Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care to adopt regulations to ensure that enrollees have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and specialty physicians. Existing law requires health care service plans to report annually to the Department of Managed Health Care on compliance with the standards developed pursuant to these provisions. Existing law requires the Insurance Commissioner to promulgate regulations applicable to health insurers that contract with providers for alternative rates to ensure that insureds have the opportunity to access needed health care services in a timely manner.

This bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2018, to permit an HIV specialist, as defined, to be an eligible primary care provider, as defined, if the provider requests primary care provider status and meets the plans or the health insurers eligibility criteria for all specialists seeking primary care provider status. The bill would provide that these provisions do not apply to a health insurance policy that does not require an insured to obtain a referral from his or her primary care physician prior to seeking covered health care services from a specialist. The bill would provide that these provisions shall not be construed to include an HIV specialist as a primary care physician for the purposes of network adequacy requirements. Because a willful violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care to adopt regulations to ensure that enrollees have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and speciality specialty physicians. Existing law requires health care service plans to report annually to the Department of Managed Health Care on compliance with the standards developed pursuant to these provisions. Existing law requires the Insurance Commissioner to promulgate regulations applicable to health insurers that contract with providers for alternative rates to ensure that insureds have the opportunity to access needed health care services in a timely manner.

This bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2018, to permit an HIV specialist, as defined, to be an eligible primary care provider, as defined, if the provider requests primary care provider status and meets the plans or the health insurers eligibility criteria for all specialists seeking primary care provider status. The bill would provide that these provisions do not apply to a health insurance policy that does not require an insured to obtain a referral from his or her primary care physician prior to seeking covered health care services from a specialist. The bill would provide that these provisions shall not be construed to include an HIV specialist as a primary care physician for the purposes of network adequacy requirements. Because a willful violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care and the Insurance Commissioner to adopt regulations to ensure that enrollees and insureds have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and speciality physicians. Existing law requires health care service plans to report annually to the Department of Managed Health Care on compliance with the standards developed pursuant to these provisions. Existing law requires the Insurance Commissioner to adopt regulations that ensure, among other things, the adequacy of the number of professional providers in relationship to the projected demands for services covered under the group policy.

This bill would require access to HIV specialists to be subject to the regulations, standards, and reporting requirements developed pursuant to the above specified provisions. The bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2018, to include permit an HIV specialist, as defined, as to be an eligible primary care provider, as defined, if the provider requests primary care provider status and meets the plans or health insurers eligibility criteria for all specialists seeking primary care provider status. Because a willful violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires the Department of Managed Health Care and the Insurance Commissioner to adopt regulations to ensure that enrollees and insureds have access to needed health care services in a timely manner. Existing law requires the Department of Managed Health Care to develop indicators of timeliness of access to care, including waiting times for appointments with physicians, including primary care and speciality physicians. Existing law requires health care service plans to report annually to the Department of Managed Health Care on compliance with the standards developed pursuant to these provisions. Existing law requires the Insurance Commissioner to adopt regulations that ensure, among other things, the adequacy of the number of professional providers in relationship to the projected demands for services covered under the group policy.

This bill would require access to HIV specialists to be subject to the regulations, standards, and reporting requirements developed pursuant to the above specified provisions. The bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2018, to include an HIV specialist, as defined, as an eligible primary care provider, as defined, if the provider requests primary care provider status and meets the plans or health insurers eligibility criteria for all specialists seeking primary care provider status. Because a willful violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

GOVERNOR'S VETO

GV Bill Id:AB 1534

Author:(Nazarian)

As Enrolled Ver:September 6, 2018

2/3 vote

Original Committee Reference: HEALTH

SUMMARY: Designates a human immunodeficiency virus (HIV) specialist as an eligible primary care provider (PCP) for a health care service plan (health plan) policy that is issued, amended, or renewed on or after January 1, 2018, and that provides hospital, medical or surgical coverage, provided that the provider requests provider status and meets the health plan's eligibility criteria for all specialists seeking PCP status.

The Senate amendments state that this bill should not be construed to include an HIV specialist as a primary care physician for the purposes of existing network adequacy requirements and add parallel provisions to the Insurance Code.

FISCAL EFFECT: According to the Senate Appropriations Committee, ongoing costs of about $20,000 per year for the Department of Managed Health Care (DMHC) to review compliance by health plans with the requirements of the bill.

Minor costs are anticipated by the Department of Insurance to ensure health insurer compliance with the requirements of the bill.

No significant additional health care costs are anticipated for the Medi-Cal program or CalPERS purchase of health insurance.

According to the California Health Benefits Review Program, most health plans in the state (including Medi-Cal managed care plans) already allow HIV specialists to act as PCPs, upon request. Further, under current practice by health plans and health insurers, an HIV specialist (or any other specialist) that is providing primary care services would bill for such services using the existing billing codes for those primary care services and would be reimbursed at the standard reimbursement rate for those services. Therefore, the cost of providing primary care services is not anticipated to increase, simply because an HIV specialist provided those services. In theory, allowing HIV specialists to serve as PCPs could impact the utilization of services. For example, allowing an HIV specialist to serve as a PCP could reduce duplicative medical testing and avoid duplicative patient visits for patients with HIV who are regularly seeing an HIV specialist but would otherwise need to schedule a separate visit with a different PCP for primary care services. On the other hand, an HIV specialist providing primary care services may be more likely to refer a patient to another specialist for services than a traditional primary care provider would be. In the aggregate, the overall change in service utilization is not likely to be significant. Therefore, staff does not anticipate significant additional costs to public programs such as Medi-Cal or CalPERS.

COMMENTS: According to the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. Given the intricate nature of the virus, something as simple as a routine flu shot could cause serious complications for an HIV patient if administered by a provider without the understanding of the patient's status. By allowing HIV specialists to serve as a PCP for their patients, this bill eliminates administrative impediments, such as ordering tests or making additional referrals, and maintains continuity of care for a disease that has become manageable.

HIV providers may be physicians, nurse practitioners, or physician assistants and may be credentialed as an HIV specialist by the American Academy of HIV Medicine. Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing. Persons living with HIV (PLWH) may see an HIV specialist who is in private practice, or practices at an HIV clinic, general healthcare clinic, or a community health center. Additionally, PLWH (especially those who are underinsured or uninsured, and thus not subject to this bill) may seek care at the clinics funded through the Ryan White CARE Act. These clinics were foundational to the control of the AIDS epidemic in the early 1990s through their provision of HIV treatment and management.

AIDS Healthcare Foundation, sponsor of this bill, cites a recent report from the California HIV/AIDS Research Program at the University of California acknowledging that this bill has the potential to increase preventive care and screening for PLWH. The California Chapter of the American College of Physicians states that this bill would help HIV-infected patients gain access to comprehensive care from specialists that fully understand HIV therapies, co-morbidities, and more.

The DMHC and Department of Finance are opposed to this bill because there is already an adequate mechanism in existing law to permit specialists to act as primary care physicians. Additionally, according to DMHC, there is not a demonstrated problem related to access to qualified HIV specialists or standing referrals for enrollees of licensed health plans.

GOVERNOR'S VETO MESSAGE:

This bill would require health plans and insurers to accept doctors who specialize in HIV as primary care providers.

Existing law allows specialists to serve as primary care providers when patients require continuing care from a particular specialist. It's not necessary to call out this particular specialty in statute.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0005302

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1534

Author:(Nazarian)

As Amended Ver:June 26, 2017

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Designates a human immunodeficiency virus (HIV) specialist as an eligible primary care provider (PCP) for a health care service plan (health plan) policy that is issued, amended, or renewed on or after January 1, 2018, and that provides hospital, medical or surgical coverage, provided that the provider requests provider status and meets the health plan's eligibility criteria for all specialists seeking PCP status.

The Senate amendments state that this bill should not be construed to include an HIV specialist as a primary care physician for the purposes of existing network adequacy requirements and add parallel provisions to the Insurance Code.

FISCAL EFFECT: According to the Senate Appropriations Committee, ongoing costs of about $20,000 per year for the Department of Managed Health Care (DMHC) to review compliance by health plans with the requirements of the bill.

Minor costs are anticipated by the Department of Insurance to ensure health insurer compliance with the requirements of the bill.

No significant additional health care costs are anticipated for the Medi-Cal program or CalPERS purchase of health insurance.

According to the California Health Benefits Review Program, most health plans in the state (including Medi-Cal managed care plans) already allow HIV specialists to act as PCPs, upon request. Further, under current practice by health plans and health insurers, an HIV specialist (or any other specialist) that is providing primary care services would bill for such services using the existing billing codes for those primary care services and would be reimbursed at the standard reimbursement rate for those services. Therefore, the cost of providing primary care services is not anticipated to increase, simply because an HIV specialist provided those services. In theory, allowing HIV specialists to serve as PCPs could impact the utilization of services. For example, allowing an HIV specialist to serve as a PCP could reduce duplicative medical testing and avoid duplicative patient visits for patients with HIV who are regularly seeing an HIV specialist but would otherwise need to schedule a separate visit with a different PCP for primary care services. On the other hand, an HIV specialist providing primary care services may be more likely to refer a patient to another specialist for services than a traditional primary care provider would be. In the aggregate, the overall change in service utilization is not likely to be significant. Therefore, staff does not anticipate significant additional costs to public programs such as Medi-Cal or CalPERS.

COMMENTS: According to the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. Given the intricate nature of the virus, something as simple as a routine flu shot could cause serious complications for an HIV patient if administered by a provider without the understanding of the patient's status. By allowing HIV specialists to serve as a PCP for their patients, this bill eliminates administrative impediments, such as ordering tests or making additional referrals, and maintains continuity of care for a disease that has become manageable.

HIV providers may be physicians, nurse practitioners, or physician assistants and may be credentialed as an HIV specialist by the American Academy of HIV Medicine. Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing. Persons living with HIV (PLWH) may see an HIV specialist who is in private practice, or practices at an HIV clinic, general healthcare clinic, or a community health center. Additionally, PLWH (especially those who are underinsured or uninsured, and thus not subject to this bill) may seek care at the clinics funded through the Ryan White CARE Act. These clinics were foundational to the control of the AIDS epidemic in the early 1990s through their provision of HIV treatment and management.

AIDS Healthcare Foundation, sponsor of this bill, cites a recent report from the California HIV/AIDS Research Program at the University of California acknowledging that this bill has the potential to increase preventive care and screening for PLWH. The California Chapter of the American College of Physicians states that this bill would help HIV-infected patients gain access to comprehensive care from specialists that fully understand HIV therapies, co-morbidities, and more.

The DMHC and Department of Finance are opposed to this bill because there is already an adequate mechanism in existing law to permit specialists to act as primary care physicians. Additionally, according to DMHC, there is not a demonstrated problem related to access to qualified HIV specialists or standing referrals for enrollees of licensed health plans.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 0001414

 THIRD READING  

Bill No: AB 1534

Author: Nazarian (D)

Amended: 6/26/17 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 6/21/17

AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/21/17

AYES: Lara, Bates, Beall, Bradford, Hill, Nielsen, Wiener

ASSEMBLY FLOOR: 76-0, 5/30/17 - See last page for vote

SUBJECT: Health care coverage: HIV specialists

SOURCE: Author

DIGEST:

This bill requires every health care service plan contract and health insurance policy that is issued, amended, or renewed on or after January 1, 2018 to permit an HIV specialist to be an eligible primary care provider, if the provider requests primary care provider status and meets the health care service plan or health insurer’s eligibility criteria for all specialists seeking primary care provider status.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health care service plans in the Health and Safety Code and the California Department of Insurance (CDI) to regulate health insurers in the Insurance Code.
   
2. Requires every health care service plan, except a specialized health care service plan, to establish and implement a procedure by which an enrollee with a condition or disease that requires specialized medical care over a prolonged period of time and is life-threatening, degenerative, or disabling may receive a referral to a specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the specialist coordinate the enrollee’s health care. Requires after the referral is made, the specialist to be authorized to provide health care services that are within the specialist’s area of expertise and training to the enrollee in the same manner as the enrollee’s primary care physician, subject to the terms of the treatment plan.
   
3. Requires every health care service plan contract that provides hospital, medical, or surgical coverage, and every policy of disability insurance that covers hospital, medical, or surgical expenses, that is issued, amended, delivered, or renewed in this state, to include obstetrician-gynecologists as eligible primary care physicians, provided they meet the plan’s or insurer’s eligibility criteria for all specialists seeking primary care physician status.
   
4. Defines “primary care physician” as defined in 5) below, as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
   
5. Defines “primary care physician” as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. Requires a primary care physician to be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. States that a non-physician medical practitioner, (defined as a physician assistant, nurse midwife, or nurse practitioner, as specified) who is supervised by a primary care physician, has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care.
   

This bill:

1. Requires every health care service plan contract and health insurance policy that is issued, amended, or renewed on or after January 1, 2018, that provides hospital, medical, or surgical coverage, excluding specialized health care service plan contracts and insurance policies, to permit an HIV specialist to be an eligible primary care provider, if the provider requests primary care provider status and meets the health care service plan’s or insurer’s eligibility criteria for all specialists seeking primary care provider status.
   
2. Defines, “primary care provider” to mean a physician or a non-physician medical practitioner, as defined, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
   
3. Defines “HIV specialist” to mean a physician, physician assistant, or a nurse practitioner who meets the criteria for an HIV specialist as published by the American Academy of HIV Medicine or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (Public Law 101-381).
   
4. Exempts from this bill a health insurance policy that does not require an insured to obtain a referral from his or her primary care physician prior to seeking covered health care services from a specialist.

Comments

1. Author’s statement. According to the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. Given the intricate nature of the virus, something as simple as a routine flu shot could cause serious complications for an HIV patient if administered by a provider without the understanding of the patient’s status. By allowing HIV specialists to serve as primary care providers for their patients, this bill eliminates administrative impediments, such as ordering tests or making additional referrals, and maintains continuity of care for a disease that has become manageable today.
2. California Health Benefits Review Program (CHBRP) analysis. AB 1996 (Thomson, Chapter 795, Statutes of 2002) requested the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996, and reviewed this bill. CHBRP’s analysis is based on an earlier version of this bill and does not incorporate the April 17, 2017 amendments. Key findings related to parental involvement, setting and location, or time of treatment, frequency of review of treatment plan include:
   1. Coverage impacts and enrollees covered. According to the responses to the CHBRP carrier survey, most health plans and policies, including Medi-Cal managed care plans and plans accessed through the California Public Employees Retirement System, allow HIV specialists to act as primary care providers if the HIV specialist meets the health plan’s requirements. CHBRP estimates that in 2018, 23.4 million Californians enrolled in state-regulated health insurance will have insurance subject to this bill;
   2. Essential health benefits. CHBRP believes the provisions of this bill do not appear to exceed essential health benefits, and would not trigger the Affordable Care Act requirement that the state defray the cost of additional benefit coverage for enrollees in qualified health plans in Covered California;
   3. Medical effectiveness. There is limited evidence from two studies with moderate research design that providers with more experience/expertise in HIV provide equivalent or better primary care screening services to persons living with HIV/AIDS compared to providers with less HIV experience/expertise or generalists.
   4. Utilization. CHBRP is unable to estimate enrollee utilization of designating an HIV specialist as a primary care provider due to limitations in health claims data;
   5. Impact on expenditures. Unknown; and,
   6. Public health. There appear to be more than 900 HIV specialists (some of whom are credentialed by the American Academy of HIV Medicine and many more who likely meet the AB 1534 definition who treat some of the persons living with HIV/AIDS in California. However, the use of primary care services provided by HIV specialists and the resulting health outcomes is unknown.
3. HIV/AIDS background. According to the Centers for Disease Control and Prevention, in 2015, an estimated 39,393 people in the United States were diagnosed with HIV, the virus that causes AIDS. In 2015, an estimated 4,720 adults and adolescents were diagnosed with HIV in California. California ranked 2nd among the 50 states in the number of HIV diagnoses in 2015. The California Office of AIDS maintains an HIV/AIDS surveillance system that records the prevalence and incidence of HIV diagnoses and the prevalence of AIDS cases (CDPH, 2016). The most recent data available from 2014 indicate that 126,241 people in California are living with HIV/AIDS. According to CHBRP, HIV providers may be physicians, physician assistants, or nurse practitioners and may be credentialed as an HIV Specialist™ by the American Academy of HIV Medicine. Persons living with HIV may see an HIV specialist who is in private practice, or practices at an HIV clinic, general healthcare clinic, or a community health center.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Senate Appropriations Committee:

• Ongoing costs of about $20,000 per year for DMHC to review compliance by health plans with the requirements of the bill (Managed Care Fund).
• Minor costs are anticipated CDI to ensure health insurer compliance with the requirements of the bill (Insurance Fund).
• No significant additional health care costs are anticipated for the Medi-Cal program or CalPERS purchase of health insurance.
• According to CHBRP, most health plans in the state (including Medi-Cal managed care plans) already allow HIV specialists to act as primary care providers, upon request. Further, under current practice by health plans and health insurers, an HIV specialist (or any other specialist) that is providing primary care services would bill for such services using the existing billing codes for those primary care services and would be reimbursed at the standard reimbursement rate for those services. Therefore, the cost of providing primary care services is not anticipated to increase, simply because an HIV specialist provided those services. In theory, allowing HIV specialists to serve as primary care providers could impact the utilization of services. For example, allowing an HIV specialist to serve as a primary care provider could reduce duplicative medical testing and avoid duplicative patient visits for patients with HIV who are regularly seeing an HIV specialist but would otherwise need to schedule a separate visit with a different primary care provider for primary care services. On the other hand, an HIV specialist providing primary care services may be more likely to refer a patient to another specialist for services than a traditional primary care provider would be. In the aggregate, the overall change in service utilization is not likely to be significant. Therefore, staff does not anticipate significant additional costs to public programs such as Medi-Cal or CalPERS.

SUPPORT: (Verified 8/22/17)

AIDS Healthcare Foundation

Beyond AIDS

California Academy of PAs

California Chapters of American College of Physicians

CaliforniaHealth + Advocates

National Association of Social Workers

OPPOSITION: (Verified 8/22/17)

Department of Finance

Department of Managed Health Care

ARGUMENTS IN SUPPORT: The AIDS Healthcare Foundation (AHF) writes that because plans do not always recognize HIV specialist’s as primary care physicians, there are too many times when the HIV specialist cannot order tests, make referrals to other specialists or any of the other services a primary care physician can provide. In addition, a patient with a non-HIV specialist primary care physician runs the risk that the primary care physician does not have the expertise necessary to know that some routine care decisions become complicated when they impact a person with HIV. This situation makes delivery of care more uncertain, interrupts the provision of care, puts additional demands on the patient and ultimately costs more in an unnecessary duplication of services. According to AHF, unlike a previous version of this bill, AB 1534 does not impact health plans’ network adequacy obligations and it does not insert HIV specialists into network adequacy considerations. The focus of this bill is discretely on the ability of a patient to select an HIV specialist to act as the patient’s primary care physician. Beyond AIDS writes a clinic that provides both HIV specialty care and primary care can currently only bill for the services of such an all-purpose provider as a primary care provider, because the combination of that with being an HIV specialist has not been recognized. Alternatively, the HIV care can be billed, but not the time-consuming and essential primary care. This is a disincentive to integrated care, and AB 1534 will resolve the problem. The California Chapters of the American College of Physicians views this bill as a critical measure to help ensure HIV-infected patients have providers that meet their unique health care needs. The California Academy of PAs writes that research shows that patients with HIV have better health outcomes, as well as an increase in cost-effective and coordinated care when a clinician with experience and expertise in HIV manages their condition. HIV specialists receive additional medical education and experience in order to provide comprehensive primary health care services to patients with HIV.

ARGUMENTS IN OPPOSITION: The DMHC has strong concerns that designating a particular disease specialist as a primary care provider in statute set a precedent for other specialty types to follow suit, potentially harming the managed care model that relies on primary care physicians. In addition, DMHC writes that there is already a mechanism (termed “standing referrals”) to permit specialists to act as primary care physicians for health plan enrollees, and specifically references HIV specialists. Furthermore, regulations already require that standing referrals for HIV patients be made to qualified HIV specialist physicians and health plans must demonstrate network adequacy standards. Designating HIV specialist physicians and non-physicians as primary care providers could potentially reduce the number of primary care physicians in the network. Finally, DMHC is unaware of any demonstrated problem related to access to qualified HIV specialists.

ASSEMBLY FLOOR: 76-0, 5/30/17

AYES: Acosta, Aguiar-Curry, Travis Allen, Arambula, Baker, Berman, Bigelow, Bloom, Bocanegra, Bonta, Brough, Burke, Caballero, Calderon, Cervantes, Chávez, Chen, Chiu, Chu, Cooley, Cooper, Cunningham, Dababneh, Dahle, Daly, Flora, Fong, Frazier, Friedman, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gomez, Gonzalez Fletcher, Gray, Grayson, Harper, Holden, Irwin, Jones-Sawyer, Kalra, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk, Quirk-Silva, Reyes, Ridley-Thomas, Rodriguez, Rubio, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Voepel, Waldron, Weber, Wood, Rendon

NO VOTE RECORDED: Chau, Choi, Eggman, Mathis

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/23/17 16:25:29

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

AB 1534 (Nazarian) - Health care coverage: HIV specialists

This bill does not meet the criteria for referral to the Suspense File.

Bill Summary:

AB 1534 would require health plans and health insurers to allow an HIV specialist to serve as primary care provider.

Fiscal Impact:

• Ongoing costs of about $20,000 per year for the Department of Managed Health Care to review compliance by health plans with the requirements of the bill (Managed Care Fund).
• Minor costs are anticipated by the Department of Insurance to ensure health insurer compliance with the requirements of the bill (Insurance Fund).
• No significant additional health care costs are anticipated for the Medi-Cal program or CalPERS purchase of health insurance.

According to the California Health Benefits Review Program, most health plans in the state (including Medi-Cal managed care plans) already allow HIV specialists to act as primary care providers, upon request. Further, under current practice by health plans and health insurers, an HIV specialist (or any other specialist) that is providing primary care services would bill for such services using the existing billing codes for those primary care services and would be reimbursed at the standard reimbursement rate for those services. Therefore, the cost of providing primary care services is not anticipated to increase, simply because an HIV specialist provided those services. In theory, allowing HIV specialists to serve as primary care providers could impact the utilization of services. For example, allowing an HIV specialist to serve as a primary care provider could reduce duplicative medical testing and avoid duplicative patient visits for patients with HIV who are regularly seeing an HIV specialist but would otherwise need to schedule a separate visit with a different primary care provider for primary care services. On the other hand, an HIV specialist providing primary care services may be more likely to refer a patient to another specialist for services than a traditional primary care provider would be. In the aggregate, the overall change in service utilization is not likely to be significant. Therefore, staff does not anticipate significant additional costs to public programs such as Medi-Cal or CalPERS.

Background:

Under current law, health plans are licensed and regulated by the Department of Managed Health Care and health insurers are licensed and regulated by the Department of Insurance.

Under the model of care used by many health plans, enrollees are assigned a primary care provider who has the authority to control referrals to specialist providers (with oversight by the health plan and the Department of Managed Health Care). The primary care provider can be either a physician or a non-physician provider under the supervision of a physician. Typically, specialists (such as HIV specialists) provide primary care services either if they are designated as a primary care provider by the health plan (usually because the HIV specialist is board certified as a general practitioner, pediatrician, obstetrician-gynecologist, internist, or family practitioner) or if the enrollee’s assigned primary care provider provides a standing referral that allows the enrollee to access care through the specialty provider without needing individual referrals. However, standing referrals are usually made with an associated treatment plan. Depending on how the treatment plan is structured, the enrollee may still need to see the assigned primary care provider to access some primary or specialty care.

Health insurers typically use a network design that does not require referral by a primary care provider for an enrollee to access specialty care services.

Proposed Law:

AB 1534 would require health plans and health insurers to allow an HIV specialist to serve as a primary care provider.

Specific provisions of the bill would:

• Require every health plan (excluding specialized plans) and every health insurance policy to permit an HIV specialist to be a primary care provider, if the provider requests primary care status and meets the health plan or health insurance policy criteria for specialists seeking primary care provider status;
• State that the provisions of the bill shall not be construed to include an HIV specialist as a primary care physician for the purposes of meeting network adequacy requirements.

Related Legislation:

AB 2372 (Burke, 2016) was similar to this bill. That bill was held on the Assembly Appropriations Committee’s Suspense File.

Staff Comments:

According to the California Health Benefits Review Program, most health plans currently allow HIV specialists to act as primary care providers. Due to limitations in claims data, the Program was not able to estimate any potential change in utilization of health care services under the bill. As noted above, based on information in the report, staff does not anticipate a significant increase in overall utilization of health care services under the bill. Similarly, because HIV specialists would be paid for providing primary care at the same reimbursement rates as are other primary care providers, there is no anticipated increase in costs for services currently being provided.

According to the California Health Benefits Review Program, a small number of research studies provide limited evidence that providers with more experience treating patients with HIV provide equivalent or better primary care services to patients with HIV compared to providers with less HIV experience or general practitioners.

The only costs that may be incurred by a local agency relate to crimes and infractions. Under the California Constitution, such costs are not reimbursable by the state.

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SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 1534

SUBJECT: Health care coverage: HIV specialists

SUMMARY:

1. Requires every health care service plan contract that is issued, amended, or renewed on or after January 1, 2018 to permit an HIV specialist to be an eligible primary care provider, if the provider requests primary care provider status and meets the health care service plan’s eligibility criteria for all specialists seeking primary care provider status.
   

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health care service plans in the Health and Safety Code and the California Department of Insurance (CDI) to regulate health insurers in the Insurance Code.
   
2. Requires every health care service plan, except a specialized health care service plan, to establish and implement a procedure by which an enrollee with a condition or disease that requires specialized medical care over a prolonged period of time and is life-threatening, degenerative, or disabling may receive a referral to a specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the specialist coordinate the enrollee’s health care. Requires after the referral is made, the specialist to be authorized to provide health care services that are within the specialist’s area of expertise and training to the enrollee in the same manner as the enrollee’s primary care physician, subject to the terms of the treatment plan.
   
3. Requires every health care service plan contract that provides hospital, medical, or surgical coverage, and every policy of disability insurance that covers hospital, medical, or surgical expenses, that is issued, amended, delivered, or renewed in this state, to include obstetrician-gynecologists as eligible primary care physicians, provided they meet the plan’s or insurer’s eligibility criteria for all specialists seeking primary care physician status.
   
4. Defines “primary care physician” as defined in 5) below, as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
   
5. Defines “primary care physician” as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. Requires a primary care physician to be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. States that a non-physician medical practitioner, (defined as a physician assistant, nurse midwife, or nurse practitioner, as specified) who is supervised by a primary care physician, has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care.
   
6. Requires every health care service plan contract issued, amended, renewed, or delivered in this state, except a specialized health care service plan, and every policy of disability insurance that covers hospital, medical, or surgical expenses, to allow an enrollee or insured the option to seek obstetrical and gynecological physician services directly from a participating obstetrician and gynecologist or directly from a participating family practice physician and surgeon designated by the plan as providing obstetrical and gynecological services.
   
7. Permits a health care service plan to establish reasonable provisions governing utilization protocols and the use of obstetricians and gynecologists, or family practice physicians and surgeons, as provided for in 6) above, participating in the plan network, medical group, or independent practice association, consistent with the intent and those customarily applied to other physicians and surgeons, such as primary care physicians and surgeons, to whom the enrollee has direct access, and not be more restrictive for the provision of obstetrical and gynecological physician services.
   
8. Prohibits an enrollee from being required to obtain prior approval from another physician, another provider, or the health care service plan prior to obtaining direct access to obstetrical and gynecological physician services, but permits the plan to establish reasonable requirements for the participating obstetrician and gynecologist or family practice physician and surgeon, as specified in 7) above, to communicate with the enrollee’s primary care physician and surgeon regarding the enrollee’s condition, treatment, and any need for follow-up care.
   
9. Requires a health care service plan to ensure that there is at least one full-time equivalent primary care physician for every 2,000 enrollees of the plan. The number of enrollees per primary care physician may be increased by up to 1,000 additional enrollees for each full-time equivalent non-physician medical practitioner supervised by that primary care physician.

This bill:

1. Requires every health care service plan contract that is issued, amended, or renewed on or after January 1, 2018, that provides hospital, medical, or surgical coverage, excluding specialized health care service plan contracts, to permit an HIV specialist to be an eligible primary care provider, if the provider requests primary care provider status and meets the health care service plan’s eligibility criteria for all specialists seeking primary care provider status.
   
2. Defines, “primary care provider” to mean a physician or a non-physician medical practitioner, as defined, who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
   
3. Defines “HIV specialist” to mean a physician, physician assistant, or a nurse practitioner who meets the criteria for an HIV specialist as published by the American Academy of HIV Medicine or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (Public Law 101-381).

FISCAL EFFECT:

According to the Assembly Appropriations Committee, costs to DMHC of approximately $160,000 in 2017-18, approximately $100,000 in 2018-19, and approximately $180,000 for 2019-20 and annually thereafter (Managed Care Fund). One-time costs are to amend existing regulations and review plan documents. Ongoing costs are to review filings to ensure compliance and to investigate and enforce the law in instances of non-compliance.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. Given the intricate nature of the virus, something as simple as a routine flu shot could cause serious complications for an HIV patient if administered by a provider without the understanding of the patient’s status. By allowing HIV specialists to serve as primary care providers for their patients, this bill eliminates administrative impediments, such as ordering tests or making additional referrals, and maintains continuity of care for a disease that has become manageable today.
2. California Health Benefits Review Program (CHBRP) analysis. AB 1996 (Thomson, Chapter 795, Statutes of 2002) requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996, and reviewed this bill. CHBRP’s analysis is based on an earlier version of this bill and does not incorporate the April 17, 2017 amendments. Key findings related to parental involvement, setting and location, or time of treatment, frequency of review of treatment plan include:
   1. Coverage impacts and enrollees covered. According to the responses to the CHBRP carrier survey, most health plans and policies, including Medi-Cal managed care plans and plans accessed through the California Public Employees Retirement System, allow HIV specialists to act as primary care providers if the HIV specialist meets the health plan’s requirements. CHBRP estimates that in 2018, 23.4 million Californians enrolled in state-regulated health insurance will have insurance subject to this bill;
   2. Essential health benefits. CHBRP believes the provisions of this bill do not appear to exceed essential health benefits, and would not trigger the Affordable Care Act requirement that the state defray the cost of additional benefit coverage for enrollees in qualified health plans in Covered California;
   3. Medical effectiveness. There is limited evidence from two studies with moderate research design that providers with more experience/expertise in HIV provide equivalent or better primary care screening services to persons living with HIV/AIDS compared to providers with less HIV experience/expertise or generalists.
   4. Utilization. CHBRP is unable to estimate enrollee utilization of designating an HIV specialist as a primary care provider due to limitations in health claims data;
   5. Impact on expenditures. Unknown; and,
   6. Public health. There appear to be more than 900 HIV specialists (some of whom are credentialed by the American Academy of HIV Medicine and many more who likely meet the AB 1534 definition who treat some of the persons living with HIV/AIDS in California. However, the use of primary care services provided by HIV specialists and the resulting health outcomes is unknown.
3. HIV/AIDS background. According to the Centers for Disease Control and Prevention, in 2015, an estimated 39,393 people in the United States were diagnosed with HIV, the virus that causes AIDS. In 2015, an estimated 4,720 adults and adolescents were diagnosed with HIV in California. California ranked 2nd among the 50 states in the number of HIV diagnoses in 2015. The California Office of AIDS maintains an HIV/AIDS surveillance system that records the prevalence and incidence of HIV diagnoses and the prevalence of AIDS cases (CDPH, 2016). The most recent data available from 2014 indicate that 126,241 people in California are living with HIV/AIDS. According to CHBRP, HIV providers may be physicians, physician assistants, or nurse practitioners and may be credentialed as an HIV Specialist™ by the American Academy of HIV Medicine (AAHIVM). Persons living with HIV may see an HIV specialist who is in private practice, or practices at an HIV clinic, general healthcare clinic, or a community health center.
   
4. Prior legislation. AB 2372 would have allowed HIV specialists, as defined, to be included as an eligible primary care provider, if the provider requests primary care provider status and meets the health care service plan’s eligibility criteria for all specialists seeking primary care provider status, that access to HIV specialists is subject to regulations that govern network adequacy, consistent with the specialty designation. AB 2372 was held in the Assembly Appropriations Committee.

AB 1954 (Burke, Chapter 495, Statutes of 2016) establishes the Direct Access to Reproductive Health Care Act, which prohibits health care service plans (health plans) and health insurers from requiring an enrollee to receive a referral prior to receiving coverage or services for reproductive and sexual health care.

AB 1181 (Escutia, Chapter 31, Statutes of 1998) establishes a system for health plans and providers to follow to provide enrollees with "standing referrals" to specialists treating various diseases and conditions.

AB 2493 (Speier, Chapter 759, Statutes of 1994) requires health care service plans, non-profit hospital service plans, and disability insurance policies that provide hospital, medical care or surgical coverage to include obstetrician-gynecologists as primary care providers, provided they meet the insurer's written eligibility criteria for all specialists seeking primary care physician status.

AB 12 (Davis, Chapter 22, Statutes of 1998) requires health care service plans and disability insurers to allow enrollees to seek obstetrical and gynecological physician services directly from either an obstetrician and gynecologist or a family practice physician.

1. Support. The AIDS Healthcare Foundation (AHF) writes that because plans do not always recognize HIV specialist’s as primary care physicians, there are too many times when the HIV specialist cannot order tests, make referrals to other specialists or any of the other services a primary care physician can provide. In addition, a patient with a non-HIV specialist primary care physician runs the risk that the primary care physician does not have the expertise necessary to know that some routine care decisions become complicated when they impact a person with HIV. This situation makes delivery of care more uncertain, interrupts the provision of care, puts additional demands on the patient and ultimately costs more in an unnecessary duplication of services. According to AHF, unlike a previous version of this bill, AB 1534 does not impact health plans’ network adequacy obligations and it does not insert HIV specialists into network adequacy considerations. The focus of this bill is discretely on the ability of a patient to select an HIV specialist to act as the patient’s primary care physician. Beyond AIDS writes a clinic that provides both HIV specialty care and primary care can currently only bill for the services of such an all-purpose provider as a primary care provider, because the combination of that with being an HIV specialist has not been recognized. Alternatively, the HIV care can be billed, but not the time-consuming and essential primary care. This is a disincentive to integrated care, and AB 1534 will resolve the problem. The California Chapters of the American College of Physicians views this bill as a critical measure to help ensure HIV-infected patients have providers that meet their unique health care needs. The California Academy of PAs writes that research shows that patients with HIV have better health outcomes, as well as an increase in cost-effective and coordinated care when a clinician with experience and expertise in HIV manages their condition. HIV specialists receive additional medical education and experience in order to provide comprehensive primary health care services to patients with HIV.
   
2. Opposition. The DMHC has strong concerns that designating a particular disease specialist as a primary care provider in statute set a precedent for other specialty types to follow suit, potentially harming the managed care model that relies on primary care physicians. In addition, DMHC writes that there is already a mechanism (termed “standing referrals”) to permit specialists to act as primary care physicians for health plan enrollees, and specifically references HIV specialists. Furthermore, regulations already require that standing referrals for HIV patients be made to qualified HIV specialist physicians and health plans must demonstrate network adequacy standards. Designating HIV specialist physicians and non-physicians as primary care providers could potentially reduce the number of primary care physicians in the network. Finally, DMHC is unaware of any demonstrated problem related to access to qualified HIV specialists.
   
3. Policy comments/questions.
   1. The problem this bill is trying to resolve is not entirely clear. The author and sponsor indicate that the intent is to ensure HIV specialists can be designated as primary care providers. According to the CHBRP survey, most carriers already allow HIV specialists to act as primary care providers. This is likely because health care service plans are already required to allow standing referrals to specialists, including HIV specialists. The law specifically authorizes the specialist to provide health care services in the same manner as the enrollee’s primary care physician; subject to the terms of a treatment plan (if a treatment plan is deemed necessary). Health insurance policies allow direct access to all providers without first receiving a referral from a primary care physician. Proponents seem to want to ensure that the HIV specialist has ability to control referrals, which may be limited under existing law as an HIV specialist with a standing referral still may have to coordinate with another primary care physician and function under a treatment plan. One of the proponents suggests that this bill will resolve payment issues. It is not clear how or if this policy change will affect reimbursement.
      
   2. Should this bill include parallel provisions in the Insurance Code? While primary care physicians are not “gatekeepers” in PPOs as they are in HMOs, there are requirements for both HMOs and PPOs to have adequate ratios of primary care “physicians” not “providers” in their networks compared to enrollees/insureds. If HIV specialists are to be considered primary care providers under the Health and Safety Code, the committee may also wish to incorporate similar provisions in the Insurance Code, which has been the Legislature’s preference and practice in recent history (i.e., the OBGYN provisions also appear in the Insurance Code as well as direct access to reproductive health services). However, it is not clear what impact this bill could have on these ratios.
      
      Relatedly, Covered California (California’s health benefit exchange) requires qualified health plan issuers (which includes PPOs) to ensure that all Covered California enrollees either select or be provisionally assigned to a primary care “clinician” by January 1, 2017 or within 60 days of effectuation into the plan, whichever is sooner. If an enrollee does not select a primary care clinician, the issuer must provisionally assign the enrollee to a primary care clinician, inform the enrollee of the assignment and provide the enrollee with an opportunity to select a different primary care clinician.
      
   3. Will other specialists want to have this same option? If existing law related to standing referrals, which applies broadly to many types of specialists, is insufficient for HIV specialists, will other specialists also seek this option to be considered primary care providers? What impact would this have on the HMO model?

SUPPORT AND OPPOSITION:

Support: AIDS Healthcare Foundation

Beyond AIDS

California Academy of PAs

California Chapters of American College of Physicians

CaliforniaHealth + Advocates

National Association of Social Workers

Oppose: Department of Managed Health Care

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1534

Author:(Nazarian)

As Amended Ver:April 6, 2017

Majority vote

SUMMARY: Designates a human immunodeficiency virus (HIV) specialist as an eligible primary care provider (PCP) for a health care service plan (health plan) policy that is issued, amended, or renewed on or after January 1, 2018, and that provides hospital, medical or surgical coverage, provided that the provider requests provider status and meets the health plan's eligibility criteria for all specialists seeking PCP status.

FISCAL EFFECT: According to the Assembly Appropriations Committee, costs to the Department of Managed Health Care of approximately $160,000 in 2017-18, approximately $100,000 in 2018-19, and approximately $180,000 for 2019-20 and annually thereafter (Managed Care Fund). One-time costs are to amend existing regulations and review plan documents. Ongoing costs are to review filings to ensure compliance and to investigate and enforce the law in instances of non-compliance.

COMMENTS: According to the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. Given the intricate nature of the virus, something as simple as a routine flu shot could cause serious complications for an HIV patient if administered by a provider without the understanding of the patient's status. By allowing HIV specialists to serve as a PCP for their patients, this bill eliminates administrative impediments, such as ordering tests or making additional referrals, and maintains continuity of care for a disease that has become manageable.

HIV providers may be physicians, nurse practitioners, or physician assistants and may be credentialed as an HIV specialist by the American Academy of HIV Medicine (AAHIVM). Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing. Persons living with HIV (PLWH) may see an HIV specialist who is in private practice, or practices at an HIV clinic, general healthcare clinic, or a community health center. Additionally, PLWH (especially those who are underinsured or uninsured, and thus not subject to this bill) may seek care at the clinics funded through the Ryan White CARE Act. These clinics were foundational to the control of the AIDS epidemic in the early 1990s through their provision of HIV treatment and management.

California Health Benefits Review Program (CHBRP) analysis. According to CHBRP, this bill does not alter the benefit coverage of 23.4 million enrollees subject to this bill, but increases enrollees' choice of PCPs, as the mandate would increase the number of qualifying HIV specialists that could be designated as PCPs. CHBRP assumes this bill would not impact current PCPs who are HIV specialists, but would impact HIV specialists such as board certified infectious disease specialists, nurse practitioners, and physician assistants, who meet the criteria for an HIV specialist to seek PCP status. According to the responses to the CHBRP carrier survey, most health plans currently allow HIV specialists to act as PCPs if the HIV specialist meets the health plan's PCP requirements. There appears to be more than 900 HIV specialists (some of whom are credentialed by AAHIVM and many more who likely meet the AB 1534 specialist definition) who treat some of the 126,000 PLWH in California. However, the use of primary care services provided by HIV specialists and the resulting health outcomes for PLWH is unknown.

According to CHBRP, the HIV specialist designation means adherence to the published criteria established by AAHIVM; the HIV Medicine Association; or, a provider who is contracted to provide outpatient medical care under the federal Ryan White CARE Act. HIV providers may be physicians, physician assistants, or nurse practitioners and may be credentialed as an HIV specialist by the AAHIVM.

AIDS Healthcare Foundation, sponsor of this bill, cites a recent report from the California HIV/AIDS Research Program at the University of California acknowledging that this bill has the potential to increase preventive care and screening for PLWH. The California Chapter of the American College of Physicians states that this bill would help HIV-infected patients gain access to comprehensive care from specialists that fully understand HIV therapies, co-morbidities, and more.

There is no registered opposition to this bill.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 0000790

Date of Hearing: May 17, 2017

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 1534

Author:(Nazarian) – As Amended Ver:April 6, 2017

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

SUMMARY:

This bill requires all comprehensive health plans to allow an HIV specialist who is a physician, physician assistant, or nurse practitioner to be eligible as a primary care provider, if the provider requests as much, and meets the plan's criteria for all specialists seeking primary care provider status.

FISCAL EFFECT:

Costs to the Department of Managed Health Care of approximately $160,000 in 2017-18, approximately $100,000 in 2018-19, and approximately $180,000 for 2019-20 and annually thereafter (Managed Care Fund). One-time costs are to amend existing regulations and review plan documents. Ongoing costs are to review filings to ensure compliance and to investigate and enforce the law in instances of non-compliance.

According to the DMHC, this bill potentially conflicts with the access standards set forth in Knox-Keene Act regulations because the bill would permit non-physicians to serve as primary care “providers.”  Access and ratio standards in regulations are keyed to primary care “physicians,” and passage of this bill will require the DMHC to reevaluate and potentially revise these regulations. Part of the cost listed above reflects this workload. 

COMMENTS:

1. Purpose. According to the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. By allowing HIV specialists to serve as a primary care provider, this bill eliminates administrative impediments to ordering tests or making additional referrals, and maintains continuity of care for a disease that has become manageable.
2. Background. HIV providers may be physicians, nurse practitioners, or physician assistants and may be credentialed as an HIV specialist by the American Academy of HIV Medicine. Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing, but pharmacists would not be eligible primary care providers under the bill. According to the California Health Benefits Review Program, there are about 900 of these providers statewide. Other providers may care for people with HIV, including infectious disease specialists and primary care providers.
3. Support. AIDS Healthcare Foundation, sponsor of this bill, cites a recent report from the California HIV/AIDS Research Program at the University of California acknowledging that this bill has the potential to increase preventive care and screening for people living with HIV/AIDS. The California Chapter of the American College of Physicians states that this bill would help HIV-infected patients gain access to comprehensive care from specialists that fully understand HIV therapies, co-morbidities, and more.
4. Prior Legislation. AB 2372 (Burke), of the 2015-16 Legislative Session, was similar to this bill, but also included provisions that required access to HIV specialists to be subject to regulations that govern network adequacy, consistent with the specialty designation. AB 2372 was held on this committee's Suspense File.

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

Date of Hearing: April 25, 2017

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1534

Author:(Nazarian) – As Amended Ver:April 6, 2017

SUBJECT: Health care coverage: HIV specialists.

SUMMARY: Designates a human immunodeficiency virus (HIV) specialist as an eligible primary care provider (PCP). Specifically, this bill:

1. Requires a health care service plan (health plan) policy that is issued, amended, or renewed on or after January 1, 2018, that provides hospital, medical or surgical coverage, to permit an HIV specialist to be an eligible PCP, provided that the provider requests provider status and meets the health plan’s eligibility criteria for all specialists seeking PCP status.
2. Defines a PCP as a physician, or a non-physician provider as defined in existing law and has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. Provides that this means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychological issues.
3. Defines an HIV specialist as a physician, physician assistant, or a nurse practitioner who meets the criteria for an HIV specialist as published by the American Academy of HIV Medicine (AAHIVM) or the HIV Medicine Association, or who is contracted to provide outpatient medical care under the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990, as specified.

EXISTING LAW:

1. Regulates health plans under the Knox-Keene Health Care Service Plan Act of 1975 through the Department of Managed Health Care (DMHC).
2. Requires every health plan contract that provides hospital, medical, or surgical coverage, that is issued, amended, delivered, or renewed in this state, to include obstetrician-gynecologists (OB/GYNs) as eligible primary care physicians, provided they meet the plan’s eligibility criteria for all specialists seeking primary care physician status.
3. Defines a primary care physician as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. Allows the primary care physician to be either a physician who has limited his or her practice of medicine to general practice or who is a board certified or board eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. Includes in this definition, a nonphysician medical practitioner, who is supervised by a primary care physician, and has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care.
4. Defines a specialist as a physician who is board certified or board eligible in the specialty of medical care provided.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, Californians living with HIV should have access to care from physicians and other providers with the training and experience required to meet their complex needs. Given the intricate nature of the virus, something as simple as a routine flu shot could cause serious complications for an HIV patient if administered by a provider without the understanding of the patient’s status. By allowing HIV specialists to serve as a PCP for their patients, this bill eliminates administrative impediments, such as ordering tests or making additional referrals, and maintains continuity of care for a disease that has become manageable.
2. BACKGROUND. HIV attacks the body’s immune system, specifically the CD4 cells (T cells) that fight infections, thus greatly increasing the risk of opportunistic diseases. If left untreated, HIV infection can lead to acquired immunodeficiency syndrome (AIDS). Due to advances in drug treatment, HIV/AIDS has progressed from an acute illness with a high mortality rate to a manageable chronic illness where patients achieve close to normal life expectancy.
   
   HIV providers may be physicians, nurse practitioners, or physician assistants and may be credentialed as an HIV specialist by the AAHIVM. Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing. Persons living with HIV (PLWH) may see an HIV specialist who is in private practice, or practices at an HIV clinic, general healthcare clinic, or a community health center. Additionally, PLWH (especially those who are underinsured or uninsured, and thus not subject to this bill) may seek care at the clinics funded through the Ryan White CARE Act. These clinics were foundational to the control of the AIDS epidemic in the early 1990s through their provision of HIV treatment and management.
   1. California Health Benefits Review Program (CHBRP) analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes of 2015, added an impact assessment on essential health benefits (EHBs), and legislation that impacts health insurance benefit designs, cost sharing, premiums, and other health insurance topics.  In its analysis of this bill, CHBRP found the following:
      1. Enrollees Covered. According to the responses to the CHBRP carrier survey, most health plans and policies, including Medi-Cal Managed Care Plans and plans accessed through CalPERS, allow HIV specialists to act as PCPs if the HIV specialist meets the health plan’s PCP requirements.
      2. Benefit Coverage. This bill does not alter the benefit coverage of 23.4 million enrollees subject to this bill, but increases enrollees’ choice of PCPs, as the mandate would increase the number of qualifying HIV specialists that could be designated as PCPs. CHBRP assumes this bill would not impact current PCPs who are HIV specialists, but would impact HIV specialists such as boardcertified infectious disease specialists, nurse practitioners, and physician assistants, who meet the criteria for an HIV specialist to seek PCP status. According to the responses to the CHBRP carrier survey, most health plans currently allow HIV specialists to act as PCPs if the HIV specialist meets the health plan’s PCP requirements.
      3. Utilization. CHBRP is unable to quantify the utilization impact of the proposed bill, due to limitations in health insurance claims data. “HIV specialists” are not specifically identified in common claims data.
      4. Impact on expenditures. CHBRP is unable to estimate changes in unit cost for PCP services provided by an HIV specialist as a PCP. However, the unit cost for PCP services is unlikely to change postmandate since an HIV specialist will bill according to diagnostic and procedure codes for the corresponding PCP services. According to the carrier survey, when an HIV specialist serves as a PCP they are reimbursed the same as any other PCPs under the fee-for-service arrangement; there is also no difference in contracted provider rates for those health plans under the capitation arrangement.
      5. EHBs. This bill allows certain providers to be designated as PCPs, expanding the eligibility to provide primary care services, but does not mandate coverage of additional benefits. Therefore, the provisions of this bill do not appear to exceed EHBs, and would not trigger the ACA requirement that the state defray the cost of additional benefit coverage for enrollees in qualified health plans in Covered California.
      6. Medical effectiveness. CHBRP had previously conducted thorough literature searches on this topic in 2016 for AB 2372 (Burke) of 2016. While some studies may refer to HIV specialists, as defined in this bill, it is hard to disentangle the term HIV specialist, HIV provider, HIV primary care physician, and infectious disease physician. Two recent studies provide limited evidence that providers with more experience/expertise in HIV provide equivalent or better primary care screening services to PLWH compared to providers with less HIV experience/expertise or generalists.
      7. Public health. There appears to be more than 900 HIV specialists (some of whom are credentialed by AAHIVM and many more who likely meet the AB 1534 specialist definition) who treat some of the 126,000 PLWH in California. However, the use of primary care services provided by HIV specialists and the resulting health outcomes for PLWH is unknown.
   2. Definitions of Specialty Physician. According to CHBRP, the HIV specialist designation means adherence to the published criteria established by AAHIVM; the HIV Medicine Association; or, a provider who is contracted to provide outpatient medical care under the federal Ryan White CARE Act. HIV providers may be physicians, physician assistants, or nurse practitioners and may be credentialed as an HIV specialist by the AAHIVM.

Primary Care Physicians. In California, primary care physicians are defined as a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referral for specialist care. A primary care physician is either a physician who has limited his or her practice of medicine to general practice or who is a board certified or board eligible internist, pediatrician, OB/GYN, or family practitioner. Specialists are defined as a physician who is board certified or board eligible in the specialty of medical care provided. Additionally, regulations require health plans to provide accessibility to all medically necessary specialists and designate specialists as allergy, anesthesiology, dermatology, cardiology and other internal medicine specialists, neonatology, neurology, oncology, ophthalmology, orthopedics, pathology, psychiatry, radiology, surgeries, otolaryngology, urology, and others designated as appropriate. Existing law requires health plans to make standing referrals to specialists when medically necessary. Existing law specifically recognizes HIV/AIDS as a specialty as defined by the federal government or a national voluntary health organization.

• 1. Similar Requirements in Other States. Two other states have regulations regarding the definition of an HIV specialist similar to those proposed in this bill. New York requires that managed care organizations provide treatment for those on HIV Special Needs Plans by HIV specialists. Maryland, in its administrative code, requires that health insurers cover treatment by HIV/AIDS specialists who must either have an American Board of Medical Specialties certification in infectious diseases, or have performed a minimum amount of HIV care and completed an HIV education requirement, which can be filled by passing the AAHIVM credentialing exam.

1. SUPPORT. AIDS Healthcare Foundation, sponsor of this bill, cites a recent report from the California HIV/AIDS Research Program at the University of California acknowledging that this bill has the potential to increase preventive care and screening for PLWH. The California Chapter of the American College of Physicians states that this bill would help HIV-infected patients gain access to comprehensive care from specialists that fully understand HIV therapies, co-morbidities, and more.
2. PREVIOUS LEGISLATION.
   1. AB 2372 (Burke) of 2016 would have designated an HIV specialist as an eligible PCP and includes provisions that access to HIV specialists is subject to regulations that govern network adequacy, consistent with the specialty designation. AB 2372 was held in Assembly Appropriations Committee.
   2. AB 2168 (Gallegos), Chapter 426, Statutes of 2000, requires standing referrals to an HIV specialist.

REGISTERED SUPPORT / OPPOSITION:

Support

AIDS Healthcare Foundation (sponsor)

Beyond AIDS

California Academy of PAs

California Chapters of the American College of Physicians

California Health+ Advocates

National Association of Social Workers

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH /