BILL ANALYSIS �
AB 1310
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Date of Hearing: August 28, 2014
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1310 (Bonta) - As Amended: August 22, 2014
SUBJECT : Medi-Cal: telehealth.
SUMMARY : Requires a health care provider located outside of
California to meet specified requirements as a condition for
enrolling in the Medi-Cal program for the purpose of providing
telehealth services to Medi-Cal beneficiaries receiving care in
California. Specifically, this bill :
1)Requires, effective July 1, 2015, a health care provider
located outside California to meet all of the following
requirements as a condition for enrolling in Medi-Cal for the
purpose of providing telehealth services to Medi-Cal
beneficiaries receiving care in California:
a) Be licensed, as specified, to perform the medical
services provided through telehealth;
b) Be enrolled and in good standing in the Medicaid program
in the state where the provider is located, be enrolled and
in good standing in the Medicare program, or both;
c) Be located inside the United States;
d) Satisfy all requirements to enroll in Medi-Cal and
requirements for providing telehealth services;
e) Consent to Medi-Cal acting through their state's
Medicaid program and through the Medicare program
concerning the provider's enrollment or participation in
Medi-Cal; and,
f) Consent to the jurisdiction and venue of Sacramento,
California concerning any legal, administrative, civil, and
criminal proceedings.
2)Conditions the implementation of this bill only to the extent
permitted by federal law and that federal financial
participation is available.
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EXISTING LAW :
1)Authorizes services to be provided to Medi-Cal beneficiaries
through telehealth and prohibits in-person contact between a
provider and a beneficiary if the service is appropriately
provided through telehealth.
2)Authorizes the Department of Health Care Services (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.
FISCAL EFFECT : According to the Senate Appropriations Committee
this bill would have:
1)One-time costs likely less than $50,000 to revise existing
regulations by DHCS (General Fund (GF) and federal funds).
2)Unknown, though likely minor, increase in administrative costs
for investigations of out-of-state Medi-Cal providers (GF 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 in-state provider. It does not seem likely
that there will be a very large number of out-of-state
providers of telehealth services under this bill. Therefore,
the actual additional investigation costs are not likely to be
significant in any given year.
3)Unknown increase in usage of Medi-Cal services due to the
availability of more providers (GF and federal funds). By
authorizing out-of-state providers to provide services through
telehealth, the 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
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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.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, telehealth
uses electronic information and telecommunications for
long-distance clinical health care, patient and professional
health-related education, public health and health
administration. 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,
the author notes, 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 author argues these denials are
based on a misinterpretation of existing law that is meant to
apply to patients, but DHCS is incorrectly applying this to
providers. The author states 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.
This bill would only apply to medical provides who provide
services through fee-for-service Medi-Cal and bill the state
for services. In the Medi-Cal managed care system, providers
are not required to enroll with DHCS as Medi-Cal providers in
order to provide services to a Medi-Cal managed care plan.
2)BACKGROUND . "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:
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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 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
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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.
3)SUPPORT . According to the sponsors of this bill, Virtual
Radiologic, DHCS had historically allowed out-of-state medical
providers who are licensed to practice in California to enroll
in the Medi-Cal program (necessary in order to bill the
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program for services). However, recently, DHCS has begun
denying applications for enrollment by out-of-state providers.
4)OPPOSITION . The California Nurses Association (CNA) opposes
this bill as they state concerns this bill will likely result
in Medi-Cal funds needed within California to support in-state
Medi-Cal providers and facilities, being sent out-of-state or
perhaps even outside of the country. CNA argues even with the
increased demand for healthcare services as a result of
healthcare reform, there is no evidence of a need to recruit
out-of-state specialists and send healthcare dollars that
could otherwise support the expansion of services within the
state to areas outside of California.
5)PREVIOUS LEGISLATION .
a) 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.
b) 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.
c) 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.
REGISTERED SUPPORT / OPPOSITION :
Support
Virtual Radiologic (sponsor)
American Telemedicine Association
Association of California Healthcare Districts
California Chapter American College of Emergency Physicians
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California Hospital Association
Dignity Health
National Multiple Sclerosis Society - California Action Network
Planned Parenthood Affiliates of California
Radisphere National Radiology Group
Opposition
California Nurses Association
Analysis Prepared by : Roger Dunstan / HEALTH / (916) 319-2097