BILL ANALYSIS �
Senate Appropriations Committee Fiscal Summary
Senator Christine Kehoe, Chair
AB 1803 (Mitchell) - Medi-Cal: emergency medical conditions
Amended: June 12, 2012 Policy Vote: Health 9-0
Urgency: No Mandate: No
Hearing Date: June 25, 2012
Consultant: Brendan McCarthy
This bill meets the criteria for referral to the Suspense File.
Bill Summary: AB 1803 requires Medi-Cal fee-for-service benefits
to include emergency services when a medical condition could
reasonably be expected to result in jeopardy to the patient's
health, commonly referred to as the "reasonable layperson"
standard.
Fiscal Impact: By placing the "reasonable layperson" standard in
statute, the bill would preclude the Department of Health Care
Services from reducing or eliminating payment for services
provided in an emergency department that were not thought to be
immediately necessary under the reasonable layperson standard.
The extent to which the Department could reduce Medi-Cal
expenditures by limiting payment for such non-emergency services
provided in an emergency department is unknown.
Background: Under current state and federal law, Medi-Cal
enrollees in managed care plans are eligible for emergency
services under what is known as the "reasonable layperson"
standard. Under the reasonable layperson standard, health plans
are required to pay for emergency services provided to an
enrollee unless the enrollee did not require those services and
reasonably should have known that he or she did not need those
services.
On the other hand, there is no federal or state law requirement
that Medi-Cal fee-for-service provide for emergency services
under the reasonable layperson standard.
In practice the Department pays for emergency services in the
Medi-Cal fee-for-service program based on the services provided,
and does not attempt to determine whether the services were
genuinely related to an emergency condition.
AB 1803 (Mitchell)
Page 1
Proposed Law: AB 1803 would specifically require Medi-Cal
fee-for-service benefits to include emergency services and would
apply the reasonable layperson standard to those services.
Related Legislation:
AB 97 (Committee on Budget) Chapter 3 of 2011 (the health
budget trailer bill) increased copayments for non-emergency
services received in an emergency department from $5 to $50.
The bill also established copayments up to $50 for emergency
services received in an emergency department. The copayment
proposals in the trailer bill were not approved by the
federal Centers for Medicare and Medicaid Services and have
not gone into effect.
AB 1467 (Committee on Budget, the health trailer bill)
would impose a $5 copay for non-emergency care received in
an emergency department under Medi-Cal managed care and
clarifies that the reasonable layperson standard applies to
emergency medical care in the Medi-Cal managed care program.
That bill has passed both houses of the Legislature and is
in Enrollment.
Staff Comments: According to the Department, in 2008 the
Medi-Cal fee-for-service program spent about $360 million for
non-emergency services in emergency departments. Some unknown
portion of those services could have been expected to have
serious health impacts under the reasonable layperson standard
(such as chest pains) even if the ultimate diagnosis revealed
that the condition was not an emergency. On the other hand, some
unknown portion of those services probably would not be
considered an emergency, even under the reasonable layperson
standard (such as cold or flu symptoms).
Under this bill, the Department could attempt to limit payments
for truly non-emergency services which do not meet the
reasonable layperson standard. However, by imposing the
reasonable layperson standard in law, the bill would preclude
the Department from withholding payments for non-emergency
services that were provided because the patient believed he or
she was experiencing symptoms that could reasonably be
considered signs of a medical emergency.
AB 1803 (Mitchell)
Page 2