BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1150
AUTHOR: Hueso and Correa
AMENDED: March 26, 2014
HEARING DATE: April 2, 2014
CONSULTANT: Bain
SUBJECT : Medi-Cal: federally qualified health centers and rural
health clinics.
SUMMARY : Requires Medi-Cal reimbursement to Federally Qualified
Health Centers and Rural Health Clinics for two visits taking
place on the same day at a single location when the patient
suffers illness or injury requiring additional diagnosis or
treatment after the first visit, or when the patient has a
medical visit and another health visit with a mental health
provider or dental provider.
Existing law:
1.Establishes the Medi-Cal program as California's Medicaid
program, administered by the Department of Health Care
Services (DHCS), which provides comprehensive health care
coverage for low-income individuals. Federally Qualified
Health Center (FQHC) and Rural Health Clinic (RHC) services
are covered benefits under the Medi-Cal program.
2.Requires FQHCs and RHCs to be reimbursed on a per-visit basis.
Defines a "visit" as a face-to-face encounter between an FQHC
or RHC patient and the following health care providers: a
physician, physician assistant, nurse practitioner, certified
nurse midwife, clinical psychologist, licensed clinical social
worker, visiting nurse, podiatrist, dentist, optometrist,
chiropractor, comprehensive perinatal services practitioner
providing comprehensive perinatal services, a four-hour day of
attendance at an Adult Day Health Care Center; and, any other
provider identified in the state plan's definition of an FQHC
or RHC visit.
3.Requires FQHC and RHC per-visit rates to be increased by the
Medicare Economic Index applicable to primary care services in
the manner provided for in federal law.
4.Permits FQHC or RHC to apply for an adjustment to its
per-visit rate based on a change in the scope of services
Continued---
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provided by the FQHC or RHC. Requires rate changes based on a
change in the scope of services provided by an FQHC or RHC to
be evaluated in accordance with Medicare reasonable cost
principles.
This bill:
1.Requires a maximum of two visits to an FQHC or RHC, taking
place on the same day at a single location, to be reimbursed
by Medi-Cal when one or more of the following conditions
exist:
a. After the first visit, the patient suffers an
illness or injury requiring additional diagnosis or
treatment; or
b. The patient has a medical visit and another
health visit (with a dental or mental health
provider).
2.Defines "another health visit" as a face-to-face encounter
between an FQHC or RHC patient and a clinical psychologist,
licensed clinical social worker, dentist, dental hygienist, or
registered dental hygienist in alternative practice.
3.Defines a "medical visit" as a face-to-face encounter between
an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse midwife, visiting nurse,
or a comprehensive perinatal practitioner providing
comprehensive perinatal services.
4.Requires an FQHC or RHC that currently includes the cost of
encounters with more than one health professional that take
place on the same day at a single location as constituting a
single visit for purposes of establishing its FQHC or RHC rate
to apply for an adjustment to its per-visit rate.
5.Requires, after the rate adjustment has been approved by DHCS,
the FQHC or RHC to bill a medical visit and another health
visit by a dental or mental health provider that take place on
the same day at a single location as separate visits.
6.Requires DHCS, by July 1, 2015, to develop and adjust all
appropriate forms to determine which FQHC's or RHC's rates to
be adjusted and to facilitate the calculation of the adjusted
rates. Prohibits an FQHC's or RHC's application for, or DHCS'
approval of, a rate adjustment pursuant from constituting a
change in scope of service.
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7.Permits an FQHC or RHC that applies for an adjustment to its
rate to continue to bill for all other FQHC or RHC visits at
its existing per-visit rate, subject to reconciliation, until
the rate adjustment has been approved.
8.Requires DHCS, by January 15, 2015, to submit a state plan
amendment to the federal Centers for Medicare and Medicaid
Services reflecting the changes described in this bill.
Requires DHCS, no later than March 30, 2015, to promptly seek
all necessary federal approvals in order to implement this
bill, including any necessary amendments to the state plan.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, while the federal
government gives permission to state Medicaid agencies to allow
FQHCs to bill Medicaid for same day visits, California has
restricted its program to only allow same day billings in the case
of a physical health care visit and dental visit. Medi-Cal
patients presenting for a physical health problem who require a
mental health service have to wait 24 hours to be seen, which
prevents many Medi-Cal beneficiaries from receiving the care they
are entitled to through Medi-Cal managed care. When left
unaddressed, mental illness can make it difficult for patients
with chronic physical illness to manage their health care,
translating into significant and costly physical health problems
for both patients and the health care system. Like dental visits,
mental health services require a completely different team of
individuals to care for the need of the patients. Allowing for
same day billing for mental health services will also result in
step towards reducing our prison population. Nearly a quarter of
both state prisoners and jail inmates who had a mental health
problem, compared to a fifth of those without, had served three or
more prior incarcerations.
2.Background on FQHCs and RHCs. FQHCs and RHCs are federal
designated clinics that are required to serve medically
underserved populations that provide primary care services. FQHCs
and RHCs provided over 10.5 million Medi-Cal visits in 2013.
Demand for Medi-Cal services is expected to increase as an
estimated 1.4 million individuals will be newly Medi-Cal eligible
as a result of the Medicaid expansion under the federal Affordable
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Care Act.
Medi-Cal reimbursement to FQHCs and RHCs is governed by state and
federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a
per-visit rate under what is known as the prospective payment
system (PPS). For Medi-Cal managed care plan patients, DHCS
reimburses FQHCs and RHCs for the difference between its per-visit
PPS rate and the payment made by the plan. This payment is known
as a "wrap around" payment. The Medi-Cal managed care wrap-around
rate was established to reimburse providers for the difference
between their PPS rate and their Medi-Cal managed care
reimbursement rate. The rationale for the enhanced reimbursement
is to ensure that FQHCs and RHCs do not use federal grant funds
intended for uninsured and special needs populations to back-fill
for potentially below-cost Medicare or Medi-Cal rates. The average
PPS rate paid to an FQHC ($178.80) and an RHC ($135.99) is
considerably higher than the most common primary care visit
reimbursement rates in Medi-Cal. Because FQHCs and RHCs are
required to receive a cost-of-living adjustment to their rates
(under the Medicare Economic Index) and because of their role in
providing primary care access to the Medi-Cal population, FQHCs
and RHCs have been exempted from recent Medi-Cal rate reductions.
3.Billing for same day visits. DHCS policy in its State Plan
Amendment on same day visits at FQHCs and RHCs is that
encounters with more than one health professional and/or
multiple encounters with the same health professional, which
take place on the same day and at a single FQHC or RHC
location, constitute a single visit, except that more than one
visit may be counted on the same day:
a. When the clinic patient, after the first visit,
suffers illness or injury requiring another diagnosis or
treatment; or,
b. When the clinic patient has a face-to-face encounter
with a with a dentist or dental hygienist and then also
has a face-to-facet encounter with another health
professional or comprehensive perinatal services
practitioner on the same date.
Mental health visits are treated for Medi-Cal billing purposes
as a visit, and separate billing on the same day for a medical
visits and a mental health visit is not allowed.
4.Governor's Budget proposal in 2012-13. DHCS proposed, as part
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of last year's Governor's Budget, to change the Medi-Cal
payment methodology for FQHCs and RHCs. Under DHCS' proposal,
payments made to FQHCs and RHCs participating in Medi-Cal
managed care plan contracts would have changed from a cost and
volume-based payment to a fixed payment to provide a broad
range of services to its enrollees. A waiver of current
operating restrictions would allow FQHCs and RHCs to provide
group visits, telehealth, and telephonic disease management.
The waiver would also allow clinics to perform multiple
services on the same day. DHCS assumed an efficiency savings
of ten percent due to using the prospective payment reform and
would be removed from the funding provided to the plans. This
proposal was rejected by the Legislature.
5.Related legislation. SB 1081 (Hernandez) would require DHCS to
authorize a 3-year alternative payment methodology (APM) pilot
project for FQHCs that would be implemented in any county and
FQHC willing to participate. Under the APM pilot project,
participating FQHCs would receive capitated monthly payments
for each Medi-Cal managed care enrollee assigned to the FQHC
in place of the wrap-around, fee-for-service per-visit
payments made by DHCS. SB 1081 would require an evaluation of
the APM pilot project be conducted by an independent entity
within six months after the APM pilot project is completed,
and that the independent entity report the findings to DHCS
and the Legislature. SB 1081 is currently scheduled for
hearing in the Senate Health Committee on April 23, 2014.
6.Prior legislation. AB 1445 (Chesbro) of 2009-10 was
substantially similar to this bill. AB 1445 was held on the
Senate Appropriations suspense file.
SB 260 (Steinberg) of 2007 was also similar to this bill. SB 260
was vetoed by Governor Schwarzenegger. In his veto message,
Governor Schwarzenegger argued the bill will increase General
Fund pressure at a time of continuing budget challenges, and
that allowing separate billing for mental health services
would lead to increased costs that our state could not afford.
SB 36 (Chesbro), Chapter 527, Statutes of 2003, established a
statutory structure for Medi-Cal payments for services
provided by FQHCs and RHCs in compliance with federal law,
changing from fee-for-service to a per-visit basis.
7.Support. Orange County Board of Supervisors, the sponsors of
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this bill, argues it allows clinic primary care providers to
make same day referrals for mental health treatment, which
will increase the chance that patients will make the
appointments and receive the services they need.
The California Primary Care Association (CPCA) writes that this
bill will help FQHCs and RHCs better provide integrated
behavioral health services to patients by allowing
reimbursement for mental health services provided on the same
day as medical services. CPAC states that, while California's
State Plan and Medi-Cal Provider Manual will permit FQHCs and
RHCs to be reimbursed for same-day medical and dental
services, mental health services are excluded. Federal
Medicare law permits reimbursement for same-day medical and
mental health visits and for federal matching funds to be
provided for states that choose to allow same-day visits.
California, however, does not take advantage of these federal
funds. Changing the state reimbursement system to allow for
payment for same day medical and mental health visits will
increase the ability of FQHCs and RHCs to provide the most
effective services to patients.
Disability Rights California (DRC) argues current practice
causes problems for individuals who come to an FQHC or RHC
with both a physical health care issue and a mental health
care issue as both conditions cannot be paid for if they are
treated by the same professional on the same day or different
professionals at the same location on the same day. DRC argues
this means that individuals who have both a physical and
mental health condition must receive separate treatments on
more than one day, and that this creates a burden for the
individual who must come back to the facility a second time
and who is untreated for one of the conditions in the
meantime. DRC states providers are forced to choose between
providing both services and being reimbursed for only one or
sending people away with a request that they return another
day for further treatment. Many times, individuals do not
return for necessary treatment that could have been provided
at the initial visit, which means their conditions often
worsen and end up costing more once treatment is provided. DRC
argues this bill would simply ensure that covered services are
provided when needed by eliminating a barrier to receiving
medically necessary care. Providing a full range of services
at one location helps to ensure that individuals receive
needed care and that the care is properly coordinated. DRC
concludes that very often, individuals have physical health
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care needs that are caused by or have a relationship to mental
health disabilities, and providing all needed services at a
single location during a single visit is effective both in
addressing physical and mental health needs and effective in
saving money in the long run.
SUPPORT AND OPPOSITION :
Support: Orange County Board of Supervisors (sponsor)
California Primary Care Association
California Mental Health Directors Association
California Psychological Association
California State Association of Counties
Disability Rights California
SEIU California
Urban Counties Caucus
Oppose: None received
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