BILL ANALYSIS �
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THIRD READING
Bill No: AB 1310
Author: Bonta (D), et al.
Amended: 8/22/14 in Senate
Vote: 21
PRIOR VOTES NOT RELEVANT
SENATE HEALTH COMMITTEE : 8-0, 6/25/14
AYES: Hernandez, Morrell, Beall, De Le�n, DeSaulnier, Evans,
Monning, Nielsen
NO VOTE RECORDED: Wolk
SENATE APPROPRIATIONS COMMITTEE : 5-0, 8/14/14
AYES: De Le�n, Hill, Lara, Padilla, Steinberg
NO VOTE RECORDED: Walters, Gaines
SUBJECT : Medi-Cal: telehealth
SOURCE : Virtual Radiologic
DIGEST : This bill requires, in order for a health care
provider that is not located in California to be enrolled in
Medi-Cal for the purpose of providing health care services by
way of telehealth for beneficiaries receiving care in
California, the provider to meet specified conditions and
criteria, including that the provider be enrolled and in good
standing in the Medicaid program for the state where the
provider is located, be enrolled in good standing in Medicare,
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or be enrolled in good standing in both programs, and that the
provider not be located outside the United States.
Senate Floor Amendments of 8/22/14 delete the prior contents of
the bill, which prohibit the Department of Health Care Services
(DHCS) 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 Medi-Cal beneficiaries located in
California at the time of service, and instead recast the bill
in its current form.
ANALYSIS :
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 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
postponed until it is feasible that the individual return to
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California.
This bill:
1.Requires, effective July 1, 2015, in order for a health care
provider that is not located in California to be enrolled in
Medi-Cal for the purpose of providing health care services by
way of telehealth for beneficiaries receiving care in
California, that provider, at a minimum, to meet all of the
following conditions and criteria:
A. Requires the provider to be licensed under the Business
and Professions Code or the Osteopathic Initiative Act, or
by the relevant California licensing entity or board to
perform the medical services provided through telehealth;
B. The provider to be enrolled and in good standing in the
Medicaid program for the state where the provider is
located, be enrolled in good standing in Medicare, or be
enrolled in good standing in both programs;
C. Prohibits the provider from being located outside the
United States;
D. Requires the provider to satisfy all requirements for
enrollment and participation in the Medi-Cal program, and
other statutory requirements for providing telehealth
services;
E. Requires the provider to consent to Medi-Cal acting
through the state Medicaid program where the provider is
located and the Medicare program with respect to any issues
concerning the provider's enrollment or participation in
Medi-Cal; and
F. Requires the provider to consent to jurisdiction and
venue in Sacramento, California, for any and all legal
proceedings in any way related to the provider's enrollment
in Medi-Cal, including, but not limited to, formal or
informal proceedings, as well as administrative, civil, and
criminal proceedings.
1.Implements this bill only to the extent permitted by federal
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law and to the extent that federal financial participation is
available.
Comments
According to the author's office, 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.
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 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:
1.Selected evaluation and management services for patient visit
and consultation;
2.Selected psychiatric diagnostic interview examination and
selected psychiatric therapeutic services;
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3.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;
4.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
5.Interpretation and report of X-rays and electrocardiograms
performed after telehealth transmission.
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
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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.
Prior Legislation
AB 415 (Logue, Chapter 547, Statutes of 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.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
According to the Senate Appropriations Committee:
One-time costs likely less than $50,000 to revise existing
regulations by DHCS (General Fund and federal funds).
Unknown, though likely minor, increase in administrative costs
for investigations of out-of-state Medi-Cal providers (General
Fund and federal funds). If DHCS performs an investigation of
an out-of-state Medi-Cal provider (for example, because of
concerns about improper billing), the costs to conduct onsite
inspections of records would be more expensive than would be
the case with an instate provider. It does not seem likely
that there will be a very large number of out-of-state
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providers of telehealth services under this bill. Therefore,
the actual additional investigation costs are not likely to be
significant in any given year.
Unknown increase in usage of Medi-Cal services due to the
availability of more providers (General Fund and federal
funds). By authorizing out-of-state providers to provide
services through telehealth, this bill increases the number of
potential Medi-Cal providers. For services like radiology
through telehealth, this bill is not likely to increase
overall demand for services, because radiology services will
almost always be provided when needed by a patient, whether
the provider is in state or out-of-state. On the other hand,
there are certain medical services for which Medi-Cal
beneficiaries can have difficult locating a provider. This
can be an issue of particular concern in rural areas. In
those cases, allowing additional providers may increase
overall utilization of services. It is important to note that
the low provider rates paid by Medi-Cal and the costs to set
up and maintain telehealth capabilities are likely to limit
utilization of telehealth by providers.
SUPPORT : (Verified 8/25/14)
Virtual Radiologic (source)
American Telemedicine Association
Association of California Healthcare Districts
California Chapter American College of Emergency Physicians
California Hospital Association
Dignity Health
National Multiple Sclerosis Society - California Action Network
Planned Parenthood Affiliates of California
Radisphere National Radiology Group
OPPOSITION : (Verified 8/25/14)
California Nurses Association
ARGUMENTS IN 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
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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.
ARGUMENTS IN OPPOSITION : The California Nurses Association
(CNA) opposes this bill because they are troubled by the public
policy implications of allowing California-licensed,
out-of-state physicians and surgeons to enroll as Medi-Cal
providers, provide telehealth services to Medi-Cal patients, and
receive reimbursement. CNA is especially concerned that this
bill will result in Medi-Cal funds needed to support in-state
Medi-Cal providers and facilities being sent out-of-state at a
time when the state economy is struggling. CNA states this bill
could open the floodgates to an exodus of Medi-Cal dollars to
out-of-state providers which are otherwise desperately needed in
California.
JL:k 8/25/14 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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