and County of San Francisco
County of San Diego
First 5 Association of California
First 5 LA
Mental Health Association in California
National Association of Social Workers,
California Chapter
Santa Clara County Board of Supervisors
Oppose: None on file.
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