BILL ANALYSIS �
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|SENATE RULES COMMITTEE | AB 1803|
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THIRD READING
Bill No: AB 1803
Author: Mitchell (D), et al.
Amended: 6/12/12 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 9-0, 6/6/12
AYES: Hernandez, Harman, Alquist, Anderson, Blakeslee, De
Le�n, DeSaulnier, Rubio, Wolk
SENATE APPROPRIATIONS COMMITTEE : 7-0, 8/16/12
AYES: Kehoe, Walters, Alquist, Dutton, Lieu, Price,
Steinberg
ASSEMBLY FLOOR : 57-14, 5/17/12 - See last page for vote
SUBJECT : Medi-Cal: emergency medical conditions
SOURCE : California Chapter of the American College of
Emergency
Physicians
DIGEST : This bill requires Medi-Cal benefits to include
emergency services and care that are necessary for the
treatment of an emergency medical condition, and medical
care directly related to the emergency medical condition,
for fee-for-service (FFS) Medi-Cal beneficiaries.
ANALYSIS :
Existing law :
CONTINUED
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1.Existing law establishes the Medi-Cal program, which is
administered by the Department of Health Care Services
(DHCS), under which qualified low-income individuals
receive health care services.
2.Establishes a schedule of benefits under the Medi-Cal
program, which includes outpatient services, including
physician services, and inpatient hospital services
subject to utilization controls.
3.Defines, in Medi-Cal statute, a service as "medically
necessary" or a "medical necessity" when it is reasonable
and necessary to protect life, to prevent significant
illness or significant disability, or to alleviate severe
pain. Defines, through Medi-Cal regulation, "emergency
services" to mean those services required for alleviation
of severe pain or the immediate diagnosis and treatment
of unforeseen medical conditions, which, if not
immediately diagnosed and treated, would lead to
disability or death.
4.Allows health plans to deny payment for emergency
services and care only if the health plan, or its
contracting medical providers:
A. Reasonably determines that the emergency services
and care were never performed.
B. In cases when the plan enrollee did not require
emergency services and care and the enrollee
reasonably should have known that an emergency did not
exist. This provision is referred to as the
"reasonable layperson" standard.
5.Requires any licensed health facility that maintains and
operates an emergency department (ED) to provide
emergency services and care to any person for any
condition in which the person is in danger of loss of
life or serious injury or illness when the health
facility has the appropriate facilities and qualified
personnel available to provide the services or care.
Prohibits the provision of emergency services and care
from being based upon the person's ethnicity,
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citizenship, age, preexisting medical condition,
insurance status, economic status, or ability to pay for
medical services.
This bill:
1.Requires Medi-Cal benefits to include emergency services
and care that are necessary for the treatment of an
emergency medical condition and medical care directly
related to the emergency medical condition, as defined in
existing law, for FFS Medi-Cal beneficiaries.
2.Defines, using a definition in existing law, "emergency
medical condition" to mean 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.
C. Serious dysfunction of any bodily organ or part.
3.Prohibits this bill from being construed to change the
obligation of Medi-Cal managed care plans to provide
emergency services and care.
Background
Medi-Cal contains different state law standards for
coverage of emergency services, depending upon whether the
beneficiary is enrolled in FFS Medi-Cal, a Medi-Cal county
organized health system (COHS) or a Medi-Cal managed care
plan that is Knox-Keene licensed. In Medi-Cal FFS and COHS
plans that are not Knox-Keene licensed, "medically
necessary" services must be provided when it is reasonable
and necessary to protect life, to prevent significant
illness or significant disability, or to alleviate severe
pain. For enrollees of Knox-Keene health plans, including
Medi-Cal managed care plans that are Knox-Keene licensed (a
requirement in the two plan model and in geographic managed
care) health plans must provide emergency services and care
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based on the broader "reasonable person" standard.
Specifically, health plans or their contracting medical
providers must reimburse for emergency services and care
provided to its enrollees until the care results in
stabilization of the enrollee, unless the plan enrollee did
not require emergency services and care and the enrollee
"reasonably should have known" that an emergency did not
exist.
In practice, DHCS indicates it does not deny coverage if a
medical condition does not turn out to be life-threatening
but adjusts physician reimbursement based on the level of
care provided. DHCS' Audits and Investigations Division
does not determine that ED evaluation and management
services were not appropriate based on the final diagnosis
alone. DHCS indicates, in accordance with Current
Procedural Terminology guidelines, it considers the
history, examination, and complexity of medical
decision-making in determining the appropriate level of ED
service and it is the services rendered that determine the
level of compensation to the physician and not the
presenting symptoms or final diagnoses.
Federal Medicaid regulations require Medicaid managed care
organizations to cover and pay for emergency services based
on the prudent layperson standard, for services needed to
evaluate or stabilize an "emergency medical condition."
Federal regulations define an "emergency medical condition"
as a medical condition manifesting itself by acute symptoms
of sufficient severity (including severe pain) that a
prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of
immediate medical attention to result in any of the
following:
Placing the health of the individual (or, with respect to
a pregnant woman, the health of the woman or her unborn
child) in serious jeopardy.
Serious impairment to bodily functions.
Serious dysfunction of any bodily organ or part.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
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Local: No
According to the Senate Appropriations Committee, by
placing the "reasonable layperson" standard in statute,
this bill precludes DHCS from reducing or eliminating
payment for services provided in ED that were not thought
to be immediately necessary under the reasonable layperson
standard. The extent to which DHCS could reduce Medi-Cal
expenditures by limiting payment for such non-emergency
services provided in an ED is unknown.
SUPPORT : (Verified 8/20/12)
California Chapter of the American College of Emergency
Physicians
(source)
California Black Health Network
ARGUMENTS IN SUPPORT : This bill is sponsored by the
California Chapter of the American College of Emergency
Physicians (Cal-ACEP), which represents emergency
physicians, to apply the reasonable layperson standard to
Medi-Cal so that all Medi-Cal patients are covered when
they seek treatment for an emergency. Cal-ACEP states that
California and federal law governing Medi-Cal and Medicaid
contain different provisions related to the reasonable (or
under federal law, "prudent person" standard) layperson
standard and the provision of emergency medical services.
However, there is a gap in FFS Medi-Cal where no reasonable
layperson standard exists. Cal-ACEP states this bill is
needed to close the gap in law. While the reasonable
layperson standard has been a long-established patient
protection in California, efforts to erode this protection
are surfacing in other states. Given that threat, Cal-ACEP
concludes it is time to close the loophole in California
law to protect all Medi-Cal patients.
ASSEMBLY FLOOR : 57-14, 5/17/12
AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Beall, Bill
Berryhill, Block, Blumenfield, Bonilla, Bradford,
Brownley, Buchanan, Butler, Charles Calderon, Campos,
Carter, Cedillo, Chesbro, Davis, Dickinson, Eng, Feuer,
Fong, Fuentes, Furutani, Galgiani, Gatto, Gordon, Gorell,
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Halderman, Hall, Hayashi, Roger Hern�ndez, Hill, Huber,
Hueso, Huffman, Jeffries, Lara, Ma, Mendoza, Miller,
Mitchell, Monning, Nestande, Olsen, Pan, V. Manuel P�rez,
Portantino, Smyth, Solorio, Swanson, Torres, Wieckowski,
Williams, John A. P�rez
NOES: Conway, Cook, Donnelly, Beth Gaines, Grove, Hagman,
Jones, Knight, Logue, Mansoor, Morrell, Nielsen, Valadao,
Wagner
NO VOTE RECORDED: Fletcher, Garrick, Harkey, Bonnie
Lowenthal, Norby, Perea, Silva, Skinner, Yamada
CTW:d 8/20/12 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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