BILL ANALYSIS �
AB 1327
Page 1
Date of Hearing: May 18, 2011
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Felipe Fuentes, Chair
AB 1327 (Portantino) - As Amended: May 10, 2011
Policy Committee: HealthVote:11-2
Urgency: No State Mandated Local Program:
No Reimbursable: No
SUMMARY
This bill requires the Department of Health Care Services (DHCS)
to conduct a three-year pilot project to determine the
feasibility of developing a blended per-capita payment rate for
services provided to enrollees with HIV or AIDS in Medi-Cal
primary care case management (PCCM). This bill also requires
DHCS to pay these rates to a Medi-Cal primary care case
management plan or successor Knox-Keene plan for beneficiaries
with HIV or AIDS.
FISCAL EFFECT
1)Due to methodological and confidentiality issues involving
establishing the identity of HIV-positive individuals, it is
unclear whether it is feasible to develop the rate described
in this bill. Depending upon the technical issues involved in
developing the rate, the administrative cost could range from
minor to over $20,000.
2)If DHCS finds that it is feasible to develop the rate, the
fiscal impact to the state from paying the new rates is
unknown but could potentially exceed $150,000 annually. The
cost would depend on how the newly calculated rate compares to
costs the state would otherwise incur for individuals with HIV
in absence of their enrollment in the PCCM or successor
Knox-Keene plan and payment of the new rate. The precise
design of the pilot project is not specified in the bill, and
the bill does not require that rates are calculated in a
manner that is cost-neutral to the state.
As an example, if new rates increased payments to the PCCM
plan by an average of $50 per member per month for enrollees
AB 1327
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in the PCCM plan, the annual state cost would be in the range
of $475,000 (50% GF). Similarly, if new rates decreased
payments to the PCCM plan, there could be associated cost
savings.
3)If the rates for participants in the pilot project were
enhanced for the duration of the project, there would be
General Fund pressure to maintain the higher rates after the
sunset date for the pilot.
COMMENTS
1)Rationale . This bill intends to ensure that DHCS pays health
plans appropriately for services provided to Medi-Cal
enrollees with HIV. Many individuals with HIV are expected to
enroll in managed care plans, or PCCM, as a result of the
ongoing mandatory enrollment of seniors and persons with
disabilities into managed care. The author indicates that the
reimbursement structure for these plans that receive payment
through capitation rates still distinguishes between HIV and
AIDS, and pays the AIDS rate only for people with a clinical
diagnosis of AIDS. The author explains that reimbursement
rates must be modernized to reflect the clinical realities of
today's HIV treatment, which reflect initiation of drug
treatment before a clinical diagnosis of AIDS is made.
The sponsor of this bill, AIDS Healthcare Foundation (AHF),
has contracted with DHCS to operate a capitated PCCM project
in Los Angeles since April 1995 for people with HIV/AIDS. As
of December 2010, there were a little less than 800 average
monthly enrollees. AHF is in the process of obtaining a
license through the Knox-Keene Health Care Service Plan Act of
1975 (Knox-Keene) from the Department of Managed Health Care
in order to operate as a full risk managed care plan. The
pilot project is specific to a PCCM plan for beneficiaries
with HIV/AIDS. AHF is the only such plan currently operating
in California.
2)Treatment for HIV and AIDS . Human Immunodeficiency Virus (HIV)
destroys a certain kind of blood cells called T-cells that are
important in immune response. Although a person infected with
HIV may not show symptoms until several years later, the virus
is active in the body and, if untreated, the HIV disease will
progress to AIDS. An AIDS diagnosis is made when the count of
or T-cells, falls below a certain level or when the person has
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a history of infections commonly associated with AIDS. In
recent years, earlier initiation of antiretroviral drug
treatment among individuals infected with HIV has become more
common in order to prevent the transition of HIV to AIDS,
leading to higher costs to treat HIV that can be similar to
the cost of AIDS treatment.
3)HIV/AIDS reporting . California requires health care providers
to confidentially report more than 80 diseases and conditions
to LHOs, who then report that data to DPH. HIV and AIDS are
reportable conditions in California using patients' names.
California made name-based reporting mandatory for HIV through
SB 699 (Soto), Chapter 20, Statutes of 2005. California's HIV
reporting statute is coupled with confidentiality protections.
Part of DHCS's evaluation of the feasibility of establishing
a rate pursuant to this bill would be to determine whether
developing an HIV-specific rate would violate California laws
related to disclosure of the results of an HIV test.
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081