BILL ANALYSIS �
AB 652
Page 1
Date of Hearing: May 3, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 652 (Mitchell) - As Amended: April 25, 2011
SUBJECT : Child health.
SUMMARY : Requires the costs of specified health assessments and
forensic medical evaluations of children in out-of-home
placements to be reimbursed by individual and group health plans
(health plans) and by plans participating in the Medi-Cal and
Healthy Families (HFP) Programs. Specifically, this bill :
1)Defines initial health assessment for children who have been
placed out-of the home within the last 30 days and requires
that it meet or exceed the guidelines established by the Child
Health and Disability Prevention Program (CHDP).
2)Defines forensic medical evaluation to mean an examination
performed by a qualified medical professional at the request
of a local child welfare agency that includes diagnostic
testing necessary to provide a complete evaluation.
3)Requires all health plans, except specialized health plans, to
cover an initial health assessment or forensic medical
evaluation in contracts issued, amended or renewed after
January 1, 2012, and prohibits the requirement of prior
authorization.
4)Prohibits Medi-Cal managed care (MCMC) plans, if permitted
under federal law, and a plan participating in HFP from
requiring prior authorization for the provision of an initial
health assessment or forensic medical evaluation.
5)Requires all health plans, including those providing coverage
to MCMC enrollees and children in HFP, to pay providers of the
initial health assessment and forensic medical evaluation
irrespective of whether they are in the contracted provider
network.
6)Requires all plans to reimburse providers for the reasonable
value of the service; establishes minimum reimbursement
amounts of $250 for the initial assessment and $750 for the
forensic medical evaluation for 2012; requires adjustment
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annually based on the Medicare Economic Index; and, authorizes
plans to contract with a provider for alternative rates.
7)Requires the obligation to reimburse providers to only apply
to initial health assessments and forensic medical evaluations
performed by designated providers in the event that a local
child welfare agency opts to limit the number of providers
eligible for reimbursement.
8)Permits a County Board of Supervisors, upon request from a
local child welfare agency, to excuse plans from the
obligation to provide coverage for children who are residents
of that county if alternative arrangements have been made by
the local child welfare agency.
9)Specifies that a court, local law enforcement agency, or local
child welfare agency may consider or rely on the reports of
qualified medical professionals concerning a child examined
irrespective of whether the medical professional received
payments.
EXISTING LAW :
1)Provides for regulation of health plans by the Department of
Managed Health Care under the Knox-Keene Health Care Service
Plan Act of 1975 and regulation of health insurers by the
California Department of Insurance under the Insurance Code.
2)Requires health plans to pay for medically necessary services
provided in a licensed acute care hospital, if the services
were related to authorized services and provided after the
plan's normal business hours, unless the plan has a system
whereby it can respond to authorization requests as specified.
3)Requires health plans to cover emergency services as a basic
health care service and to reimburse providers within
specified timeframes for emergency services and care provided
to plan enrollees for the purpose of stabilizing the enrollee,
unless the plan enrollee did not require emergency services
and the enrollee should have known that an emergency did not
exist.
4)Establishes the Medi-Cal Program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health benefits to children in foster care,
low-income children, their parents or caretaker relatives,
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pregnant women, elderly, blind or disabled persons, nursing
home residents, and refugees who meet specified eligibility
criteria.
5)Requires mandatory enrollment of Medi-Cal eligible families
and children into an MCMC plan in specified counties and
limits the mandatory enrollment of foster children.
6)Requires DHCS to establish urgent disenrollment procedures for
disenrollment of foster children in out-of-county placements
within two working days of receipt by DHCS of a request for
disenrollment made by the child welfare services agency, the
foster caregiver, or other person authorized to make medical
decisions on behalf of the foster child.
7)Requires MCMC plans to process and pay appropriately
documented claims submitted by out-of-plan providers for
services provided to foster children in out-of-county
placements while they are Medi-Cal members of the plan.
8)Provides that a child who has been, or is at substantial risk
of being, abused or neglected is within the jurisdiction of
the juvenile court which may adjudge the child to be a
dependent child of the court and make a determination
regarding the appropriate placement of the child.
9)Establishes CHDP, including guidelines for complete health
assessments for the early detection and prevention of disease
and disabilities for low-income children and youth.
10)Establishes HFP to provide low cost health, dental and vision
coverage to uninsured children, until the age 19, in working
families.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . The sponsor of this bill, Los Angeles
(L.A.) County, states that children entering the child welfare
system often have undetected health and mental health
problems. The sponsor notes that state regulations require an
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initial medical examination for all children newly placed in
out-of-home care and authorize counties or local law
enforcement agencies to refer a child for a forensic medical
evaluation to determine if the child is a victim of physical
or sexual abuse or neglect. Most children who are removed by
the local child welfare agency and placed in out-of-home care
are automatically eligible for fee-for-service (FFS) Medi-Cal;
however, the child must first be disenrolled from prior
coverage, if any. According to the sponsor, the county
department of health services (DHS) is only reimbursed for
these services when they are provided to children with FFS
Medi-Cal, and not when they are provided by highly trained
specialists to children who are newly placed in out-of-home
care who have other types of health coverage, such as MCMC or
another health plan, because they are deemed to be "out of
network" without prior authorization from the plan. The
sponsor states that this bill seeks to provide reimbursement
to counties for these medical services that are essential to
the health and safety of these vulnerable children.
2)BACKGROUND . L.A. County operates six Medical Hub Clinics that
were established in 2006 to provide high quality, coordinated
medical care to children who are referred by the county
Department of Children and Family Services (DCFS). Children
in foster care are at much greater risk for medical and mental
health problems than children in the general population, and
in many cases such issues are undiagnosed prior to placement
in out-of-home care. Services include initial medical exams
that cover health and developmental history, physicals,
vision, dental, and mental health screenings, immunizations,
laboratory tests, and health education; forensic evaluations
to determine if the child has been victimized by physical or
sexual abuse, or neglect; and, necessary follow-up treatment.
L.A. County reports that its medical hub services are
performed in a victim-sensitive manner by highly trained and
experienced medical providers who qualify as medical experts
in court. The results are shared with DCFS and critical to
DCFS' evaluation with regard to child placement as well as to
law enforcement investigations.
DHS Medical Hub Clinics are located at Harbor-UCLA Medical
Center, High Desert Multi-Service Ambulatory Care Center
(MACC), LAC+USC Medical Center, Martin Luther King, Jr. MACC,
and Olive View-UCLA Medical Center. A satellite to the
LAC+USC Medical Hub opened in 2009 in the East San Gabriel
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Valley. An additional Medical Hub is operated privately by
Children's Hospital Los Angeles.
3)CALIFORNIA HEALTH BENEFITS REVIEW PROGRAM . The California
Health Benefits Review Program (CHBRP) was created in response
to AB 1996 (Thomson), Chapter 795, Statutes of 2002, which
requests the University of California to assess legislation
proposing a mandated benefit or service, and prepare a written
analysis with relevant data on the public health, medical, and
economic impact of proposed health plan and health insurance
benefit mandate legislation. In its analysis of the prior
version of this bill, CHBRP reports, in relevant part, the
following:
a) Medical Effectiveness . CHBRP examined whether the
services delivered in an initial health assessment are
considered to be medically effective based on existing
literature. CHBRP found that there is a preponderance of
evidence to suggest that a number of preventive services
for children and adolescents are effective, including
immunizations and screening for visual impairment, obesity,
major depressive disorder, hearing loss, and sexually
transmitted diseases. With regard to forensic medical
evaluations, CHBRP notes that its standard medical
effectiveness evaluation criteria does not apply to the
coverage requirement in this bill so the medical
effectiveness portion of the analysis is limited to
summarizing the methods for performing these evaluations.
b) Utilization, Cost, Coverage & Public Health Impacts .
CHBRP reports that these components of its analysis focus
separately on each provision mandating coverage of initial
health assessments and forensic medical evaluations. With
regard to the former, CHBRP indicates that it relied on the
number of children who entered foster care in 2009-10 to
obtain an annual estimate of the number of children who
receive an initial health assessment. Approximately 28,244
children entered foster care in California in 2009-10 and
would have likely had an initial health assessment. The
average per-unit cost is estimated to be about $41 to $62,
which varies depending on whether related laboratory tests
or immunizations are included. The average Medi-Cal
reimbursed rate for an initial health assessment as
reported by local child welfare agencies is estimated to be
approximately $55 but varies depending on whether
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laboratory and vaccinations are included.
CHBRP anticipates that the requirement in this bill relating
to coverage of initial health assessments will result in no
measurable impact in terms of coverage, no measurable
change in utilization, nor any impacts on premiums or
health care expenditure. Because no measurable changes in
utilization are expected, no measurable impacts on public
health are expected as a result of this provision of the
bill. Lastly, CHBRP states that it is possible for a
foster child to also be covered by another form of health
insurance while being enrolled in Medi-Cal. Therefore, it
is possible that the effect of the mandate to cover initial
health assessments could be to shift some costs incurred by
Medi-Cal to health plans and policies that are subject to
this bill for those services that are provided to foster
children by out-of-network providers but CHBRP is unable to
determine the magnitude of these potential cost shifts.
With regard to the provision of this bill mandating coverage
of forensic medical evaluations, CHBRP estimates that 9.1%
of physical and sexual abuse allegations receive a forensic
medical evaluation annually and therefore, among
individuals in health plans and policies affected by this
mandate, approximately 9,000 of these evaluations are
performed yearly and of those, about 1,000 enrollees
receiving an evaluation currently have coverage. CHBRP
estimated the average per-unit cost of forensic medical
evaluations to be $735. This mandate is estimated to
increase premiums by nearly $7 million. The distribution
of the impact on premiums is as follows: total employer
premium expenditures for California Public Employees'
Retirement System HMOs are estimated to increase by
$177,000; enrollee contributions toward premiums for group
insurance are estimated to increase by $817,000; and, total
premiums for purchasers of individual market health
insurance are estimated to increase by $464,000. CHBRP
estimates expenditures for MCMC plans to increase by $2.17
million and expenditures for Managed Risk Medical Insurance
Board Plans to increase by $737,000. Increases as measured
by per member per month (PMPM) premiums for this newly
mandated benefit coverage vary by market segment but range
from an average of $0.01 to $0.08 PMPM. Total health
expenditures are projected to increase by approximately
$911,000 for the year following implementation of this
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mandate.
CHBRP also states that, currently, forensic medical
evaluations are administered by medical personnel at the
request of local child welfare agencies or law enforcement
for child victims of physical and sexual abuse, and paid
for out of law enforcement budgets and/or child welfare
agency budgets. According to CHBRP, there is some
anecdotal evidence that budget constraints on law
enforcement or local child welfare agencies may have a
small effect on the number of forensic medical evaluations
requested. CHBRP has no data and no literature to support
such a claim. Therefore, CHBRP was not able to quantify
any dampening effect of budget constraints on the number of
forensic medical evaluations performed. To the extent that
law enforcement budget or local child welfare agencies
constraints are currently limiting the number of forensic
medical evaluations performed, passage of this bill may
increase the total number of evaluations.
Lastly, CHBRP reports that the standard public health
outcomes for evaluating health benefit coverage are not
applicable in the case of forensic medical evaluations.
CHBRP found no evidence in the literature related to
forensic exams and health outcomes. CHBRP notes that,
although this bill could impact utilization of forensic
medical evaluations, it was unable to estimate any change
in utilization. Therefore, the public health impacts of
this mandate are unknown.
4)SUPPORT . The Children's Hospital Association (CHA) writes in
support that these evaluations these necessary evaluations are
often performed to provide diagnostic information to determine
the course of treatment for the affected children and the
appropriate health plan then denies payment. CHA points out
that disputed reimbursement and questions regarding covered
benefits only add to administrative costs while diverting
resources from providing actual patient care and this bill
will clarify that these services are covered benefits which
will reduce questions and disputes. The Mental Health
Association in California supports this bill because it will
provide these children with quicker access to services.
5)OPPOSITION . The California Association of Health Plans (CAHP)
writes in opposition that it is the wrong time for the
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Legislature to consider enacting new benefit mandates since,
starting in 2014, many Californians can enroll in health
coverage through the newly created insurance Exchange
established under the PPACA and, in California, through AB
1602 (John A. P�rez), Chapter 655, Statutes of 2010. CAHP
also asserts that the reimbursement amounts specified in this
bill of $250 for each initial assessment and $750 for each
forensic evaluation are not representative of the actual
medical-related costs associated with the exams. The
Association of California Life & Health Insurance Companies
and America's Health Insurance Plans object to all mandate
bills because they would prove counterproductive to industry
efforts to make health insurance more affordable and available
and could have real impacts both on individuals struggling to
maintain coverage and on the State budget. Health Net adds in
opposition that this bill inappropriately shifts the cost of
these exams from the county child welfare departments and
local law enforcement agencies to health plans and insurers in
order to backfill county General Fund deficits.
6)TECHNICAL AMENDMENT . On page 6, line 11, delete "at least".
7)AUTHOR'S AMENDMENTS . In response to concerns raised by
committee staff, the author will offer the following
amendments in committee to clarify the term "qualified medical
professional":
On page 3, below line 18, page 5, below line 22, and page 7,
below line 28, insert:
(3) "Qualified medical professional" means any board-certified
or board-eligible physician in child maltreatment, a physician
enrolled in a child maltreatment fellowship program, a
physician who has received direct training from a recognized
child maltreatment expert, or a child maltreatment expert who
is qualified as an expert witness in a court of law.
REGISTERED SUPPORT / OPPOSITION :
Support
County of Los Angeles (sponsor)
Children's Hospital Association
California Council of Community Mental Health Agencies
Mental Health Association in California
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Opposition
America's Health Insurance Plans
Association of California Life & Health Insurance Companies
California Association of Health Plans
Health Net
Analysis Prepared by : Marjorie Swartz and Cassie Royce /
HEALTH / (916) 319-2097