BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1310
AUTHOR: Bonta
AMENDED: June 10, 2014
HEARING DATE: June 25, 2014
CONSULTANT: Bain
SUBJECT : Medi-Cal: telehealth.
SUMMARY : Prohibits the Department of Health Care Services 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.
Existing law:
1.Prohibits in-person contact between a health care provider and
a patient from being required under the Medi-Cal program for
services appropriately provided through telehealth, subject to
reimbursement policies adopted by the Department of Health
Care Services (DHCS), to compensate a licensed health care
provider who provides health care services through telehealth
that are otherwise reimbursed pursuant to the Medi-Cal
program.
2.Prohibits DHCS from requiring a health care provider to
document a barrier to an in-person visit for Medi-Cal coverage
of services provided via telehealth. Prohibits DHCS from
limiting the type of setting where services are provided for
the patient or by the health care providers for the purposes
of payment for covered treatment or services provided through
telehealth.
3.Authorizes DHCS to provide, by regulation and consistent with
federal Medicaid law, for the care and treatment of persons
eligible for Medi-Cal by providers in another state in those
cases where out-of-state care or treatment is rendered on an
emergency basis or is otherwise in the best interests of the
person under the circumstances. Limits, through Medi-Cal
regulation, coverage of necessary out-of-state medical care,
to only specified conditions, such as when an emergency arises
from accident, injury or illness, or when the health of the
individual would be endangered if care and services are
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postponed until it is feasible that the individual return to
California.
This bill:
1.Prohibits DHCS from requiring a California-licensed health
care provider 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.
FISCAL EFFECT : The current form of this bill has not been
analyzed by a fiscal committee.
PRIOR VOTES : Not relevant.
COMMENTS :
1.Author's statement. According to the author, telehealth is
the use of electronic information and telecommunications
technologies to support long-distance clinical health care,
patient and professional health-related education, public
health and health administration. Telehealth services provide
valuable tools for health care providers to be able to deliver
increased access at a lower cost to patients. Existing law
currently prohibits DHCS from limiting the type of setting
where services are provided for the patient or by the health
care provider, for purposes of payment for Medi-Cal covered
telehealth services. However, DHCS is currently denying
claims for services provided to patients, located in
California at the time of service, by a California-licensed
provider who is located out-of-state. The denials are based on
a misinterpretation of existing law that are meant to apply to
patients, but are instead being incorrectly applied to
providers by DHCS. This bill is necessary to clarify existing
law to ensure that Medi-Cal beneficiaries have equivalent
access to telehealth services as their privately insured
counterparts, by expressly allowing for the provision of
telehealth services across state lines, as long as the
providers are California-licensed health care professionals.
2.Medi-Cal coverage of out-of-state services and telehealth
providers. "Telehealth" is defined as the mode of delivering
health care services and public health via information and
communication technologies to facilitate the diagnosis,
consultation, treatment, education, care management, and
self-management of a patient's health care while the patient
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3
is at the originating site and the health care provider is at
a distant site. Examples of Medi-Cal coverage of telehealth
include the following:
a. Selected evaluation and management services
for patient visit and consultation;
b. Selected psychiatric diagnostic interview
examination and selected psychiatric therapeutic
services;
c. Store and forward teledermatology and
teleophthalmology by "store and forward" (the
transmission of medical information to be reviewed at
a later time by a physician/optometrist at a distant
site who is trained in ophthalmology, optometry or
dermatology where the physician or optometrist at the
distant site reviews the medical information without
the patient being present in real time;
d. Transmission fee (an amount paid to both the
originating site and distant site when providing
service by a two-way, real-time interactive
communications system); and,
e. Interpretation and report of X-rays and
electrocardiograms performed after telehealth
transmission.
While existing Medi-Cal law provides coverage for telehealth
services, another provision of Medi-Cal law and regulation
limits Medi-Cal coverage of out-of-state medical care.
Specifically, Medi-Cal covers necessary out-of-state medical
care only under the following conditions:
a. When an emergency arises from accident, injury
or illness;
b. Where the health of the individual would be
endangered if care and services are postponed until it
is feasible that he or she return to California;
c. Where the health of the individual would be
endangered if he or she undertook travel to return to
California;
d. When it is customary practice in border
communities for residents to use medical resources in
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adjacent areas outside of California; or,
e. When an out-of-state treatment plan has been
proposed by the beneficiary's attending physician, and
the proposed plan has been received, reviewed and
authorized by DHCS before the services are provided.
DHCS can authorize such out-of-state treatment plans
only when the proposed treatment is not available from
resources and facilities within California.
Prior authorization is required for all out-of-state services,
except for emergency services and services provided in border
areas adjacent to California where it is customary practice
for California residents to avail themselves of such services.
No services are covered by Medi-Cal outside the United States,
except for emergency services requiring hospitalization in
Canada or Mexico.
When California licensed out-of-state physicians who seek to
bill Medi-Cal using telehealth services have applied to be
Medi-Cal providers through DHCS' Medi-Cal Provider Enrollment
Division using their out-of-state location as their practice
location, their applications have been denied by DHCS. In
DHCS' denial letters, the Provider Enrollment Division
indicates that out-of-state medical care for Medi-Cal
beneficiaries is covered only when emergency services have
been provided to a Medi-Cal beneficiary traveling
out-of-state, and that the provider's application being denied
does not indicate that the provider has provided emergency
services to a Medi-Cal beneficiary in the location of the
provider.
DHCS indicates health care providers billing Medi-Cal for
telehealth services providers must also be enrolled as
Medi-Cal providers in order to be reimbursed for providing
services to Medi-Cal beneficiaries. In addition, physicians
who use telehealth technologies to provide care to patients
located in California must be licensed in California. DHCS
indicates the Medical Board of California requires physicians
who use telehealth technologies to provide care to patients
located in California to also be licensed in California,
except a person who is licensed as a health care practitioner
in another state and is employed by a tribal health program
does not need to be licensed in California to perform services
for the tribal health program.
1.Prior legislation. AB 415 (Logue), Chapter 547, Statutes of
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2011, established the Telehealth Advancement Act of 2011 to
revise and update existing law to facilitate the advancement
of telehealth as a service delivery mode in managed care and
the Medi-Cal program.
AB 175 (Galgiani), Chapter 419, Statutes of 2010, for the
purposes of Medi-Cal reimbursement, expanded, until January 1,
2013, the definition of "teleophthalmology and teledermatology
by store and forward" to include services of an optometrist
who is trained to diagnose and treat eye diseases.
AB 1733 (Logue), Chapter 782, Statutes of 2012, updated
several code sections to replace the term "telemedicine" with
"telehealth" and expanded the potential for the use of
telehealth in additional health care programs administered by
DHCS, such as the Program of All-Inclusive Care for the
Elderly.
2.Support. This bill is sponsored by Virtual Radiologic (vRad)
to clarify existing telehealth law that allows licensed
California physicians to provide telehealth services to
Medi-Cal beneficiaries across state lines. In 2011, vRad
received a number of denial letters from DHCS for their
radiologists who would provide services across state lines.
These denial letters stated that these California-licensed
physicians could not be enrolled as Medi-Cal providers
because out-of-state medical care for Medi-Cal beneficiaries
is covered only when emergency services have been provided to
a Medi-Cal beneficiary while traveling outside of the state.
vRad indicates it enrolled physicians as Medi-Cal providers
without issue until 2012, when DHCS resumed denying
applications citing the same Medi-Cal statute. vRad has not
been able to resolve the situation with DHCS
administratively, and is turning to the Legislature to
clarify this issue. vRad states radiologists, as consulting
practitioners, are the physician's physician, and due to
advances in technology, teleradiology provides on-site
physicians with access to a nationwide network of
subspecialists, who can provide accurate analyses of scans
within minutes. vRad argues privately insured patients
benefit from this unparalleled access to subspecialists
through timely accurate diagnoses, and Medi-Cal patients
should be able to benefit also.
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3.Recommended amendment. This bill is intended to address
denials by DHCS' Provider Enrollment Division of
California-licensed physicians who work out-of-state, but who
seek to bill Medi-Cal for telehealth services that are not
emergency services provided in the state in which the
out-of-state provider is located. Staff recommends the
language in this measure delete the reference to Medicare, and
to amend the section of law that limits Medi-Cal coverage of
out-of-state services.
SUPPORT AND OPPOSITION :
Support: Virtual Radiologic (sponsor)
California Hospital Association
Dignity Health
Oppose: None received
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