BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1868
AUTHOR: Gomez
AMENDED: June 10, 2014
HEARING DATE: June 25, 2014
CONSULTANT: Bain
SUBJECT : Medi-Cal: optional benefits: podiatric medicine.
SUMMARY : Provides Medi-Cal coverage of medical and surgical
services provided by a podiatrist within his or her scope of
practice that, if provided by a physician, would be considered
physician services, for services which can be provided by either
a physician or a podiatrist.
Existing law:
1.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS) and under which
qualified low-income persons receive health care benefits. The
Medi-Cal program is, in part, governed and funded by federal
Medicaid provisions.
2.Excludes specified optional benefits from coverage under the
Medi-Cal program, including podiatry, except for beneficiaries
under the Early and Periodic Screening Diagnosis and Treatment
Program (individuals under age 21), and beneficiaries
receiving long-term care in a nursing facility that is a
skilled nursing facility or intermediate care facility that is
licensed as a nursing facility.
This bill:
1. Provides Medi-Cal coverage of medical and surgical services
provided by a podiatrist within his or her scope of practice
that, if provided by a physician, would be considered
physician services, and which services can be provided by
either a physician or a podiatrist.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, potential increased Medi-Cal costs of up to $1.2
million (nearly 50 percent General Fund, remainder federal
funds). Any reimbursement to podiatrists authorized under this
bill are for services already covered if provided by a
physician; therefore, increased costs would be attributed to
higher utilization of covered services.
Continued---
AB 1868 | Page 2
PRIOR VOTES :
Assembly Health: 18- 0
Assembly Appropriations:14- 0
Assembly Floor: 76- 0
COMMENTS :
1.Author's statement. According to the author, in 2009,
podiatric services were eliminated in the state's Medi-Cal
program through budget cuts. This bill would reinstate full
foot and ankle care by podiatrists in the Medi-Cal system. The
elimination of podiatric services from Medi-Cal has
exacerbated an already acute access problem for low-income
individuals and those living with a disability. Currently,
podiatrists perform physician services and have full medical
staff admitting and surgical privileges in hospitals and
surgery centers. However, hospital podiatrists are prohibited
from providing on-call services to emergency patients in the
Medi-Cal system. This has led to a delay in care in cases of
diabetic foot care, traumatic foot, and ankle injuries as
patients attempt to find a provider. A delay in care of a
diabetic patient can lead to complications and even
amputation. Eliminating podiatric services has also placed an
increased burden on emergency room providers who are now
tasked with providing essential foot and ankle services for
these Medi-Cal patients.
2.Medicaid optional and mandatory benefits. States establish and
administer their own Medicaid programs and determine the type,
amount, duration, and scope of services within broad federal
guidelines. States are required to cover certain "mandatory
benefits," and can choose to provide other "optional benefits"
through the Medicaid program, for which they can receive
federal financial participation (federal "matching funds").
The federal Centers for Medicare and Medicaid Services
indicates the following are mandatory and optional benefits in
Medicaid:
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| | |
| Mandatory Benefits | Optional Benefits |
| | |
|--------------------------+-------------------------------------|
| | |
| Inpatient | Prescription drugs |
| hospital services | |
AB 1868 | Page
3
| | |
| | Clinic services |
| Outpatient | |
| hospital services | |
| | Physical therapy |
| | |
| Early and | |
| Periodic Screening, | Occupational therapy |
| Diagnostic, and | |
| Treatment Services | |
| (EPSDT). | Speech, hearing and language |
| | disorder services |
| | |
| Nursing facility | |
| services | Respiratory care services |
| | |
| | |
| Home health | Other diagnostic, screening, |
| services | preventive and rehabilitative |
| | services |
| | |
| Physician | |
| services | Podiatry services |
| | |
| | |
| Rural health | Optometry services |
| clinic services | |
| | |
| | Dental services |
| Federally | |
| qualified health | |
| center services | Dentures |
| | |
| | |
| Laboratory and | Prosthetics |
| X-ray services | |
| | |
| | Eyeglasses |
| Family planning | |
| services | |
| | Chiropractic services |
| | |
| Nurse Midwife | |
| services | Other practitioner services |
| | |
AB 1868 | Page 4
| | |
| Certified | Private duty nursing |
| Pediatric and Family | services |
| Nurse Practitioner | |
| services | |
| | Personal Care |
| | |
| Freestanding | |
| Birth Center | Hospice |
| services (when | |
| licensed or | |
| otherwise recognized | Case management |
| by the state) | |
| | |
| | Services for individuals age |
| Transportation to | 65 or older in an Institution |
| medical care | for Mental Disease (IMD) |
| | |
| | |
| Tobacco cessation | Services in an intermediate |
| counseling for | care facility for the mentally |
| pregnant women | retarded |
| | |
| | |
| | State Plan Home and |
| | Community-Based Services - |
| | 1915(i) |
| | |
| | |
| | Self-Directed Personal |
| | Assistance Services - 1915(j) |
| | |
| | |
| | Community First Choice |
| | Option - 1915(k) |
| | |
| | |
| | Tuberculosis Related |
| | Services |
| | |
| | |
| | Inpatient psychiatric |
| | services for individuals under |
| | age 21 |
| | |
| | |
AB 1868 | Page
5
| | Other services approved by |
| |the Secretary* |
| | |
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*This includes services furnished in a religious non-medical
health care institution, emergency hospital services by a
non-Medicare certified hospital, and critical access hospital.
1.Background on Medi-Cal optional benefit elimination. In 2009,
the Legislature and Governor enacted AB 5 [Committee on
Budget], Chapter 20, Statutes of 2009), which eliminated some
optional benefits for adults that had been covered under
Medi-Cal. Optional benefits eliminated by AB 5 were
acupuncture services, audiology and speech therapy services,
chiropractic services, optometric and optician services,
including services provided by a fabricating optical
laboratory, podiatric services, psychology services, and
incontinence creams and washes. When the state eliminated
optional benefits, services that were previously provided by
an acupuncturist, podiatrist, a psychologist, which are no
longer covered by Medi-Cal can still be provided by a
physician. DHCS indicates its optional benefit exclusion
policy also allows certain populations (pregnant women and
beneficiaries under 21 years old) to continue to receive these
optional services. DHCS also indicates all Medi-Cal eligible
beneficiaries can access optional benefit services in certain
settings, such as hospital outpatient departments/ emergency
rooms, and some optional services (such as podiatry and
chiropractic services) can be received in Federally Qualified
Health Centers (FQHCs) and Rural Health Clinics (RHCs).
Most of the General Fund savings from the optional benefit
elimination in AB 5 resulted from the elimination of adult
dental. Litigation brought by RHCs resulted in podiatry and
other services being reinstated at RHCs and FQHCs. Optometry
services were reinstated (eye exams and procedures by
optometrist) to adults 21 and over in July 2010, but all eye
appliances (glasses, contact lenses, low vision devices) and
dispensing optician services, including services provided by
fabricating optical laboratories for adults 21 and over, are
still excluded from coverage. Psychology services were
reinstated in January 1, 2014, and last year, the Legislature
and Governor reinstated some adult dental services in AB 82
AB 1868 | Page 6
(Budget Committee), Chapter 23, Statutes of 2013, the 2013-14
budget health trailer bill. The Department of Finance
estimates the restoration of podiatry as a Medi-Cal benefit
would have a total funds cost of $1.1 million ($555,000
General Fund).
2.Support. This bill is sponsored by the California Podiatric
Medical Association (CPMA) to reinstate full foot and ankle
care by podiatrists in Medi-Cal. CPMA states this elimination
removed Medi-Cal coverage by podiatrists, but not the services
themselves as the same services provided by a physician are
covered in Medi-Cal. CPMA argues eliminating coverage of
services provided by podiatrists has resulted in much more
expensive complications down the road as podiatrists perform
physician services and have full medical staff admitting and
surgical privileges in hospitals and surgery centers. However,
CPMA indicates hospital podiatrists are prohibited from
providing on-call services to emergency patients in the
Medi-Cal system. This has led to a delay in care in cases of
diabetic foot care, traumatic foot, and ankle injuries as
patients attempt to find a provider. It has also placed an
increased burden on emergency room providers who are now
tasked with providing essential foot and ankle services for
these Medi-Cal patients. CPMA states recent studies show
access to podiatrists can prevent complications for patients
and actually provide savings for delivery systems, as diabetic
ulcerations are the primary factor leading to lower extremity
amputations. CPMA cites a study conducted by Thomson Reuters
Healthcare that found, for Medicare eligible patients, a
savings of $4,271 per patient with diabetes can be realized
over a three year period if there is at least one visit to a
podiatrist in the year preceding ulceration, and each $1
invested in care by a podiatrist results in $9 to $13 of
savings. Overall, patients with diabetes were less likely to
experience a lower extremity amputation if a podiatrist was a
member of the patient care team according to Thomson Reuters
Healthcare. CPMA concludes that eliminating podiatric services
from Medi-Cal has exacerbated an already acute access problem
for the low income and disabled population, and this bill
would provide better access to foot and ankle care for this
vulnerable patient population.
3.Policy question. The Senate version of the budget proposed to
restore the optional benefits eliminated in 2009, but this
proposal was not included in the final budget agreement.
Several optional benefits eliminated by AB 5 have since been
AB 1868 | Page
7
restored, but other important benefits, including podiatry and
glasses and contact lenses, have not been. Which Medi-Cal
optional benefits should be restored?
SUPPORT AND OPPOSITION :
Support: California Podiatric Medical Association (sponsor)
American Diabetes Association
Association of Regional Center Agencies
California Commission on Aging
California Labor Federation
California Medical Association
California Teamsters Public Affairs Council
Disability Rights California
Western Center on Law and Poverty
Oppose: None received
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