BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1239
AUTHOR: Wolk
AMENDED: April 21, 2014
HEARING DATE: April 30, 2014
CONSULTANT: Diaz
SUBJECT : Pupil health care services: school nurses.
SUMMARY : Allows the governing board of a school district to
bill a pupil's health insurer or the Medi-Cal program, or both,
for the cost of health care services provided to the pupil.
Requires the governing board of a school district eligible to
receive concentration grants, as specified, to employ at least
one school nurse as a supervisor of health, as specified.
Provides that this bill does not apply to schools served by a
school health center, as defined.
Existing law:
1.Specifies the qualifications for a school nurse to be a valid
certificate of registration issued by the Board of Nurse
Examiners of the State of California or the California Board
of Nursing Education and Nurse Registration and a health and
development credential, a standard designated services
credential with a specialization in health, or a services
credential with a specialization in health.
2.Establishes the Local Control Funding Formula (LCFF) to
finance the K-12 school system, with base, supplemental, and
concentration grants in place of the previous K-12 funding
streams. Provides concentration grants that are equal to 50
percent of the adjusted base grant for local educational
agencies (LEAs) with unduplicated pupils exceeding 55 percent
of the LEA's enrollment. Defines "unduplicated pupil" as a
pupil enrolled in a school district or a charter school who is
either classified as an English learner, eligible for a free
or reduced-price meal, or is a foster youth.
3.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
Authorizes LEAs to bill the Medi-Cal program for health care
services, including nursing services.
Continued---
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4.Regulates health plans through the Department of Managed
Health Care (DMHC) and health insurance policies through the
California Department of Insurance.
This bill:
1.Requires the governing board of a school district that is
eligible to receive the concentration grants to employ at
least one school nurse as a supervisor of health to supervise
other school nurses, registered nurses, or licensed vocational
nurses; requires the governing board to consider certain
factors in determining the number of nurses to be supervised
by the supervisor of health, including the acuity of pupil
health care needs and the total healthy pupil population at
each school site.
2.Allows a school district to contract with a county office of
education (COE) for the services of a school nurse employed by
the COE.
3.Allows the governing board of a school district to bill a
pupil's health insurer or the Medi-Cal program, or both, for
the cost of health care services provided to the pupil.
4.Specifies that the provisions in this bill do not apply to
schools served by a school health center (SHC), as defined.
Encourages schools with SHCs to also employ a school nurse.
5.Specifies that any nurses hired pursuant to the requirements
in this bill will supplement, and not supplant, existing
employees of the school district.
6.Makes a legislative declaration that schools lack qualified
health professionals and that nurses are uniquely qualified to
attend to pupils' suffering from chronic and acute health
conditions.
FISCAL EFFECT : This bill has not been heard by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, federal
guidelines issued by the Department of Health and Human
Services and policy statements by both the American Academy of
Pediatrics and the National Association of School Nurses
recommend a ratio of one school nurse to every 750 students.
California ranks 45th in the nation for the ratio of school
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nurses, which is one school nurse to every 2,740 students. The
lack of school nurses is detrimental to students' academic
success. Studies have proven that there is a connection
between health and academic failure, with poor health
affecting students' attendance, grades, and ability to learn
while in school. Approximately 20-30 percent of students in
the state are affected by chronic diseases such as asthma,
diabetes, obesity, and severe allergies, which lead to more
absenteeism and lower school performance. There are student
populations that may require daily professional school nursing
services to help manage their chronic diseases. Increasing the
number of school nurses in the neediest schools will
positively affect students' academic performance.
2.Nurse-to-student ratios. Many of California students do not
have regular access to a school nurse. An article published on
the California Health Report (CHR) Web site in October 2013,
"School nurses spread thin in California," states that 57
percent of school districts do not have a full-time nurse.
Among school districts with nurses, excluding COEs, the number
of students per nurse ranges from 180 to more than 20,000. The
CHR article cites budget cuts to school districts for the
decline in school nurses. On average, 247 school nurse
credentials were granted annually by the state Commission on
Teacher Credentialing between 2002 and 2009. Most recent
estimates indicate that the state has approximately 2,700
full-time equivalent school nurses. According to the
California Department of Education (CDE) Web site, for the
2011-12 school year, there were approximately 6,220,993
school-age children in the state.
3.Funding for nurses. Existing law authorizes LEAs to bill
Medi-Cal for health care services, including nursing services.
According to DHCS's Web site, the purpose of the LEA billing
option is to allow LEAs to become Medi-Cal providers; bill the
Medi-Cal program for the health services provided by employed
or contracted medical professionals; and facilitate
reinvestment in health and social services for students and
their families so that schools can provide comprehensive
health services to eligible Medi-Cal students. The funds are
restricted in their use, as they must supplement existing
services, not supplant. Expenditures are overseen by an
interagency collaborative led by the school and must meet CDE
regulations that are focused on improving students' health and
a variety of other services. LEAs must have an approved
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provider agreement with DHCS through CDE to be eligible to
provide services. Claims are filed using the traditional
fee-for-service system.
4.SHCs. SHCs provide a broad array of primary care and
preventive services, including comprehensive health
assessments; prescriptions for medications; treatment for
acute illness; asthma treatment; oral health education; dental
screenings; and mental health assessments, crisis
intervention, brief and long-term therapy, and other services.
SHCs are administered by a variety of organizations, including
school districts, Federally Qualified Health Centers, county
health departments, hospitals, community-based agencies, and
private physician groups. They are financed through various
sources, including grants from state, local, and private
sources; reimbursements from public programs, such as the
Child Health and Disability Prevention Program and Medi-Cal;
partnerships with local community clinics and nonprofits; and
fundraising efforts by their school districts. According to
California School-Based Health Alliance, more than half of
SHCs recover less than 50 percent of their operating costs
from billing sources, as many of them provide health
education, case management, parent support, and teacher
consultation, much of which is not reimbursable.
5.LCFF. The LCFF replaces the previous K-12 finance system and
creates base, supplemental, and concentration grants in place
of the previous K-12 funding streams, including revenue limits
and most state categorical programs. According to the CDE Web
site, the goal of the LCFF is to simplify how LEAs receive
state funding. LEAs will receive funding based on the
demographic profile of the students they serve and gain
greater flexibility to use these funds to improve outcomes of
students. Under the LCFF, school districts are not prohibited
from hiring additional school nurses or other health care
personnel if they choose. For school districts and charter
schools, the LCFF funding targets consist of grade-level base
grants plus supplemental and concentration grants that reflect
student demographic factors. For COEs, the LCFF funding
targets consist of an amount for COE operations plus grants
for instructional programs. Implementation of the LCFF begins
in 2013-14.
6.Double referral. This bill will be heard in the Senate
Committee on Education on April 30, 2014. Should the bill pass
out of Senate Education, it will be referred to Senate Health
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Committee.
7.Related legislation. AB 1955 (Pan). would establish the
Healthy Kids, Healthy Minds Demonstration Project to increase
the LCFF base grant amounts for participating school sites
that employ one full-time school nurse and one full-time
mental health professional, and ensure that the school sites'
libraries are open one hour before, and three hours after, the
regular school day. AB 1955 is currently in the Assembly
Health Committee.
8.Prior legislation. AB 2608 (Bonilla), Chapter 755, Statutes of
2012, made permanent and expanded provisions relating to
program improvement activities in the Medi-Cal Local Billing
Option (LBO) program through which LEAs can draw down federal
funding for health care services provided to Medi-Cal-eligible
students. Required money collected for administrative
activities for program improvement activities be
proportionately reduced from federal Medicaid payments to all
participating LEAs so that no one LEA loses a disproportionate
share of its Medicaid payments. Required DHCS to amend the
Medicaid state plan and regulatory requirements pertaining to
the provision of medical transportation services by LEAs so
that they are no more restrictive than federal requirements.
AB 2454 (Torlakson), of 2010 would have required, commencing
July 1, 2020, school districts to employ one nurse for every
750 pupils enrolled in the district and authorized school
districts to bill a pupil's health insurer for the cost of
health care services. AB 2454 was held under submission in the
Assembly Appropriations Committee.
SB 870 (Ducheny), Chapter 712, Statutes of 2010, the 2010-11
Budget bill, required DHCS to withhold one percent of LEA
reimbursements, not to exceed $650,000, for the purpose of
funding the work and related administrative costs associated
with the audit resources approved in a specified budget change
proposal to ensure fiscal accountability of the LEA Medi-Cal
LBO and to comply with the Medi-Cal State Plan.
SB 1200 (Leno), of2010 would have added availability of
school-based health care to the timely access to care
provisions for which DMHC could adopt standards. SB 1200 was
held under submission in the Assembly Appropriations
Committee.
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AB 426 (Hall), of 2009 would have required CDE, in
consultation with specified entities, to recommend to the
Legislature ways to address specific health-related needs of
pupils on school campuses, including but not limited to,
diabetes, asthma and obesity-related diseases. AB 426 was
referred to the Assembly Education Committee and was never
heard.
AB 1540 (Committee on Health), Chapter 298, Statutes of 2009,
extended the LEA LBO program improvement provision sunset date
from January 1, 2010, to January 1, 2013.
AB 131 (Committee on Budget), Chapter 80, Statutes of 2005,
the 2005 health budget trailer bill, sunset the LEA program
improvement provisions January 1, 2010.
SB 231 (Ortiz), Chapter 655, Statutes of 2001, enacted the LEA
program improvement activities requirements, required
Department of Health Care Services to obtain a state plan
amendment to accomplish various goals to enhance reimbursement
for Medi-Cal services provided at school sites and student
access to those services, and sunset various provisions of
that bill January 1, 2006.
SB 256 (Maddy), Chapter 654, Statutes of 1993, established the
LEA LBO program by requiring that services provided by LEAs be
a Medi-Cal-covered benefit.
9.Support. A coalition of supporters write that nurses are the
only professional health care provider found in schools, and
disadvantaged students disproportionately have health and
mental health issues that impact their ability to learn and
progress through school. Supporters argue that often school
nurses may be the only health provider with whom these
students and their families have contact. They further state
that school nurses are uniquely qualified to provide services,
information, and referrals to children in need of health care.
10.Oppose Unless Amended. The California Association of Health
Plans (CAHP) states that health plans generally pay for care
through a system of contracted providers, with an enrollee's
care managed by a primary care provider. CAHP states the
provision in this bill to allow a school district to bill a
pupil's health insurer will result in confusion for the school
district, plans, and pupils and their families. CAHP further
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argues that since plans currently do not have contracts with
school districts, it is unclear how health care services would
be billed and what rates would be paid.
11.Policy comment.
a. School district reimbursement and authorization to
bill. This bill requires school districts identified
through the LCFF as eligible for concentration grants to
employ at least one school nurse as a supervisor of
health. The author indicates that this requirement would
be funded by reimbursements from a pupil's health insurer
or Medi-Cal, or both. However, it is unclear, through the
permissive billing scheme identified in this bill, how
the required school nurses would be funded. There is
nothing in existing law that indicates billing those
entities is prohibited. In addition, authorizing billing
does not require Medi-Cal, health plans, or insurers to
make payment for these services. If the bill is intended
to require health insurers and plans to pay for a pupil's
care, it should be referred to the California Health
Benefits Review Program per committee policy.
SUPPORT AND OPPOSITION :
Support: American Nurses Association\California
Breathe California
California Nurses Association
California School Nurses Organization
California School Nurses Organization- Bay Coast
chapter
Los Angeles County Office of Education School Nurses
Manteca Unified School District, Health Services
Department
Marin County Office of Education
Marin School Nurse Organization
San Joaquin County Office of Education
Several Individuals
Oppose: Association of California Life & Health Insurance
Companies (unless amended)
California Association of Health Plans (unless
amended)
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