BILL ANALYSIS �
AB 667
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Date of Hearing: April 26, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 667 (Mitchell) - As Amended: April 11, 2011
SUBJECT : Medi-Cal: subacute care program.
SUMMARY : Establishes medical necessity standards for Medi-Cal
pediatric subacute care services. Specifically, this bill :
1)Defines "pediatric subacute services" in the Medi-Cal Program
as the health care services needed by a person under 21 years
of age who uses medical technology that compensates for the
loss of vital bodily functions.
2)Requires that medical necessity be substantiated by one of the
following:
a) Tracheostomy with dependence on mechanical ventilation
for a minimum of six hours each day;
b) Dependence on total parenteral nutrition (lay term) or
other intravenous nutritional support and one of the
following:
i) Dependence on tracheostomy care requiring suctioning
at least every six hours and room air mist or oxygen;
ii) Continuous intravenous therapy as specified;
iii) Peritoneal dialysis;
iv) Tube feeding;
v) Other medical technologies require the services of a
professional nurse; or,
vi) Biphasic Positive Airway Pressure (BiPAP) as
specified and lacking cognitive or physical ability to
protect the airway.
c) Dependence on tracheostomy care requiring suctioning at
least every six hours and room air mist or oxygen and one
of the conditions in 2) b) ii) through vi) above;
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d) Dependence on skilled nursing care in the administration
of any three of 2) b) i) through vi) above; or,
e) Dependence on BiPAP and Continuous Positive Airway
Pressure (CPAP), as specified, and one of the conditions in
2) b) i) through vi) above
3)Provides that the medical necessity in this bill in intended
solely to evaluate the potential eligibility of a patient for
pediatric subacute care who would otherwise be receiving acute
hospital care.
4)States legislative findings that the regulatory criteria have
not been adjusted in 10 years and states legislative intent to
update the criteria for admissions based on the individual's
need for other complex treatment to be utilized as qualifying
criteria for patient transfer.
5)Deletes the requirement that subacute care be defined by the
Department of Health Care Services (DHCS) based on a study
established in 1980 and makes other technical and clarifying
changes.
EXISTING LAW :
1)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.
2)Establishes a Medi-Cal subacute care program.
3)Establishes, by regulation, level of care, reimbursement,
scope and duration of benefits and standards for participation
in Medi-Cal pediatric subacute care.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author this bill is
needed to update the criteria used to evaluate and authorize
admission into Medi-Cal pediatric subacute facilities. The
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author asserts that children whose needs could be adequately
provided for in a pediatric subacute facility are often not
transferred to this setting because they do not meet the
criteria specified in regulations. The children therefore
remain in an acute care hospital at a substantially higher
cost to Medi-Cal. According to the author, California has 10
pediatric subacute care hospitals providing cost-effective
health care services to approximately 400 children under the
age of 21 who require medical technology due to loss of vital
bodily function. The author further states that all pediatric
subacute patients need 24 hour nursing and special services
such as: inhalation therapy; tracheostomy care; intravenous
feeding tubes; and, complex wound care.
2)BACKGROUND . Established on July 1, 1983 by DHCS the subacute
care program refers to patients in licensed facilities who
meet subacute care criteria. Specific reimbursement rates
have been developed for providers of subacute care. Pediatric
subacute care is a level of care needed by a person less than
21 years of age who uses a medical technology that compensates
for the loss of a vital bodily function.
AB 36 (Quakenbush), Chapter 1030, Statutes of 1993, authorized
DHCS (formerly the Department of Health Services) to establish
cost-based reimbursement for the provision of Medi-Cal
benefits to any technology dependent child who is placed at a
lower cost facility, established the services required to be
provided at the facility and authorized adoption of the
regulations that this bill seeks to codify. AB 36 conditioned
implementation on federal approval and full federal financial
approval through the Medi-Cal Program. AB 36 also included a
January 1, 1996 repeal date or alternatively, was repealed by
its own terms after the establishment of a pediatric service
continuum, whichever was earlier. AB 36 contained legislative
intent that in determining placement and treatment needs of
technology dependent children, an effort should be made to
place the child in the least costly and least restrictive
level of care that still provides for the child's medical
safety and dignity.
3)SUPPORT . The Subacute Saratoga Hospital and the Children's
Recovery Center, in support state that this bill is needed to
codify and update the criteria used to determine when it is
appropriate to transfer a Medi-Cal patient to a pediatric
subacute care program. According to the supporters, pediatric
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subacute care patients are medically fragile; all of them
require 24 hour nursing and special services such as
inhalation therapy, tracheostomy care, intravenous feeding
tubes, and complex wound care. The supporters point out that
prior to creation of the pediatric subacute care program,
these patients were in high cost intensive care units of
children's hospitals or state developmental centers.
The supporters also argue that current admission criteria for
pediatric subacute care are contained in regulations and
include a limited number of specific qualifying conditions.
These regulations have never been updated to reflect enhanced
and improved technology such as BiPAP or CPAP which did not
exist at the time the criteria was developed. These devices
are now commonly used as an alternative to a trach and require
careful supervision by skilled clinical staff - particularly
for young children with serious respiratory issues.
According to the supporters, virtually all of the children
treated in California's 10 pediatric subacute care facilities
are covered under Medi-Cal or the California Children's
Services Program. This bill would clarify that the use of
these devices is a qualifying condition for patients,
hospitals, subacute facilities, and state staff responsible
for authorizing patient admissions. The supporters assert
that since pediatric subacute rates are approximately
one-fifth of those paid for care in a pediatric intensive care
unit of an acute hospital or a state developmental center,
substantial Medi-Cal savings will also accrue every time a
child is successfully placed in one of these facilities.
Children, they conclude, would also benefit greatly from the
specialty care, rehabilitation/developmental services and more
family-friendly environment offered in this setting.
REGISTERED SUPPORT / OPPOSITION :
Support
Children's Recovery Center
Subacute Saratoga Hospital
Opposition
None on file.
AB 667
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Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097