BILL ANALYSIS �
AB 1803
Page 1
Date of Hearing: April 24, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1803 (Mitchell) - As Amended: April 23, 2012
SUBJECT : Medi-Cal: emergency medical conditions.
SUMMARY : Provides that emergency services and care that are
necessary for the treatment of an emergency medical condition
are a covered benefit in the fee-for-service (FFS) Medi-Cal
program. Specifically, this bill :
1)Adds emergency services and care necessary for the treatment
of an emergency medical condition and medical care directly
related to the emergency condition and provided on a FFS
basis, to the list of covered benefits in the Medi-Cal
program.
2)Defines by reference "emergency services and care," "emergency
medical condition," and other related definitions which
currently apply to a hospital's obligation to screen, treat,
and stabilize any patient that presents in an emergency
department (ED) without regard to the patient's ability to
pay, or insurance status.
3)Specifies that this bill shall not be construed to change the
obligation of a Medi-Cal managed care (MCMC) plan to provide
emergency services and care.
EXISTING LAW :
1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), to provide
comprehensive specified health care services and long-term
care to pregnant women, children, and people who are aged,
blind, and disabled. Services are reimbursed through FFS,
capitated payments to managed care plans, or other contractual
arrangement.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes hospital inpatient and outpatient services,
subject to utilization controls, and establishes Medi-Cal
hospital reimbursement requirements.
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3)Authorizes DHCS to contract, on a bid or nonbid basis, with
any qualified individual, organization, or entity to provide
services to, arrange for, or case manage, the care of Medi-Cal
beneficiaries. Defines a MCMC plan as any entity that enters
into one of several types of contracts with DHCS including
County Organized Health Systems, Geographic Managed Care
plans, Local Initiatives, and commercial plans.
4)Requires in federal law, under provisions of the federal
Emergency Medical Treatment and Active Labor Act (EMTALA), and
in state law, hospital ED to provide emergency screening and
stabilization services without regard to the patient's
insurance status or ability to pay. EMTALA requires hospitals
to maintain an on-call roster of specialists in a manner that
best meets the needs of its patients.
5)Requires, under state law, a hospital to render emergency care
and services without first questioning the patient's ability
to pay and defines "emergency medical condition" as a medical
condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that the absence of
immediate medical attention could reasonably be expected to
result in any of the following:
a) Placing the patient's health in serious jeopardy;
b) Serious impairment to bodily functions; or,
c) Serious dysfunction of any bodily organ or part.
6)Requires hospitals to share proof of Medi-Cal eligibility with
other emergency services providers.
7)Requires a health care service plan to reimburse providers for
emergency services and care provided to its enrollees, until
the care results in stabilization of the enrollee, except as
specified. Prohibits, as long as federal or state law
requires that emergency services and care be provided without
first questioning the patient's ability to pay, a health care
service plan from requiring a provider to obtain authorization
prior to the provision of emergency services and care
necessary to stabilize the enrollee's emergency condition.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
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1)PURPOSE OF THIS BILL . According to the author, this bill
would codify the "reasonable layperson standard" for emergency
medical services for persons in the Medi-Cal FFS program. The
author states that this change will create a uniform policy
and ensure that FFS Medi-Cal patients have this important and
fundamental patient protection. According to the author,
under California law, the reasonable layperson standard for
emergency medical services is in place for health plans
regulated by the Department of Managed Health Care including
MCMC plans. However, the author argues, the standard is not
in place for Medi-Cal FFS enrollees and this gap in California
law, where no reasonable layperson standard exists, threatens
patient safety and needs to be closed.
The reasonable layperson standard states that if a reasonable
person believes a medical condition is manifested by acute
symptoms of sufficient severity (including severe pain)
presents itself in a manner, that the absence of immediate
medical attention could be reasonably expected to result in
harm, the treatment shall be paid by the managed care plan.
These conditions include: a) placing the patient's health in
serious jeopardy; b) serious impairment to bodily functions;
or, c) serious dysfunction of any bodily organ or part. The
author is concerned that without this protection for FFS
Medi-Cal patients, care rendered in the ED will be subject to
after-the-fact review even though it met the reasonable person
standard. According to the sponsor, this has occurred in
Washington State, which implemented a system to review all FFS
claims for medical necessity. Under the Washington system,
because the prudent lay person (or reasonable person in
California) standard only applied in managed care, but not
FFS, all EMTALA screening exams were still required to be
covered by managed care plans, but not for FFS visits if it
was later determined to not be medically necessary.
According to the author, the Washington example shows the danger
of not having the reasonable layperson standard in place. The
state has identified approximately 500 conditions (final
diagnosis codes) they have determined are not emergencies and
will no longer cover those conditions based on the final
diagnosis codes.
2)BACKGROUND . Medi-Cal is California's version of the federal
Medicaid program. Medicaid is a 46-year-old joint federal and
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state program offering a variety of health and long-term
services to low-income women and children, the elderly, and
people with disabilities. Each state has discretion to
structure benefits, eligibility, service delivery, and payment
rates under requirements established by federal law. The
Medi-Cal program utilizes a variety of service delivery and
payment systems. Originally the primary mechanism was FFS
Medi-Cal which means that a Medi-Cal enrollee obtains services
from an approved Medi-Cal provider who is willing to take
him/her as a patient for the service and accepts the Medi-Cal
payment rate set by the state and governed by federal law.
However, California has adopted the national trend to use
various models of managed care in place of FFS in Medi-Cal.
In MCMC, as in commercial managed care, the enrollee's choice
of providers may be limited to those in the plan's network,
but the plan is required to ensure timely access to care. As
of August 2011, MCMC in California served about 4.4 million
enrollees in 30 counties, or about 60% of the total Medi-Cal
population.
3)EMERGENCY MEDICAL SERVICES . There is extensive law regarding
a hospital's obligation to provide emergency medical services
regardless of ability to pay. Enrollees of a health plan,
including a MCMC plan have the protection of the "reasonable
person standard." Federal and state law set limits on the
reimbursement rate that a MCMC plan is allowed to pay for
emergency services provided to a plan enrollee by an
out-of-network or noncontracted hospital. There are even
requirements on hospitals to share proof of Medi-Cal
eligibility with other emergency care and services providers
to prevent illegal billing of Medi-Cal enrollees and
prohibitions on providers billing a Medi-Cal enrollee directly
for covered services. In spite of this extensive law relating
to the provision of emergency services in the Medi-Cal
program, the sponsor of this bill appears to have identified a
significant gap with regard to coverage of emergency medical
services in the FFS Medi-Cal program. This bill seeks to cure
this by adding emergency medical care and services to the list
of covered benefits and by referencing the "reasonable person"
standard from other existing provisions.
AB 97 (Committee on Budget), Chapter 3, Statutes of 2011, the
Health Budget Trailer bill, implemented a mandatory copayment
of $50 for nonemergency use of the ED. Pending approval from
the Centers for Medicare and Medicaid Services (CMS), DHCS
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planned to implement this copayment in both the FFS and
managed care settings (except for Family Planning Access Care
Treatment beneficiaries). Hospitals would have been required
to collect the $50 copayment from the beneficiaries at the
time of service, and the hospital would have been reimbursed
the appropriate Medi-Cal reimbursement rate minus the $50
copayment. In June 2011, DHCS submitted a request to CMS to
amend the State's Bridge to Reform Waiver to allow DHCS to
impose mandatory copayments. On February 6, 2012, DHCS
received notice from CMS that this request was not approved as
it was not consistent with federal Medicaid requirements.
DHCS stated that it disagrees with the CMS decision and is
examining its options moving forward, including administrative
appeal options. DHCS assumed an October 1, 2012 start date
for the imposition of copayments in the State Budget.
Therefore, according to DHCS there is some additional time to
resolve this matter before the State experiences any savings
erosion.
4)SUPPORT . The sponsor, the California Chapter of the American
College of Emergency Physician (California ACEP) supports this
bill because it is important legislation standardizing the
reasonable layperson standard so that all Medi-Cal patients
are covered when they seek treatment for an emergency.
According to this support, the law currently requires that if
a reasonable layperson believes they are having an emergency
and they go to the ED, the MCMC plan must pay for the care
provided regardless of whether the patient's condition turns
out to be less serious than the patient originally feared.
California ACEP states that while the reasonable layperson
standard had been a long established patient protection in
California, efforts to erode this protection are surfacing in
other states. The sponsor concludes that given that threat,
it is time to close the loophole in California law to protect
all Medi-Cal patients.
5)PREVIOUS LEGISLATION .
a) AB 1142 (Price), Chapter 511, Statutes of 2009, requires
a hospital that obtains proof of a patient's Medi-Cal
eligibility subsequent to the date of service, to provide
all information regarding that person's Medi-Cal
eligibility to all hospital-based providers, ambulance
service providers, and other hospital-based providers that
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bill separately for their professional services. Permits
DHCS to assess a penalty, up to three times the amount
payable by Medi-Cal, against a provider who, despite having
proof of Medi-Cal eligibility seeks payment from or fails
to cease collection efforts against the beneficiary.
b) AB 1203 (Salas), Chapter 603, Statutes of 2008,
establishes uniform requirements governing communications
between health plans and non-contracting hospitals related
to post-stabilization care following an emergency.
Prohibits a non-contracting hospital from billing a patient
who is a health plan enrollee for post-stabilization
services, except as specified.
REGISTERED SUPPORT / OPPOSITION :
Support
California Chapter of the American College of Emergency
Physician (sponsor)
California Black Health Network
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097