Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law prohibits a requirement of in-person contact between a health care provider and patient under the Medi-Cal program for any service otherwise covered by the Medi-Cal program when the service is appropriately provided by telehealth, as defined. Existing law, for purposes of payment of covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would prohibit the department from conditioning Medi-Cal provider enrollment or reimbursement for radiology services provided to Medi-Cal beneficiaries undergoing imaging procedures at locations within California on the location of the radiologist, if the radiologist meets specified conditions and criteria, as specified.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law prohibits a requirement of in-person contact between a health care provider and patient under the Medi-Cal program for any service otherwise covered by the Medi-Cal program when the service is appropriately provided by telehealth, as defined. Existing law, for purposes of payment of covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would prohibit the department from conditioning Medi-Cal provider enrollment or reimbursement for radiology services provided to Medi-Cal beneficiaries undergoing imaging procedures at locations within California on the location of the radiologist, if the radiologist meets specified conditions and criteria, as specified.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law prohibits a requirement of in-person contact between a health care provider and patient under the Medi-Cal program for any service otherwise covered by the Medi-Cal program when the service is appropriately provided by telehealth, as defined. Existing law, for purposes of payment of covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would prohibit the department from requiring a radiologist to be located in California as a condition of conditioning Medi-Cal provider enrollment or reimbursement for teleradiology services, as defined, radiology services provided to Medi-Cal beneficiaries undergoing imaging procedures at locations within California on the location of the radiologist, if the radiologist meets specified conditions and criteria, as specified.

Existing law, the Lanterman Developmental Disabilities Services Act, requires the State Department of Developmental Services to enter into contracts with private nonprofit corporations to operate regional centers to provide community services and supports for persons with developmental disabilities and their families. Existing law states the intent of the Legislature that the design and activities of regional centers reflect, among other things, a strong commitment to the delivery of direct service coordination to persons with disabilities and their families.

This bill would make technical, nonsubstantive changes to those provisions.

Date of Hearing: May 13, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

ABPCA Bill Id:AB 1485

Author:(Patterson) – As Amended Ver:May 5, 2015

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill prohibits the Department of Health Care Services (DHCS) from using the location of a radiologist as a condition of approving Medi-Cal provider enrollment or reimbursement for radiology services provided to Medi-Cal beneficiaries undergoing imaging procedures, if the radiologist meets requirements, as specified.

FISCAL EFFECT:

1. One-time costs, likely in the range of $50,000, to review and revise existing regulations, as well as policies and procedures, by the Department of Health Care Services (DHCS) (GF/federal). Although this bill is specific to radiology, if this review prompted DHCS to assess and revisit out-of-state provider payment policies for other health care services, the regulatory effort could be more significant.

2. Ongoing costs to DHCS to process additional provider enrollments, and to potentially perform investigations into out-of-state radiologists for Medi-Cal fraud or abuse, in the range of $100,000-$150,000 annually (GF/federal).

3. Enforcement investigations and enrollment activities for out-of-state providers would incur additional travel time and expense on average than the same activities for in-state providers.

COMMENTS:

1. Purpose. The author states that high speed broadband and the Internet are providing patients unparalleled access to radiology subspecialists through national radiology networks, which can, within minutes, provide expert analyses to attending physicians, regardless of the location of the patient or radiologist. However, existing law governing Medi-Cal provider enrollment and reimbursement have not kept pace with these innovations. The author intends this bill to clarify existing law, providing necessary statutory guidance for DHCS regarding Medi-Cal provider enrollment and reimbursements for radiologists.

2. Telehealth in Medi-Cal. “Telehealth” is defined as the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Existing law prohibits a requirement of in-person contact between a health care provider and patient under the Medi-Cal program for any service otherwise covered by the Medi-Cal program when the service is appropriately provided by telehealth. Existing law also, for purposes of payment of covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

3. Current Practice. According to the author, DHCS will not reimburse California licensed out-of-state physicians who seek to bill Medi-Cal for telehealth services for fee-for-service beneficiaries. These providers cannot be enrolled in Medi-Cal using their out-of-state location practice location, or DHCS will deny their applications. DHCS’ denial letters state that out-of-state medical care for Medi-Cal beneficiaries is covered only when emergency services have been provided to a Medi-Cal beneficiary traveling out-of-state.
   
   

4. Support. Virtual Radiologic, the sponsor of the bill, states that the bill is necessary to provide statutory guidance to DHCS. The sponsor points to its experience working with DHCS; in particular, that DHCS has switched its position several times in the last few years, making clear legislative guidance necessary. Virtual Radiologic reports that in some cases, after receiving denial letters for Medi-Cal reimbursement and provider enrollment, DHCS rescinded denials, agreeing that technological advances in the delivery of radiology services are consistent with existing law. Other times, DHCS has denied such provider enrollment and reimbursement requests.

5. Opposition. Union of American Physicians and Dentists/ American Federation of State, County & Municipal Employees (AFSCME)-Local 206, AFSCME, California Labor Federation, and California Nurses Association oppose this bill, on the principle that this practice would allow Medi-Cal dollars to be contracted to out-of-state for-profit corporations, and would take away employment opportunities and Medi-Cal dollars from state and local economies.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 28, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

ABPCA Bill Id:AB 1485

Author:(Patterson) – As Amended Ver:April 21, 2015

SUBJECT: Medi-Cal: radiology.

SUMMARY: Prohibits the Department of Health Care Services (DHCS) from using the location of a radiologist as a condition of approving Medi-Cal provider enrollment or reimbursement for radiology services provided to Medi-Cal beneficiaries undergoing imaging procedures, if the radiologist meets requirements, as specified. Specifically, this bill:

1. Makes the declaration this bill must not be considered a precedent for other types of health care service providers because the services performed by radiologists are provided to attending physicians and not to patients, therefore they do not supplant work performed by other California health care providers.
   
   

2. Requires a radiologist to meet the following conditions for Medi-Cal enrollment and reimbursement for radiology services, when located outside of California:
   
   

   1. Must be licensed in California;
      
      

   2. Must be enrolled and in good standing in the Medicaid program for the state where the radiologist is located, in Medicare, or in both programs;
      
      

   3. The radiologist must be located in the United States;
      
      

   4. The radiologist must satisfy all requirements for enrollment and participation in the Medi-Cal program;
      
      

   5. The radiologist must consent to Medi-Cal acting through the state Medicaid program where the radiologist is located and the Medicare program with respect to any issues concerning the radiologist’s enrollment or participation in Medi-Cal; and,
      
      

   6. The radiologist must consent to enrollment in Medi-Cal, including, but not limited to, formal or informal proceedings, as well as administrative, civil, and criminal proceedings.
      
      

EXISTING LAW:

1. Establishes the Medi-Cal program under the direction of DHCS, as California’s Medicaid program, to provide qualifying low-income individuals health care and a uniform schedule of benefits.
   
   

2. Allows DHCS to establish regulations, consistent with federal Medicaid law, to provide for the care and treatment of persons eligible for medical assistance by providers in another state in those cases in which the out-of-state care or treatment is rendered on an emergency case or is otherwise in the best interests of the person.

3. Authorizes services to be provided to Medi-Cal beneficiaries through telehealth and does not require in-person contact between a provider and a beneficiary if the service is appropriately provided through telehealth.
   
   

4. Prohibits a health insurer or health care service plan from limiting the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth.
   
   

FISCAL EFFECT: This bill has not yet been analyzed by the fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. The author states that high speed broadband and the Internet are providing patients unparalleled access to radiology subspecialists through national radiology networks, which can within minutes provide expert analyses to attending physicians, regardless of the location of the patient or radiologist; however existing law governing Medi-Cal provider enrollment and reimbursement have not kept pace with these innovations. The author argues that privately insured and Medi-Cal managed care patients already benefit from this unparalleled access to subspecialists and timely accurate diagnoses and that Medi-Cal fee-for-service patients should also have the opportunity to access this type of care. The author concludes this bill will clarify existing law to provide necessary statutory guidance for DHCS regarding Medi-Cal provider enrollment and reimbursements for radiologists.
   
   

2. BACKGROUND.
   
   

   1. Telehealth. “Telehealth” is defined as the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site.
      
      

As California continues with full implementation of the Patient Protection and Affordable Care Act, there has been great concern from stakeholders throughout the state about provider access to services. In an effort to ensure quality services are provided to patients, health reform policies have focused on innovative methods to adjust the way delivery systems contract and pay for services. Telehealth has received increased attention as it may serve to improve access to care for the increasing number of newly insured individuals. The California HealthCare Foundation reports that health plans, providers, and information technology vendors are currently effectively using telehealth applications to increase quality of care, reduce costs, and increase access for the underserved. Studies have demonstrated telehealth services have improved outcomes and continuity of care for patients, particularly in rural settings.

2. Examples of Medi-Cal coverage of telehealth include the following:
   
   

   1. Selected psychiatric diagnostic interview examination and selected psychiatric therapeutic services;
      
      

   2. Store and forward teledermatology and teleophthalmology by “store and forward” (the transmission of medical information to be reviewed at a later time by a physician/optometrist at a distant site who is trained in ophthalmology, optometry or dermatology where the physician or optometrist at the distant site reviews the medical information without the patient being present in real time);
      
      

   3. Interpretation and report of X-rays and electrocardiograms performed after telehealth transmission.
      
      

While existing Medi-Cal law provides coverage for telehealth services, another provision of Medi-Cal law and regulation limits Medi-Cal coverage of out-of-state medical care. Specifically, Medi-Cal covers necessary out-of-state medical care only under the following conditions:

1. When an emergency arises from accident, injury, or illness;
   
   

2. Where the health of the individual would be endangered if care and services are postponed until it is feasible that he or she return to California;
   
   

3. Where the health of the individual would be endangered if he or she undertook travel to return to California;
   
   

4. When it is customary practice in border communities for residents to use medical resources in adjacent areas outside of California; or,
   
   

5. When an out-of-state treatment plan has been proposed by the beneficiary's attending physician, and the proposed plan has been received, reviewed, and authorized by DHCS before the services are provided. DHCS can authorize such out-of-state treatment plans only when the proposed treatment is not available from resources and facilities within California.
   
   

Prior authorization is required for all out-of-state services, except for emergency services and services provided in border areas adjacent to California where it is customary practice for California residents to avail themselves of such services. No services are covered by Medi-Cal outside the United States, except for emergency services requiring hospitalization in Canada or Mexico.

California will not reimburse California licensed out-of-state physicians who seek to bill Medi-Cal for telehealth services for fee-for-service beneficiaries. These providers cannot be enrolled in Medi-Cal using their out-of-state location practice location, or DHCS will deny their applications. DHCS’ denial letters state that out-of-state medical care for Medi-Cal beneficiaries is covered only when emergency services have been provided to a Medi-Cal beneficiary traveling out-of-state. This argument seems contrary to existing law which states a health insurer or health care service plan is prohibited from limiting the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth.

3. Standards of care. According to the Medical Board of California (MBC), telehealth is seen as a tool in medical practice, not a separate form of medicine. There are no legal prohibitions to using technology in the practice of medicine, as long as the practice is done by a California licensed physician. The MBC specifies that telehealth is not a telephone conversation, email/instant messaging conversation, or fax; it typically involves the application of videoconferencing or store and forward technology to provide or support health care delivery. The MBC is also clear that the standard of care is the same whether the patient is seen in-person, through telehealth or other methods of electronically enabled health care.
   
   

1. SUPPORT. Virtual Radiologic, the sponsor of the bill, states that the bill is necessary to provide statutory guidance to DHCS. The sponsor points to its experience working with DHCS; in particular that DHCS has switched its position several times in the last few years, making clear legislative guidance necessary. Virtual Radiologic reports during some periods, after receiving denial letters for Medi-Cal reimbursement and provider enrollment, DHCS has subsequently rescinded denials, agreeing that technological advances in the delivery of radiology services are consistent with existing law. Other times, DHCS has denied such provider enrollment and reimbursement requests.
   
   

2. OPPOSITION. The Union of American Physicians and Dentists/AFSCME-Local 206 states this bill will allow radiology services through the Medi-Cal program to patients who live across state lines. The opposition states that this practice would allow Medi-Cal dollars to be contracted to out-of-state for-profit corporations, and will take away employment opportunities and Medi-Cal dollars from state and local economies.
   
   

3. RELATED LEGISLATION. AB 250 (Obernolte) clarifies that Marriage and Family Therapist interns and trainees may provide services via telehealth, under specified supervision, to gain supervised hours required for licensure. AB 250 was heard by the Assembly Business and Professions Committee on April 7, 2015 and passed out with a vote of 14-0. AB 250 is currently in the Assembly Health Committee.
   
   

4. PREVIOUS LEGISLATION.
   
   

   1. AB 1310 (Bonta) of 2014would have required a health care provider located outside of California to meet specified requirements as a condition for enrolling in the Medi-Cal program for the purpose of providing telehealth services to Medi-Cal beneficiaries receiving care in California. AB 1310 died in the Assembly Health Committee.
      
      

   2. AB 415 (Logue), Chapter 547, Statutes of 2011, establishes the Telehealth Advancement Act of 2011 to revise and update existing law to facilitate the advancement of telehealth as a service delivery mode in managed care and the Medi-Cal program.
      
      

   3. AB 175 (Galgiani), Chapter 419, Statutes of 2010, for the purposes of Medi-Cal reimbursement, expanded, until January 1, 2013, the definition of “teleophthalmology and teledermatology by store and forward” to include services of an optometrist who is trained to diagnose and treat eye diseases.
      
      

   4. AB 1733 (Logue), Chapter 782, Statutes of 2012, updated several code sections to replace the term “telemedicine” with “telehealth” and expanded the potential for the use of telehealth in additional health care programs administered by DHCS, such as the Program of All-Inclusive Care for the Elderly.
      
      

5. POLICY CONSIDERATIONS. The author and sponsor emphasize the need for DHCS provider enrollment procedures to keep pace with recent innovations within medical technology. Although the language of this bill highlights increased access to provider enrollment, regardless of location, for radiologists, this bill is silent on other innovative forms of technology, which include hospital-based telehealth (e.g. stroke care and care in the intensive care unit), home and community-based care (e.g. management of chronic care), and other ancillary services (e.g. telepathology, telepharmacology, teledermatology, etc.). The Committee may wish to consider whether this bill is too narrow in scope by excluding all forms of telehealth but teleradiology, and therefore requiring future legislation to allow for new innovations in technology.
   
   

6. TECHNICAL AMENDMENT. The intent language of the bill states that this bill shall not be considered a precedent for other types of health care service providers, because the services performed by radiologists are provided to attending physicians and not patients, and therefore they do not supplant the employment of other California health care providers. This language could be interpreted to suggest radiologists do not currently provide services to patients at all, which is not the intent of the author. The author’s intent is to state that these provisions will not lead to the supplanting of in-state radiologists. The Committee may suggest the following technical amendment to clarify the intent language:
   
   

   1. Strike Section 14132.735(a).
      
      

   2. Insert the following language:
      
      

(a) It is the intent of the Legislature that:

(1) This section shall not be a precedent for other health care providers.

(2) Remotely located radiologists supplement, and do not supplant, on-site radiologists as an integral part of providing a high level of care in local communities.

REGISTERED SUPPORT / OPPOSITION:

Support

Virtual Radiologic (sponsor)
Association of California Healthcare Districts

Opposition

Union of American Physicians and Dentists/AFSCME-Local 206

Analysis Prepared by: An-Chi Tsou / HEALTH / (916) 319-2097