Amended in Senate June 10, 2014

Amended in Assembly May 24, 2013

California Legislature—2013–14 Regular Session

Assembly Bill No. 1310

Introduced by Assembly Member begin delete Brown end delete begin insert Bonta end insert

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(Coauthor: Assembly Member Morrell)

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(Principal coauthor: Assembly Member Brown)

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February 22, 2013

An act to amend Section begin delete 14132.25 end delete begin insert 14132.72 end insert of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

AB 1310, as amended, begin delete Brown end delete   begin insert Bonta end insert . Medi-Cal: begin delete pediatric subacute care. end delete begin insert telehealth. end insert

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. begin delete Existing law requires the department to establish a subacute care program in health facilities in order to more effectively use limited Medi-Cal dollars while ensuring needed services for patients who meet subacute care criteria, as established by the department. For the purposes of the subacute care program, existing law defines pediatric subacute services as the health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function. Existing law also provides that, for the purposes of the subacute care program, medical necessity for pediatric subacute care services, as defined, shall be substantiated in one of 5 ways. end delete begin insert Existing law prohibits a requirement of in-person contact between a health care provider and patient under the Medi-Cal program for any service otherwise covered by the Medi-Cal program when the service is appropriately provided by telehealth, as defined. Existing law, for purposes of payment of covered treatment or services provided through telehealth, end insert begin insert prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider. end insert

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This bill would expand the definition of pediatric subacute services to include the health care services needed by a person under 21 years of age who requires treatment for one or more active complex medical conditions or requires the administration of one or more technically complex treatments.

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This bill would also provide that one of the ways that medical necessity for pediatric subacute care services shall be substantiated is by dependence on complex wound care management or the presence of a medical condition and necessity of care such that his or her health care needs may be satisfied by placement in a facility providing pediatric subacute care services, but, in the absence of access to a pediatric subacute care service, the only alternative in patient care appropriate to meet the patient’s medical needs is an acute care hospital bed. The bill would also provide that medical necessity may be shown solely by dependence on total parenteral nutrition or other intravenous nutritional support, without a showing of dependence on additional treatments, and by dependence on tracheostomy care, as specified, in conjunction with dependence on tube feeding by means of a jejunostomy tube.

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This bill would prohibit the department from requiring a health care provider licensed in California to be located in California as a condition of Medi-Cal provider enrollment or reimbursement for telehealth services provided to Medicare or Medicaid beneficiaries located in California at the time of service.

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Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

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begin insert SECTION 1. end insert   

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begin insert Section 14132.72 of the end insert begin insert Welfare and Institutions
Code end insert begin insert is amended to read: end insert

14132.72.  

(a) For purposes of this section, the definitions in
subdivision (a) of Section 2290.5 of the Business and Professions
Code shall apply.

(b) It is the intent of the Legislature to recognize the practice
of telehealth as a legitimate means by which an individual may
receive health care services from a health care provider without
in-person contact with the provider.

(c) In-person contact between a health care provider and a
patient shall not be required under the Medi-Cal program for
services appropriately provided through telehealth, subject to
reimbursement policies adopted by the department to compensate
a licensed health care provider who provides health care services
through telehealth that are otherwise reimbursed pursuant to the
Medi-Cal program.  Nothing in this section or the Telehealth
Advancement Act of 2011 begin insert (Chapter 547 of the Statutes of 2011) end insert
shall be construed to conflict with or supersede the provisions of
Section 14091.3 of this code or any other existing state laws or
regulations related to reimbursement for services provided by a
noncontracted provider.

(d) The department shall not require a health care provider to
document a barrier to an in-person visit for Medi-Cal coverage of
services provided via telehealth.

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(e) Notwithstanding Section 14122 or any other law, the
department shall not require a health care provider licensed in
California to be located in California as a condition of Medi-Cal
provider enrollment or reimbursement for telehealth services
provided to Medicare or Medicaid beneficiaries located in
California at the time of service.

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(e)

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begin insert ( end insert begin insert f) end insert  For the purposes of payment for covered treatment or services
provided through telehealth, the department shall not limit the type
of setting where services are provided for the patient or by the
health care provider.

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(f)

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begin insert (g) end insert  Nothing in this section shall be interpreted to authorize the
department to require the use of telehealth when the health care
provider has determined that it is not appropriate.

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(g)

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begin insert ( end insert begin insert h) end insert  Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, and make specific this
section by means of all-county letters, provider bulletins, and
similar instructions.

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SECTION 1.  

Section 14132.25 of the Welfare and Institutions
Code is amended to read:

14132.25.  

(a) On or before July 1, 1983, the State Department
of Health Care Services shall establish a subacute care program
in health facilities in order to more effectively use the limited
Medi-Cal dollars available while at the same time ensuring needed
services for these patients. The subacute care program shall be
available to patients in health facilities who meet subacute care
criteria. Subacute care may be provided by any facility designated
by the director as meeting the subacute care criteria that has an
approved provider participation agreement with the department.

(b) The department shall develop a rate of reimbursement for
this subacute care program. Reimbursement rates shall be
determined in accordance with methodology developed by the
department, specified in regulation, and may include the following:

(1) All-inclusive per diem rates.

(2) Individual patient-specific rates according to the needs of
the individual subacute care patient.

(3) Other rates subject to negotiation with the health facility.

(c) Reimbursement at subacute care rates, as specified in
subdivision (b), shall only be implemented if funds are available
for this purpose pursuant to the annual Budget Act.

(d) The department may negotiate and execute an agreement
with any health facility that meets the standards for providing
subacute care. An agreement may be negotiated or established
between the health facility and the department for subacute care
based on individual patient assessment. The department shall
establish level of care criteria and appropriate utilization controls
for patients eligible for the subacute care program.

(e) For the purposes of this section, pediatric subacute services
are the health care services needed by a person under 21 years of
age who uses a medical technology that compensates for the loss
of a vital bodily function, requires treatment for one or more active
complex medical conditions, or requires the administration of one
or more technically complex treatments.

(f) Medical necessity for pediatric subacute care services shall
be substantiated in any one of the following ways:

(1) A tracheostomy with dependence on mechanical ventilation
for a minimum of six hours each day.

(2) Dependence on tracheostomy care requiring suctioning at
least every six hours, and room air mist or oxygen as needed, and
dependence on one of the five treatment procedures listed in
subparagraphs (B) to (F), inclusive:

(A) Dependence on intermittent suctioning at least every eight
hours and room air mist and oxygen as needed.

(B) Dependence on continuous intravenous therapy, including
administration of a therapeutic agent necessary for hydration or
of intravenous pharmaceuticals, or intravenous pharmaceutical
administration of one or more agents, via a peripheral or central
line, without continuous infusion.

(C) Dependence on peritoneal dialysis treatments requiring at
least four exchanges every 24 hours.

(D) Dependence on tube feeding by means of a nasogastric,
gastrostomy, or jejunostomy tube.

(E) Dependence on other medical technologies required
continuously, that, in the opinion of the attending physician and
the Medi-Cal consultant, require the services of a licensed
registered nurse.

(F) Dependence on biphasic positive airway pressure at least
six hours a day, including assessment or intervention every three
hours and lacking either cognitive or physical ability of the patient
to protect his or her airway.

(3) Dependence on total parenteral nutrition or other intravenous
nutritional support.

(4) Dependence on skilled nursing care in the administration of
any three of the following six treatment procedures:

(A) Dependence on intermittent suctioning at least every eight
hours and room air mist and oxygen as needed.

(B) Dependence on continuous intravenous therapy, including
administration of a therapeutic agent necessary for hydration or
of intravenous pharmaceuticals, or intravenous pharmaceutical
administration of one or more agents, via a peripheral or central
line, without continuous infusion.

(C) Dependence on peritoneal dialysis treatments requiring at
least four exchanges every 24 hours.

(D) Dependence on tube feeding by means of a nasogastric,
gastrostomy, or jejunostomy tube.

(E) Dependence on other medical technologies required
continuously that in the opinion of the attending physician and the
Medi-Cal consultant, require the services of a licensed registered
nurse.

(F) Dependence on biphasic positive airway pressure at least
six hours a day, including assessment or intervention every three
hours for a patient lacking either cognitive or physical ability of
the patient to protect his or her airway.

(5) Dependence on biphasic positive airway pressure or
continuous positive airway pressure at least six hours a day,
including assessment or intervention every three hours, for a patient
lacking either cognitive or physical ability to protect his or her
airway, and dependence on one of the following five treatment
procedures:

(A) Dependence on intermittent suctioning at least every eight
hours and room air mist and oxygen as needed.

(B) Dependence on continuous intravenous therapy, including
administration of a therapeutic agent necessary for hydration or
of intravenous pharmaceuticals, or intravenous pharmaceutical
administration of one or more agents, via a peripheral or central
line, without continuous infusion.

(C) Dependence on peritoneal dialysis treatments requiring at
least four exchanges every 24 hours.

(D) Dependence on tube feeding by means of a nasogastric,
gastrostomy, or jejunostomy tube.

(E) Dependence on other medical technologies required
continuously that in the opinion of the attending physician and the
Medi-Cal consultant, require the services of a licensed registered
nurse.

(6) Dependence on complex wound care management, including
daily assessment or intervention by a licensed registered nurse and
daily dressing changes, wound packing, debridement, negative
pressure wound therapy, or a special mattress.

(7) The patient has a medical condition and requires an intensity
of medical or skilled nursing care such that his or her health care
needs may be satisfied by placement in a facility providing
pediatric subacute care services, but, in the absence of a facility
providing pediatric subacute care services, the only other inpatient
care appropriate to meet the patient’s health care needs under the
Medi-Cal program is in an acute care licensed hospital bed.

(g) The medical necessity determination outlined in subdivision
(f) is intended solely for the evaluation of a patient who is
potentially eligible and meets the criteria to be transferred from
an acute care setting to a subacute level of care.

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