BILL ANALYSIS �
SB 986
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Date of Hearing: July 2, 2014
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Mike Gatto, Chair
SB 986 (Hernandez) - As Amended: May 27, 2014
Policy Committee: HealthVote:17-0
Urgency: No State Mandated Local Program:
No Reimbursable: No
SUMMARY
This bill allows Medi-Cal beneficiaries receiving specified
transplant services to be exempt from mandatory enrollment in
Medi-Cal managed care (MCMC) for an additional period of time
after the expiration of a medical exemption request (MER),
subject to certain criteria, until January 1, 2018.
Specifically, this bill:
1)Allows the exemption from Medi-Cal managed care plan
enrollment to be extended for up to an additional 12 months if
the treating physician determines it is medically necessary.
2)Applies to allogeneic bone marrow transplantation, allogeneic
blood stem cell transplantation, cord blood transplantation,
or haploidentical transplantation, as defined.
3)Specifies managed care contract provisions that shall not be
used as a basis for returning a beneficiary to a managed care
plan.
FISCAL EFFECT
1)One-time costs of about $25,000 to revise existing regulations
by the Department of Health Care Services (GF/federal).
2)Likely minor one-time costs to make system changes to allow
the Medi-Cal fiscal intermediary to track eligible medical
exemption requests (GF/federal).
3)Likely minor ongoing staff costs to track medical exemption
requests eligible for extension under the bill and communicate
with treating physicians about potential extensions (General
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Fund and federal funds).
4)Increased Medi-Cal costs, likely under $100,000 per year, to
provide care to eligible beneficiaries in the fee-for-service
system (GF/federal). In 2013, 21 Medi-Cal beneficiaries were
exempted from enrollment in managed care due to a specified
transplant that would qualify for extension under this bill.
According to DHCS, the average annual cost to Medi-Cal for
medical care to transplant recipients in the managed care
system is about $1,300 per year less than in the
fee-for-service system, and this bill would have potentially
applied to only 20 people in 2013. Given enrollment growth in
managed care, this number could grow in future years.
COMMENTS
1)Purpose . According to the author, it is preferable to allow
individuals to receive transplant follow-up care from the same
hospital and medical staff that provided their transplant
surgery. This bill allows individuals who have medical
exemption requests in place to exempt them from enrollment in
managed care, for a very specific type of surgery prone to
complications, to continue the MER so they can continue care
with the same providers.
2)Background . A Medi-Cal beneficiary with a complex medical
condition can request to remain in FFS Medi-Cal for up to 12
months as an alternative to mandatory enrollment in a MCMC
plan by submitting a MER. Among the qualifying complex
medical conditions are pregnancy, need for an organ
transplant, and cancer. The transplants that are the subject
of the bill are used in cancer treatment.
3)Previous Legislation . AB 1553 (Monning) of 2012 would have
established requirements and a process for MERs in MCMC. AB
1553 was referred to Senate Health Committee but not heard.
4)Staff Comments . The author identifies a specific problem
related to continuity of follow-up care for a specific type of
transplant. This bill offers one solution to the identified
problem, for a limited number of beneficiaries receiving these
transplant services, and requires administrative effort and
systems in place to track which beneficiaries are eligible for
special treatment under very specific circumstances. There
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may be other possible solutions that could address such
problems from a broader perspective.
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081