Agenda

Return

C.25

To:	Board of Supervisors
From:	Legislation Committee
Date:	May 12, 2009

Contra

Costa

County

Subject:

SUPPORT POSITION for AB 1445 (Chesbro): Medi-Cal: Health Centers and Rural Health Clinics

APPROVE	OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR	RECOMMENDATION OF BOARD COMMITTEE

Action of Board On: 05/12/2009

APPROVED AS RECOMMENDED

OTHER

Clerks Notes:

VOTE OF SUPERVISORS

AYE:

John Gioia, District I Supervisor
Gayle B. Uilkema, District II Supervisor
Mary N. Piepho, District III Supervisor
Susan A. Bonilla, District IV Supervisor
Federal D. Glover, District V Supervisor

Contact:

L. DeLaney, 5-1097

I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown.
ATTESTED: May 12, 2009
David Twa,

BY:	, Deputy

RECOMMENDATION(S):

SUPPORT Assembly Bill 1445 (Chesbro), a bill that authorizes Medi-Cal reimbursement to federally qualified health centers and rural health clinics for a maximum of two visits for one patient on the same day, as specified, as recommended by the Legislation Committee.

FISCAL IMPACT:

This bill has not been analyzed by a fiscal committee

BACKGROUND:

Specifically, this bill:


1) Authorizes reimbursement for a maximum of two visits, as specified, on the same day at a single location under the following conditions:

BACKGROUND: (CONT'D)

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.

2) Defines "medical visit" as a face-to-face encounter between a federally qualified health centers (FQHC) or rural health clinics (RHC) patient and a physician, physician assistant, nurse practitioner, certified midwife, visiting nurse, or comprehensive perinatal services practitioner.

3) Defines "another health visit" as a face-to-face encounter between a FQHC or RHC patient and a clinical psychologist, licensed clinical social worker, dentist, or dental hygienist.

4) Specifies that this bill constitutes a change in the scope of services and that FQHCs and RHCs must file a scope of service change as required by law.

5) Requires the Department of Health Care Services, no later than March 30, 2010, to seek all necessary federal approvals in order to implement this bill.

According to the author, this bill is necessary to take advantage of the availability of federal Medicaid funds to support mental health services for Medi-Cal patients served by federally qualified health centers (FQHCs). The author points out that federal Medicaid law permits reimbursement for same-day FQHC visits for mental health services. The author contends that this bill will allow FQHCs to better integrate behavioral health services with medical care services which is a best practice for dealing with mental health issues.

The author notes that numerous studies over the last 30 years have found high rates of physical health problems and death among individuals with serious mental illness. In addition, studies also reveal that less than 50% of those with mental illnesses actually seek help for their mental health condition while 80% of those same individuals had a primary care visit within the previous six months. The author cites these statistics to underscore the importance of primary care providers as the first line of defense for detection and treatment of mental illness. However, the author also points out that one in four patients referred to specialty mental health or substance abuse services never make it to the first appointment. The author argues that this bill will allow clinic primary care providers to make same day referrals for mental health treatment thus increasing the chances that patients will actually make the appointments and get the services they need.

BACKGROUND

California licenses nonprofit community clinics and many licensed community clinics are also federally designated as FQHCs. Under federal law, FQHCs and designated RHCs are eligible for enhanced Medicare and Medicaid (Medi-Cal in California) reimbursement. The rationale for the enhanced reimbursement is to ensure that FQHCs 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. FQHC services are reimbursed in Medi-Cal on a fixed "per visit" rate rather than by individual services. FQHC provider types are specified in existing statue as those for which a visit can be billed in a single day: physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse.

Current law only allows multiple billable visits in a single day if they are for medical and dental services. Only mental health visits provided by a clinical psychologist are separately billable FQHC visits, but not for services on the same day as a medical visit. Mental health visits are currently coded for Medi-Cal billing purposes as a medical visit for which only one visit per patient per day is allowed. The federal Substance Abuse and Mental Health Services Administration released a report in July 2008, titled "Reimbursement of Mental Health Services in Primary Care Settings," which identified potential barriers and solutions for reimbursement of mental health services. This report was developed to improve access to mental health services for persons with public insurance and recommended authorizing same-day services billing for separate practitioners as proposed in this bill.

FQHCs are federally funded public or nonprofit community clinics that serve a high number of both Medi-Cal and uninsured patients. FQHCs are open door providers that treat patients on a sliding fee scale basis and make available a comprehensive array of health and social services regardless of the patient's ability to pay. FQHCs are CHCs, a federal grant program established in the 1960s to improve access to primary and preventive care for individuals in medically underserved communities and special populations, such as the medically uninsured, homeless persons, and migrant farmworkers. In 1996, the health center programs (migrant health centers, community health centers, health care for the homeless, and health centers for residents of public housing) were consolidated under Section 330 of the federal PHS Act. All PHS grant recipients are nonprofit, public, or otherwise tax-exempt entities. CHCs receiving PHS grant funds, and meeting specific federal requirements, are FQHCs entitled to higher reimbursement under Medicare and Medicaid.

PRIOR LEGISLATION

a) SB 260 (Steinberg) of 2007, a substantially similar bill, was also vetoed. In returning SB 260, the Governor stated, "While I support improving access to health care services, including mental health services, I cannot support this bill as it would increase General Fund pressure at a time of continuing budget challenges?separate billing for mental health services would lead to increased costs that our state cannot afford."

b) SB 36 (Chesbro), Chapter 527, Statutes of 2003, creates a statutory structure for the implementation of a PPS for Medi-Cal reimbursement of FQHCs, in response to the federal Medicare, Medicaid, and State Children's Health Insurance Program Benefits Improvement and Protection Act of 2000 (BIPA) which phased out cost-based reimbursement for FQHC/RHCs and required states to implement a PPS or federally-approved alternative.

c) SB 1413 (Chesbro) of 2002 would have restructured Medi-Cal reimbursement for FQHCs in response to BIPA and also contained a provision similar to the changes proposed in this bill. Governor Gray Davis vetoed SB 1413.

SUPPORT

The sponsor of this bill, the California Primary Care Association, writes in support that this bill will allow FQHC clinics to more effectively develop and implement integrated primary and behavioral health services, which, in the purest form, places the mental health professional into the primary care setting as a team member working closely with primary care providers. In these clinics, the primary care provider may make a "warm handoff" to the on-site mental health professional when they note the need for a further mental health assessment, allowing the mental health practitioner to promptly assess and treat the patient.

The California Mental Health Directors' Association (CMHDA) supports this bill and believes that allowing billing for same day medical and mental health visits will maximize federal Medicaid funds and improve continuity of care for clinic patients. CMHDA points out that same day services are the hallmark of a fully integrated primary behavioral health care model. The California Medical Association writes that medical and mental health services are important components of an integrated strategy for maintaining and improving health for Medi-Cal beneficiaries and points out that mental health treatment can improve patient compliance with chronic disease management and treatment.

REGISTERED SUPPORT / OPPOSITION:

Support

California Primary Care Association (Sponsor) Alliance for Rural Health AltaMed Health Services American College of Obstetricians and Gynecologists California Association of Marriage and Family Therapists California Association of Rural Health Clinics California Chiropractic Association California Hospital Association California Psychiatric Association California Psychological Association California School Centers Association California School Health Centers Association California Society for Clinical Social Work California State Association of Counties California State Rural Health Association Community Clinic Association County of San Bernardino County of Santa Clara Disability Rights California Eisner Pediatric & Family Medical Center North Coast Clinics Network Six Rivers Planned Parenthood Urban Counties Caucus 46 community clinics

Opposition

None on file.