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, as specified. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program program provisions. Existing law provides that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for teleophthalmology, teledermatology teledermatology, and teledentistry by store and forward, as defined to mean the asynchronous transmission of medical information to be reviewed at a later time by a licensed physician or optometrist, as specified, at a distant site.

This bill would enact similar provisions relating to the use of reproductive health care under the Medi-Cal program. The bill would provide that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient shall not be required under the Medi-Cal program for reproductive health care provided by store and forward. The bill would define that term to mean an asynchronous transmission of medical information to be reviewed at a later time by a physician, nurse practitioner, certified nurse midwife, licensed midwife, physician assistant, or registered nurse at a distant site, where the provider at the distant site reviews the dental information without the patient being present in real time, as defined and as specified. The bill would require Medi-Cal managed care plans that contract with the department to cover reproductive health care provided by store and forward.

This bill would also provide that, to the extent federal financial participation is available and any necessary federal approvals are obtained, telephonic and electronic patient management services, as defined, provided by a physician or nonphysician health care provider acting within his or her scope of licensure shall be a benefit under the Medi-Cal program in fee-for-service and managed care delivery systems, as specified. The bill would authorize the department to seek approval of any state plan amendments necessary to implement these provisions.

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, as specified. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for teleophthalmology, teledermatology and teledentistry by store and forward, as defined to mean the asynchronous transmission of medical information to be reviewed at a later time by a licensed physician or optometrist, as specified, at a distant site.

This bill would enact similar provisions relating to the use of reproductive health care under the Medi-Cal program. The bill would provide that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient shall not be required under the Medi-Cal program for reproductive health care provided by store and forward. The bill would define that term to mean an asynchronous transmission of medical information to be reviewed at a later time by a physician, nurse practitioner, certified nurse midwife, licensed midwife, physician assistant, or registered nurse at a distant site, where the provider at the distant site reviews the dental information without the patient being present in real time, as defined and as specified.

This bill would also provide that, to the extent federal financial participation is available and any necessary federal approvals are obtained, telephonic and electronic patient management services, as defined, provided by a physician or nonphysician health care provider acting within his or her scope of licensure shall be a benefit under the Medi-Cal program in fee-for-service and managed care delivery systems, as specified. The bill would authorize the department to seek approval of any state plan amendments necessary to implement these provisions.

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

SB 960 (Hernandez) - Medi-Cal: telehealth: reproductive health care

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

SB 960 would require reproductive health care services provided through telehealth to be covered by the Medi-Cal program. The bill would require telephonic and electronic patient management services to be covered by the Medi-Cal program.

Fiscal Impact:

• Likely one-time costs in the low hundreds of thousands for the Department of Health Care Services to gain federal approvals, adopt regulations, and make any necessary system changes to allow for the provision of services under the bill (General Fund and federal funds).
• Unknown impact on Medi-Cal spending for reproductive health care services (General Fund and federal funds). By allowing reproductive services to be provided through telehealth, the bill is likely to make it easier for Medi-Cal beneficiaries to access such services. Whether this will actually increase the utilization of services is uncertain. To a large extent, the authority to use telehealth to access such services will make ordering such services more convenient for beneficiaries, but will not increase overall utilization (since a beneficiary would most likely have sought out services in another manner without the bill). There also may be some increase in utilization of services. For example a beneficiary may request a test for a sexually transmitted infection for symptoms that would have resolved on their own before the beneficiary sought a test through traditional health care settings. The extent to which that would happen is unknown.
• Increased costs in the tens of millions per year for Medi-Cal coverage of telephonic and electronic patient management services (General Fund and federal funds). The requirement in the bill for Medi-Cal coverage of telephonic and electronic patient management services goes beyond reproductive health care and would be available for all appropriate health care services. Based to an analysis of a similar requirement in another bill by the California Health Benefits Review Program, staff estimates that the overall increase in Medi-Cal spending from this requirement could be between $10 million and $40 million per year.

Background:

Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. Medi-Cal provides coverage to childless adults and parents with household income up to 138% of the federal poverty level and to children with household income up to 266% of the federal poverty level. The federal government provides matching funds that vary from 50% to 90% of expenditures depending on the category of beneficiary.

Current law provides that a face-to-face visit is not required between a patient and a provider for Medi-Cal coverage of teleopthamology, teledermatology, and teledentistry by store and forward. In this case, store and forward means technologies that capture information from a patient and send it to a provider at a different location, for example an x-ray image taken in a clinic and then sent to a dentist in another location for examination. To date, the use of store and forward telehealth technology in Medi-Cal does not allow patients to directly request services or send information about symptoms directly to health care providers (for example using a smart phone).

Proposed Law:

SB 960 would require reproductive health care services provided through telehealth to be covered by the Medi-Cal program The bill would require telephonic and electronic patient management services to be covered by the Medi-Cal program.

Specific provisions of the bill would:

• Add reproductive health care services to those telehealth services that are covered under the Medi-Cal program without the need for a face-to-face visit;
• Require Medi-Cal managed care plans to cover reproductive health care provided by telehealth store and forward;
• Specify the medical provider types that can provide reproductive health care by telehealth store and forward;
• Require telephonic and electronic patient management services to be a benefit in the Medi-Cal program, in both fee-for-service and managed care;
• Limit the required reimbursement for services when the telephonic or electronic patient management service is related to another service or procedure provided to the patient, when the telephonic or electronic patient management service leads to a related service or visit, when the health care provider receives a bundled or capitated payment, or when the telephonic or electronic patient management service is not initiated by the patient;
• Define reproductive health care, by reference to another statute.

Related Legislation:

• AB 2507 (Gordon) would expand the definition of telehealth to include telephone, email, and synchronous text. That bill is pending in the Assembly Appropriations Committee.
• SB 289 (Mitchell, 2015) would have mandated that health insurers and health plans provide coverage for telephonic and electronic patient management services provided by a contracted physician or non-physician health care provider. That bill was held on this committee’s Suspense File.

Staff Comments:

SB 289 (Mitchell, 2015) would have mandated the coverage of telephonic and electronic patient management services for all health plans and insurers. According to the analysis of that bill by the California Health Benefits Review Program, the requirements to cover those service modalities would have had an overall effect of increasing utilization of health care services. As is described in the analysis of that bill provided by Program, there is a good deal of uncertainty about how the behavior of patients and providers would change under that bill. By requiring reimbursement to providers for telephonic and electronic patient management services, that bill was very likely have to increased providers’ willingness to use such services with their patients, increasing utilization. Some of the increased utilization of telephonic and electronic patient management services would have reduced in person visits with providers. For example, a patient may have found it more convenient to call or email a provider with a question about an ongoing health issue, rather than making an in person appointment. In that case, the bill would not have reduced overall utilization of services: it would have resulted in a substitute visit. On the other hand, the ability to communicate with a provider on the phone or through electronic means would also have resulted in supplemental visits (i.e. more utilization than would occur under current law). For example, a patient with a minor question or who is experiencing a minor illness that would not necessarily have led to an in person visit with a provider would have been more likely to make a phone call or use an electronic means to communicate with a provider. In those cases, the bill would have resulted in an increase in overall utilization of health care services.

The California Health Benefits Review Program modelled a variety of scenarios for utilization under SB 289. Under all scenarios, there would have been both substitution and supplementation of in person visits. In all scenarios, however, the supplementation would have resulted in an overall increase of utilization of services and therefore an increase of health care costs.

The California Health Benefits Review Program analysis for SB 289 assumed that Medi-Cal managed care plans would not have been able to pass the cost of the benefit mandate along to the state, due to the state’s bargaining power. However, the requirement in this bill is specific to the Medi-Cal program and explicitly includes both fee-for-service and managed care. Because Medi-Cal managed care rates are required to be actuarially sound, staff anticipates that Medi-Cal managed care plans would be able to pass along increased costs to the state, once they were able to demonstrate that utilization was occurring.

Current law are regulation allows Medi-Cal managed care plans to provide services to enrollees not specifically required under law. Therefore, Medi-Cal managed care plans can already contract with providers to allow the use of telehealth for reproductive health care services, provided that the Medi-Cal managed care plan and the provider can agree on the rates and terms that would apply to those services.

Current federal law and state regulation provides that Medi-Cal enrollees can access family planning (including reproductive health care) from any Medi-Cal provider, even when the provider is not in the enrollee’s Medi-Cal managed care plan network. By authorizing the use of telehealth for reproductive health care services, the bill will make it easier for Medi-Cal beneficiaries to seek services outside of their managed care plan network. To the extent that providers and Medi-Cal managed care plans cannot agree on the rates and terms for providing reproductive health care services through telehealth, the bill is likely to result in a shift in the provision of health care services from Medi-Cal managed care plan networks to out-of-network providers.

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SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 960

SUBJECT: Medi-Cal: telehealth: reproductive health care

SUMMARY:

Adds “reproductive health care” by store and forward provided by a physician, nurse practitioner, certified nurse midwife, licensed midwife, physician assistant, or registered nurse operating within her scope of practice, to existing law that prohibits face to face contact for teleophthalmology, teledermatology and teledentisty from being required in the Medi-Cal program. Requires Medi-Cal managed care plans to cover reproductive health care, teleophthalmology, teledermatology, and teledentistry. 

Existing law:

1. Provides for the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services, as specified.
2. Provides that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for “teleophthalmology, teledermatology and teledentistry by store and forward,” as defined to mean the asynchronous transmission of medical information to be reviewed at a later time by a licensed physician or optometrist, as specified, at a distant site.
3. States legislative intent to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the health care provider.
4. Prohibits a health plan or health insurer from requiring in-person contact between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health plan or the insured and health insurer, and between the health plan or health insurer and its participating providers or provider groups.
5. Prohibits a health plan or health insurer 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, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health plan or the insured and the health insurer, and between the health plan or health insurer and its participating providers or provider groups.
6. Applies 4) and 5) above to health care and Medi-Cal managed care plan contracts with the DHCS.
7. Prohibits existing law from being interpreted to authorize a health plan or health insurer to require the use of telehealth when the health care provider has determined that it is not appropriate.
8. Establishes the Department of Managed Health Care (DMHC) to regulate health plans and the California Department of Insurance (CDI) to regulate health insurers, and other insurance carriers and insurance agents.

This bill:

1. Adds “reproductive health care” by store and forward provided by a physician, nurse practitioner, certified nurse midwife, licensed midwife, physician assistant, or registered nurse operating within her scope of practice, to existing law that prohibits face to face contact for teleophthalmology, teledermatology and teledentisty from being required in the Medi-Cal program. Defines “reproductive health care” as the general reproductive health care services described in existing law related to FamilyPACT.
2. Requires Medi-Cal managed care plans to cover reproductive health care, teleophthalmology, teledermatology, and teledentistry. 
3. Makes, to the extent that federal financial participation is available and any necessary federal approvals have been obtained, for telephonic and electronic patient management services provided by a physician, or a non-physician health care provider acting within his or her scope of licensure, a benefit under the Medi-Cal program, both in fee-for-service and managed care delivery systems delivered by Medi-Cal managed care plans.
4. Requires reimbursement for telephonic and electronic patient management services to be based on the complexity of and time expended in rendering those services.
5. Prohibits 4) above from being construed to authorize a Medi-Cal managed care plan to require the use of telephonic and electronic patient management services when the physician or non-physician health care provider has determined that those services are not medically necessary.
   
6. Prohibits this bill from being construed to alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting or in a manner than is not otherwise authorized by law.
7. Requires all laws regarding the confidentiality of health information and a patient’s right of access to his or her medical information to apply to telephonic and electronic patient management services.
8. Specifies that this bill does not apply to a patient in the custody of the Department of Corrections and Rehabilitation or any other correctional facility.
9. Prohibits separate reimbursement of a physician or a non-physician health care provider from being required for any of the following:
   1. A telephonic or electronic visit that is related to a service or procedure provided to an established patient within a reasonable period of time prior to the telephonic or electronic visit, as recognized by the Current Procedural Terminology (CPT) codes published by the American Medical Association (AMA);
   2. A telephonic or electronic visit that leads to a related service or procedure provided to an established patient within a reasonable period of time, or within an applicable postoperative period, as recognized by the CPT codes published by the AMA.;
   3. A telephonic or electronic visit provided as part of a bundle of services for which reimbursement is provided for on a prepaid basis, including capitation, or which reimbursement is provided for using an episode-based payment methodology; and,
   4. A telephonic or electronic visit that is not initiated by an established patient, by the parents or guardians of a minor who is an established patient, or by a person legally authorized to make health care decisions on behalf of an established patient.
10. Prohibits anything in this bill from being construed to prohibit a Medi-Cal managed care plan from requiring documentation reasonably relevant to a telephonic or electronic visit, as recognized by the CPT codes published by the AMA.
11. Defines “telephonic and electronic patient management service” as the use of electronic communication tools to enable treating physicians and non-physician health care providers to evaluate and manage established patients in a manner that:
    1. Does not require an in-person visit with the physician or non-physician health care provider;
    2. Is initiated by the established patient, the parents or guardians of a minor who is an established patient, or a person legally authorized to make health care decisions on behalf of an established patient. “Initiated by an established patient” does not include a visit for which a provider or a person employed by a provider contacts a patient to initiate a service; and,
    3. Is recognized by the CPT codes published by the AMA.
12. Permits DHCS to seek approval of any state plan amendments necessary to implement this bill.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, this bill will expand access to reproductive health care services through the use of existing and innovative technology that connects patients with their health care provider more efficiently and cost effectively.  The use of telehealth is expanding, and is a vital component of health care that increases access to care, and lowers the cost of health care services.  Planned Parenthood developed a mobile app to facilitate the testing and treatment of sexually transmitted infections (STIs) and urinary tract infections (UTIs), and the provision of hormonal birth control, without requiring an office visit.  Using these types of mobile, web-based technologies will increase access to care in all communities -- rural, urban, and suburban underserved areas.  However, Medi-Cal reimbursement for telehealth services is limited to only a few fields of medicine.  This bill will enable certain services that Planned Parenthood provides to patients through health centers to also be reimbursed when delivered through its mobile application. At a time when we have increased insurance coverage for millions of Californians, this bill ensures that low income women seeking reproductive health care services, regardless of location, can receive the care they need in the most efficient way possible. 
2. Impact of undiagnosed disease and unintended pregnancies. About one in eight U.S. residents with HIV do not realize they are infected, and they cause nearly one-third of HIV transmissions, according to a CDC report released in June 2015. With regard to bacterial STIs, the Department of Public Health reported that California ranked first among all states in 2014 for the total number of cases of chlamydia, gonorrhea, and syphilis. Additionally, disparities persist for STIs, with the highest rates found among young people, African-Americans, and gay and bisexual men. However, according to the federal Department of Health and Human Services, because many cases of STIs go undiagnosed, the reported cases of chlamydia, gonorrhea, and syphilis represent only a fraction of the true burden of STIs. Untreated STIs can lead to serious long-term health consequences, especially for adolescent girls and young women. Finally, in California, about half of all pregnancies are unintended. Women with unintended pregnancies are less likely to receive prenatal care, and health outcomes are worse for both mother and baby. According to a 2015 study by the Guttmacher Institute, the annual public cost of unintended pregnancies in California is more than $1.75 billion.
3. Telehealth. Existing law defines “telehealth” 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. A 2014 report by the California Health Benefits Review Program on AB 1771 (Perez of 2014), found these services, especially in underserved areas, could substitute for 60% of current, more costly face-to-face visits, while improving access by increasing capacity for more patient visits to occur.
4. Planned Parenthood Direct. In June 2015, Planned Parenthood Affiliates of California (PPAC) launched a mobile application called Planned Parenthood Direct, which allows men and women to order confidential STI testing kits through their mobile phone and, if they test positive, receive treatment.  It had been available in Minnesota and Washington since the 2014 and allows people to talk to a Planned Parenthood provider online and face to face through a secure video consultation system, and then receive birth control or an STI test kit and treatment, if necessary, in the mail. According to Planned Parenthood, these two apps build upon other resources that the organization has introduced to the health care field to increase access to reproductive health care services. According to PPAC, Planned Parenthood Direct is only cash pay, but they are working to accept insurance coverage.  Under this scenario, the interface will verify a patient’s insurance to see if the service is covered, and if it is, whether or not a co-pay applies before the service is provided.
5. CPT codes. These codes are used to report episodes of patient care initiated by an established patient or guardian of an established patient. If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of the subsequent evaluation and management service, procedure, and visit. If the telephone call refers to an evaluation and management service reported within the previous seven days or within the postoperative period of the previously completed procedure, then the service is not reported. There are also CPT codes for telephone services provided by a qualified non-physician who may report telephone assessment and management services with similar criteria as described above. While CPT codes exist, there is no Medi-Cal reimbursement for telephone and email consultation for reproductive services, and reimbursement for store and forward telehealth services is limited to only a few fields of medicine. According to the CHBRP analysis of AB 1771, with a few exceptions, the Centers for Medicare and Medicaid Services (CMS) do not reimburse for telephone (and email) communications, and most commercial insurance carriers follow CMS reimbursement decisions.
6. Related legislation. AB 2507 (Gordon) expands the definition of telehealth to also include telephone, email and synchronous text, and chat conferencing as billable telehealth modalities and requires health plans and insurers to reimburse telehealth services to the same extent as services provided through in person. AB 2507 is set to be heard in the Assembly Health Committee on April 19, 2016.
7. Prior legislation. AB 1771 would have required health plans and health insurers, with respect to plan contracts and insurance policies issued, amended, or renewed on or after January 1, 2016, to cover telephone visits provided by a physician. AB 1771 was held on suspense in the Senate Appropriations Committee.

AB 415 (Logue, Chapter 547, Statutes of 2011), among other provisions, prohibits DHCS from requiring that a health care provider document a barrier to an in-person visit prior to paying for services provided via telehealth to a Medi-Cal beneficiary. Repeals the prohibition of paying for a service provided by telephone or facsimile and would instead prohibit DHCS from limiting the type of setting where services are provided for the patient. Prohibits health plans and insurers from requiring that in-person contact occur between a health care provider and a patient before payment is made for the services appropriately provided through telehealth, subject to the terms of the relevant contract. Repeals the prohibition for paying for a service provided by telephone or facsimile and would instead prohibit health plans and insurers from limiting the type of setting where services are provided for the patient or by the health care provider.

SB 1665 (Thompson, Chapter 864, Statutes of 1996), establishes the Telemedicine Development Act (TDA) to set standards for the use of telemedicine by health care practitioners and insurers. TDA specifies, in part, that face-to-face contact between a health care provider and a patient is not required under the Medi-Cal Program for services appropriately provided through telemedicine, when those services are otherwise covered by the Medi-Cal program, and requires a health care practitioner to obtain verbal and written consent prior to providing services through telemedicine.

1. Support. A number of Planned Parenthood affiliates write to say that access to sensitive services, such as birth control and STI testing, can be challenging for certain low-income populations, particularly for those in rural and underserved communities. Supporters state that payment for these telehealth services should be expanded to include reproductive health care in order to provide ease of access to reproductive care, which will in turn minimize the spread of disease and reduce the number of unintended pregnancies. The National Health Law Program (NHeLP) states that there are many barriers that interfere with a patient’s ability to access care: distance, lack of transportation, lack of child care, as well as others. NHeLP states that timeliness is especially important to the delivery of quality reproductive health care services, in addition to other fields of medicine and that telehealth plays a critical role in ensuring timely health care delivery. The County Health Executives Association of California writes that telemedicine has been a useful tool in expanding services, especially to the more rural areas of California where access to care can be difficult. The California Family Health Council (CFHC) writes that women with unintended pregnancies are less likely to receive prenatal care, and health outcomes are worse for both mother and baby. CFHC asserts that paying Medi-Cal providers to provide sexual and reproductive health care via telehealth would ease access to these services, which will in turn minimize the spread of disease and reduce the number of unintended pregnancies and could also expand the patient base who might be interested in these services. The California Academy of Family Physicians states that this bill empowers patients by allowing them more control over their care, which leads to improved connectedness, continuity, and overall quality of the patient-provider relationship. The California Medical Association states that not only do telehealth services reduce the use of expensive services, increase access, and improve quality of care, but patients also feel more satisfaction with their care. Stanford Health Care writes that efforts to expand telehealth coverage and reimbursement are to be supporter to better address the numerous health issues Californians face. The American Civil Liberties Union writes that this bill aligns with California’s historic leadership in establishing public policies that increase access to reproductive health care, which in turn, minimizes the spread of STIs and reduces the number of unintended pregnancies in the state.
2. Oppose. The California Catholic Conference writes that eliminating the requirement for a face-to-face visit with a reproductive health care professional, alongside other types of non-invasive medical care and in order to achieve additional cost-savings to the state, is a potential direct reduction in the standard of care for women on publicly subsidized health care and bad public policy. CCC states that because of the marvelous blessing bestowed upon women by our ever-loving God, which allows for the miracle of life and is intended for procreation for only part of their lives, women should demand that the medical profession work with their reproductive health, which must remain its own class of medical care and deserves respect, understanding and acceptance by all.
3. Oppose unless amended. The California Association of Health Plans (CAHP) writes that they support the objectives of telehealth in improving enrollee access to health care as a means of controlling health care costs; however, they must oppose this Medi-Cal coverage mandate. CAHP writes that this bill does not add these telehealth services as a visit that is counted as a patient encounter, and if telehealth visits are not counted in the rate setting process then Medi-Cal managed care plans will not be compensated for the provisions of these services.

SUPPORT AND OPPOSITION:

Support: Planned Parenthood Affiliates of California (sponsor)

American Civil Liberties Union of California

American Congress of Obstetricians and Gynecologists, District IX (California)

California Academy of Family Physicians

California Family Health Council

California Medical Association

The Children’s Partnership

Community Action Fund of Planned Parenthood of Orange and San Bernardino Counties

County Health Executives Association of California

National Health Law Program

Planned Parenthood Action Fund of the Pacific Southwest

Planned Parenthood Action Fund of Santa Barbara, Ventura & San Luis Obispo

Planned Parenthood Advocacy Project Los Angeles County

Planned Parenthood Mar Monte

Planned Parenthood Northern California Action Fund

Stanford Health Care

Oppose: California Association of Health Plans (unless amended)

California Catholic Conference

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