BILL ANALYSIS �
AB 1785
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Date of Hearing: April 10, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1785 (Bonnie Lowenthal) - As Introduced: February 21, 2012
SUBJECT : Medi-Cal: federally qualified health centers: rural
health clinics.
SUMMARY : Adds marriage and family therapist (MFT) to the
current list of medical providers that qualify for a
face-to-face encounter with a patient at a Federally Qualified
Health Center (FQHC) or Rural Health Center (RHC) for purposes
of a per visit Medi-Cal payment under the prospective payment
system (PPS).
EXISTING LAW :
1)Establishes the Medi-Cal program as California's Medicaid
program, administered by the Department of Health Care
Services (DHCS), which provides comprehensive health care
coverage for low-income individuals and their families;
pregnant women; elderly, blind, or disabled persons; nursing
home residents; and, refugees who meet specified eligibility
criteria.
2)Establishes a schedule of benefits under Medi-Cal, which
includes FQHC and RHC clinic services, as defined, as covered
benefits.
3)Requires, under federal law, Medicaid programs to reimburse
FQHCs and RHCs using a PPS. Requires the PPS to be a minimum
facility-specific, cost-based amount, paid on a per visit
basis and adjusted annually based on a Medicare inflation
factor.
4)Allows only one visit per day to be reimbursed by Medi-Cal,
except for a subsequent visit by a patient to a dental
professional. Defines a "visit" as a face-to-face encounter
between a patient of an FQHC or RHC and the following health
care professionals:
a) Physician;
b) Physician assistant;
c) Nurse practitioner;
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d) Certified nurse midwife;
e) Clinical psychologist;
f) Licensed clinical social worker;
g) Visiting nurse;
h) Osteopath;
i) Podiatrist;
j) Dentist;
aa) Dental hygienist and a dental hygienist in alternative
practice;
bb) Optometrist;
cc) Chiropractor;
dd) A comprehensive perinatal services practitioner
providing comprehensive perinatal services;
ee) A four-hour day if attendance at an adult day health
care center; and,
ff) Any other provider identified in the state plan's
definition of an FQHC or RHC visit.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill will
enable FQHCs and RHC s to hire qualified and licensed marriage
and family therapists (MFTs) and allow reimbursement through
Medi-Cal for covered mental health services. The author
states that under existing law, psychologists and licensed
clinical social workers (LCSWs) are employed by RHCs and FQHCs
to provide mental health services, and receive reimbursement
through Medi-Cal for that care. However, the author points
out that while a RHC or FQHC can employ an MFT, the lack of
reimbursement for the care provided to Medi-Cal patients acts
as a disincentive for hiring.
In support of the need for this bill, the author cites the "2007
California Health Interview Survey" finding that approximately
8.3% of California adults, or 2.2 million people, reported
having mental health needs. According to the author adults
covered by public health insurance, including Medi-Cal, have
higher rates of mental health needs than other adults. Of
particular relevance, according to the author is the "2010
Behavioral Risk Factor Survey," which found a higher
proportion of rural residents (9.4%) self -declared that they
had a mental health issue (stress, depression, and other
emotional problems) for eight to 21 days compared with
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residents of urban counties (8.2%). The author also states
that while chronic conditions such as heart disease and
diabetes are common among the general adult population, adults
with mental health needs have a higher burden of chronic
disease. The author concludes that adults with mental health
needs are 1.5 times more likely to have high blood pressure,
heart disease, or asthma; suggesting that integrating mental
health services into primary care settings, like RHCs or FQHCs
may offer the greatest opportunity for addressing potential or
developing mental health problems.
The author also argues that this bill is needed because
California's clinics serve many, if not most of the estimated
1.5 to 2 million low-income population transitioning to
Medi-Cal coverage once health care reform is implemented in
2014. This means there will be an even greater demand for
mental health services that could potentially be met by FQHCs
and RHCs. According to the author, in 2010 clinics served
almost 5 million patients. Nearly two-thirds of the patients
had incomes below the federal poverty level (FPL), 81% were
below 200% FPL and 43% speak a primary language other than
English. Of these, almost 1.5 million (30%) were uninsured.
Although these numbers reinforce the capabilities of RHCs and
FQHCs for reaching out to and serving ethnic and racial
minorities, the author argues, to meet the requirements for
mental health services for the expansion population, the
clinics will need to be able to hire and be paid by Medicaid
for MFTs in addition to LCSWs.
2)BACKGROUND . FQHCs and RHCs are community-based clinics that
provide comprehensive primary care and preventive care,
including health, oral, and mental health/substance use
disorder services to persons of all ages, regardless of their
ability to pay. FQHCs receive grants under section 330 of the
federal Public Health Service Act. Federal certification of
FQHCs and RHCs requires clinics to provide a wide array of
preventive and primary care services in underserved urban or
rural communities. Clinics must also adhere to numerous rules
about use of clinicians, data collection and reporting, and
other operational issues. The clinic is also required to
provide services regardless of a patient's ability to pay.
Once federally certified, the clinic is entitled to become a
Medi-Cal provider. According to DHCS, there are currently 681
FQHCs, and 293 federally designated RHCs in California. In
Fiscal Year 2009-10, FQHCs and RHCs represented over 90% of
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Medi-Cal expenditures for clinic-based care. In 2010, 64% of
primary care visits in the doctor's office or clinic setting
were at FQHCs and RHCs.
3)PPS . Because FQHCs and RHCs are safety net providers and care
for a significant number of the uninsured, their continued
survival depends heavily on the stability and adequacy of
revenues from the Medi-Cal program. To help preserve this
role, under federal law, FQHCs and RHCs are eligible for
enhanced Medicare and Medi-Cal reimbursement. The enhanced
rate helps compensate them for the uncompensated costs they
occur in caring for the uninsured. The rationale for the
enhanced reimbursement is to ensure that FQHCs do not use
federal grant funds, intended for uninsured and special needs
populations, to back-fill for potentially below-cost Medicare
or Medi-Cal rates.
These FQHC and RHC services are reimbursed in Medi-Cal on a
fixed "per visit" rate rather than by individual services.
Current law only allows multiple billable visits in a single
day if they are for dental services. Mental health visits are
treated for Medi-Cal billing purposes as a medical visit for
which only one visit per patient per day is allowed.
Prohibiting same-day services billing for separate
practitioners has been identified as a barrier to improved
access to mental health services for persons with public
insurance. This finding was contained in a July 2008 report
by the federal Substance Abuse and Mental Health Services
Administration, which is titled "Reimbursement of Mental
Health Services in Primary Care Settings." The report
identified the limitation on same-day services billing for
separate practitioners as one of the seven priority potential
barriers and solutions for reimbursement of mental health
services in primary care settings.
4)FUTURE WORKFORCE NEEDS . The Centers for Medicare and Medicaid
Services, as part of the Special Terms and Conditions of the
California 2010 Section 1115 Bridge to Reform Medicaid waiver,
required DHCS, to conduct a Mental Health and Substance Use
System Needs Assessment (Needs Assessment). According to this
February 2012 Needs Assessment, FQHCs and RHCs play an
important role in the provision of mental health and substance
use services in California, particularly for people living in
rural areas and for underserviced populations such as people
experiencing homelessness. Citing data from the federal
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Health resources and Services Administration's Uniform Data
System for FQHCs, the Needs Assessment shows that 4% of FQHC
patients (108,597) received mental health services and 1%
(21,893) received substance abuse service in 2010. Of all
visits, 4% were for mental health services (502,327 visits)
and 2% were for substance abuse services (220,488). The
author argues that although the number of patients served and
visits may be small compared to the number of patients served
through traditional inpatient and outpatient providers, it
shows that a substantial number of patients seek services in a
community-based primary care setting where there is less
stigma than in a mental health agency, and where they can
obtain culturally appropriate services. The author points out
that if MFTs were reimbursed by Medi-Cal, they would be able
to reach even more patients.
The Needs Assessment found overall an acute shortage of licensed
psychiatrists in California, particularly in rural areas.
While California had a relatively higher ratio of
psychologists, the numbers in rural areas were also quite
small or non-existent. This report found that while the data
shows a relatively high number of LCSWs and MFTs in the state,
only a fraction of these individuals were working in the
public mental health system serving Medi-Cal clients Based
on what limited data is available, the Needs Assessment also
found limited racial and ethnic diversity and linguistic
capacity amongst all of the current mental health providers in
these categories.
5)SUPPORT . The California Association of Marriage and Family
Therapists (CAMFT) sponsors of this bill, writes in support
this bill is intended to increase the pool of licensed
professionals who can be hired in FQHCs or RHCs so that
adequate services can be provided to the patients of these
facilities. According to CAMFT, the scope of practice of an
MFT includes individuals, couples, or groups. It also
includes the use, application, and integration of the
diagnosis, assessment, prognosis, and treatment of mental
disorders. In further support, CAMFT points out educational
requirements include cross-cultural training, specific
instructions in alcoholism and other chemical substance
dependency, and psychopharmacology. CAMFT argues, like
clinical social workers and psychologists, MFTs are reimbursed
by health insurers and plans for diagnosing and treating
severe mental illness such as schizophrenia, shizoaffective
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disorder; bipolar disorder; major depressive disorders; panic
disorder, obsessive-compulsive disorder; autism; anorexia; and
bulimia. The sponsors point out that as FQHCs or RHCs need
additional mental health providers, MFTs are qualified to do
such work.
6)OPPOSITION . The National Association of Social Workers,
California Chapter (NASW-CA), writes in opposition that social
workers have a long history working in federally qualified
health centers and in rural communities. According to this
opposition, their training and orientation on community based
systems is ideal for these centers. The opposition also
believes there are sufficient numbers of unemployed social
workers and LCSWs that can fill these positions if they become
available. According to NASW-CA, there are currently several
California schools of social work that have specialized
programs for training social workers for work in rural
communities.
7)PREVIOUS LEGISLATION .
a) AB 1445 (Chesbro) of 2009 would have allowed FQHCs and
RHCs to be reimbursed by Medi-Cal for multiple visits by a
patient with a single or different health care professional
on the same day at a single location, when a patient has an
appointment with a mental health professional or has
contracted an illness or been injured and requires
additional treatment. AB 1445 died in the Senate
Appropriations Committee.
b) SB 260 (Steinberg) of 2007 was similar to AB 1445 and
was vetoed by Governor Schwarzenegger, who said in his veto
message:
"While I support improving access to health care
services, including mental health services, I cannot
support this bill as it would increase General Fund
pressure at a time of continuing budget challenges.
Mental health services are already included in the
Medi-Cal rates for federally qualified health
centers and rural health clinics. Allowing separate
billing for mental health services would lead to
increased costs that our state cannot afford."
c) SB 36 (Chesbro), Chapter 527, Statutes of 2003,
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established a statutory structure for Medi-Cal payments for
services provided by FQHCs and RHCs in compliance with
federal law, changing from fee-for-service to a per-visit
basis.
8)POLICY COMMENTS .
a) Budget Proposal . Currently, a Medi-Cal managed care
plan that contracts with an FQHC or RHC as part of its
network pays the FQHC or RHC a rate that is comparable to
the rate paid to other providers of similar services.
Federal law requires the Medicaid program to make up the
difference between the negotiated rate and the guaranteed
PPS rate using a reconciliation process. In the 2012-13
budget, DHCS is proposing to seek federal authority to
instead allow payment of a capitated bundled rate that
would include the reconciliation amount and a 10% reduction
based on "efficiency savings." According to DHCS there are
currently onerous and outdated restrictions such as
limitations on the types of providers and the prohibition
on multiple payments for multiple services on the same day
but the trailer bill language doesn't change this. The
Senate Budget Committee, Subcommittee #3 heard and rejected
this proposal on March 22, 2012. The Assembly could adopt
the proposal in a fashion that accomplishes the purpose of
this bill by removing the limitations on the types of
providers. However, it would only apply in situations
where the clinic contracts with a Medi-Cal managed care
plan and also could include a 10% reduction in the
reimbursement rate.
b) Per Visit Rule . Regardless of the outcome of the budget
proposal, without a change in the per visit rule, an FQHC
or RHC will not be able to seek reimbursement for a client
to be able to see a health care provider and a mental
health professional on the same day. This may limit the
full potential of this bill to provide increased access to
mental health services even though it could expand the
potential workforce.
REGISTERED SUPPORT / OPPOSITION :
Support
The California Association of Marriage and Family Therapists
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(Sponsor)
California Commission on Aging
California Council of Community Mental Health Agencies
California Family Resource Association
California Primary Care Association
California State Association of Counties
Opposition
National Association of Social Workers, California Chapter
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097