AB 1591: Medi-Cal: federally qualified health centers and rural health centers: licensed professional clinical counselor.
- Session Year: 2017-2018
- House: Assembly
- Latest Version Date: 2017-09-15
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that federally qualified health center (FQHC) services and rural health clinic (RHC) services, as defined, are covered benefits under the Medi-Cal program, to be reimbursed, to the extent that federal financial participation is obtained, to providers on a per-visit basis. Visit is defined as a face-to-face encounter between a patient of an FQHC or RHC and specified health care professionals. Existing law allows an FQHC or RHC to apply for an adjustment to its per-visit rate based on a change in the scope of services it provides.
This bill would, no later than July 1, 2018, include a licensed professional clinical counselor within those health care professionals covered under that definition. The bill would require an FQHC or RHC that currently includes the cost of the services of a licensed professional clinical counselor for the purposes of establishing its FQHC or RHC rate to apply to the department for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, would require the FQHC or RHC to bill for these services as a separate visit, as specified. The bill would require an FQHC or RHC that does not provide the services of a licensed professional clinical counselor, and later elects to add this service and bill these services as a separate visit, to process the addition of these services as a change in scope of service.
This bill would incorporate additional changes to Section 14132.100 of the Welfare and Institutions Code proposed by SB 323 to be operative only if this bill and SB 323 are enacted and this bill is enacted last.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that federally qualified health center (FQHC) services and rural health clinic (RHC) services, as defined, are covered benefits under the Medi-Cal program, to be reimbursed, to the extent that federal financial participation is obtained, to providers on a per-visit basis. Visit is defined as a face-to-face encounter between a patient of an FQHC or RHC and specified health care professionals. Existing law allows an FQHC or RHC to apply for an adjustment to its per-visit rate based on a change in the scope of services it provides.
This bill would, no later than July 1, 2018, include a licensed professional clinical counselor within those health care professionals covered under that definition. The bill would require an FQHC or RHC that currently includes the cost of the services of a licensed professional clinical counselor for the purposes of establishing its FQHC or RHC rate to apply to the department for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, would require the FQHC or RHC to bill for these services as a separate visit, as specified. The bill would require an FQHC or RHC that does not provide the services of a licensed professional clinical counselor, and later elects to add this service and bill these services as a separate visit, to process the addition of these services as a change in scope of service.
This bill would incorporate additional changes to Section 14132.100 of the Welfare and Institutions Code proposed by SB 323 to be operative only if this bill and SB 323 are enacted and this bill is enacted last.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that federally qualified health center (FQHC) services and rural health clinic (RHC) services, as defined, are covered benefits under the Medi-Cal program, to be reimbursed, to the extent that federal financial participation is obtained, to providers on a per-visit basis. Visit is defined as a face-to-face encounter between a patient of an FQHC or RHC and specified health care professionals. Existing law allows an FQHC or RHC to apply for an adjustment to its per-visit rate based on a change in the scope of services it provides.
This bill would would, no later than July 1, 2018, include a licensed professional clinical counselor within those health care professionals covered under that definition. The bill would require an FQHC or RHC that currently includes the cost of the services of a licensed professional clinical counselor for the purposes of establishing its FQHC or RHC rate to apply to the department for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, would require the FQHC or RHC to bill for these services as a separate visit, as specified. The bill would require an FQHC or RHC that does not provide the services of a licensed professional clinical counselor, and later elects to add this service and bill these services as a separate visit, to process the addition of these services as a change in scope of service.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that federally qualified health center (FQHC) services and rural health clinic (RHC) services, as defined, are covered benefits under the Medi-Cal program, to be reimbursed, to the extent that federal financial participation is obtained, to providers on a per-visit basis. Visit is defined as a face-to-face encounter between a patient of an FQHC or RHC and specified health care professionals. Existing law allows an FQHC or RHC to apply for an adjustment to its per-visit rate based on a change in the scope of services it provides.
This bill would include a licensed professional clinical counselor within those health care professionals covered under that definition. The bill would require an FQHC or RHC that currently includes the cost of the services of a licensed professional clinical counselor for the purposes of establishing its FQHC or RHC rate to apply to the department for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, would require the FQHC or RHC to bill for these services as a separate visit, as specified. The bill would require an FQHC or RHC that does not provide the services of a licensed professional clinical counselor, and later elects to add this service and bill these services as a separate visit, to process the addition of these services as a change in scope of service.
Existing state and federal law regulates the activities of consumer credit reporting agencies. Existing state law, the Consumer Credit Reporting Agencies Act, codifies legislative findings and declarations in this regard. The act states that its purpose is to require consumer credit reporting agencies to adopt reasonable procedures for meeting the needs of commerce for consumer credit, personnel, insurance, hiring of a dwelling unit, and other information in a manner that is fair and equitable to the consumer, as specified.This bill would make nonsubstantive changes to these provisions.Existing state and federal law regulates the activities of consumer credit reporting agencies. Existing state law, the Consumer Credit Reporting Agencies Act, codifies legislative findings and declarations in this regard. The act states that its purpose is to require consumer credit reporting agencies to adopt reasonable procedures for meeting the needs of commerce for consumer credit, personnel, insurance, hiring of a dwelling unit, and other information in a manner that is fair and equitable to the consumer, as specified.
This bill would make nonsubstantive changes to these provisions.
(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)No change in costs shall, in and of itself, be considered a scope-of-service change unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, physician shall be interpreted in a manner consistent with the Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a marriage and family therapist, or a licensed professional clinical counselor.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals, licensed professional clinical counselors, or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, licensed professional clinical counselor, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist or a licensed professional clinical counselor, as applicable.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)An entity that first qualifies as an FQHC or RHC in the year 2001 or later, a newly licensed facility at a new location added to an existing FQHC or RHC, and any entity that is an existing FQHC or RHC that is relocated to a new site shall each have its reimbursement rate established in accordance with one of the following methods, as selected by the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(2)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(3)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, or in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, shall be billed by and reimbursed at the same rate as the FQHC or RHC establishing the intermittent clinic site or the mobile unit, subject to the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(m)The department shall, no later than March 30, 2008, promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(n)The department shall implement this section only to the extent that federal financial participation is obtained.
SEC. 1.5.Section 14132.100 of the Welfare and Institutions Code, as amended by Section 50 of Chapter 52 of the Statutes of 2017, is amended to read:14132.100.(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)No change in costs shall, in and of itself, be considered a scope-of-service change unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, physician shall be interpreted in a manner consistent with the Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a marriage and family therapist, or a licensed professional clinical counselor.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals, licensed professional clinical counselors, or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, licensed professional clinical counselor, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist or a licensed professional clinical counselor, as applicable.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)An entity that first qualifies as an FQHC or RHC in the year 2001 or later, a newly licensed facility at a new location added to an existing FQHC or RHC, and any entity that is an existing FQHC or RHC that is relocated to a new site shall each have its reimbursement rate established in accordance with one of the following methods, as selected by the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(2)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(3)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, or in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, shall be billed by and reimbursed at the same rate as the FQHC or RHC establishing the intermittent clinic site or the mobile unit, subject to the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2)(A)For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing Drug Medi-Cal services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B)An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).
(D)Within 90 days of receipt of the request for a scope-in-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A)In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B)In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6)For purposes of this subdivision, the following definitions shall apply:
(A)Drug Medi-Cal organized delivery system or DMC-ODS means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B)Special Terms and Conditions shall have the same meaning as set forth in subdivision (o) of Section 14184.10.
(m)Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal beneficiaries as part of the mental health plans network.
(2)(A)For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B)An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D)Within 90 days of receipt of the request for a scope-in-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(n)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(o)The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(p)The department shall implement this section only to the extent that federal financial participation is available.
(q)Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific subdivisions (l) and (m) by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of subdivisions (l) and (m), including all of the following:
(1)Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days prior to the meeting described in paragraph (2).
(2)Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.
(3)Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4)Providing at least 60 days advance notice of the effective date of the proposed action or change.
SEC. 2.Section 1.5 of this bill incorporates amendments to Section 14132.100 of the Welfare and Institutions Code proposed by both this bill and Senate Bill 323. That section shall only become operative if (1) both bills are enacted and become effective on or before January 1, 2018, (2) each bill amends Section 14132.100 of the Welfare and Institutions Code, and (3) this bill is enacted after Senate Bill 323, in which case Section 1 of this bill shall not become operative.
(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)No change in costs shall, in and of itself, be considered a scope-of-service change unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, physician shall be interpreted in a manner consistent with the Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a marriage and family therapist, or a licensed professional clinical counselor.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals, licensed professional clinical counselors, or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, licensed professional clinical counselor, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist or a licensed professional clinical counselor, as applicable.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)An entity that first qualifies as an FQHC or RHC in the year 2001 or later, a newly licensed facility at a new location added to an existing FQHC or RHC, and any entity that is an existing FQHC or RHC that is relocated to a new site shall each have its reimbursement rate established in accordance with one of the following methods, as selected by the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(2)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(3)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, or in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, shall be billed by and reimbursed at the same rate as the FQHC or RHC establishing the intermittent clinic site or the mobile unit, subject to the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(m)The department shall, no later than March 30, 2008, promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(n)The department shall implement this section only to the extent that federal financial participation is obtained.
SEC. 1.5.Section 14132.100 of the Welfare and Institutions Code, as amended by Section 50 of Chapter 52 of the Statutes of 2017, is amended to read:14132.100.(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)No change in costs shall, in and of itself, be considered a scope-of-service change unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, physician shall be interpreted in a manner consistent with the Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist. therapist, or a licensed professional clinical counselor.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals professionals, licensed professional clinical counselors, or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, licensed professional clinical counselor, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist. therapist or a licensed professional clinical counselor, as applicable.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity (as entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)An entity that first qualifies as an FQHC or RHC in the year 2001 or later, a newly licensed facility at a new location added to an existing FQHC or RHC, and any entity that is an existing FQHC or RHC that is relocated to a new site shall each have its reimbursement rate established in accordance with one of the following methods, as selected by the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(2)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(3)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, or in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, shall be billed by and reimbursed at the same rate as the FQHC or RHC establishing the intermittent clinic site or the mobile unit, subject to the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2)(A)For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing Drug Medi-Cal services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B)An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).
(D)Within 90 days of receipt of the request for a scope-in-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A)In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B)In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6)For purposes of this subdivision, the following definitions shall apply:
(A)Drug Medi-Cal organized delivery system or DMC-ODS means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B)Special Terms and Conditions shall have the same meaning as set forth in subdivision (o) of Section 14184.10.
(m)Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal beneficiaries as part of the mental health plans network.
(2)(A)For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B)An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D)Within 90 days of receipt of the request for a scope-in-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(l)(n)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(m)(o)The department shall, no later than March 30, 2008, shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(n)(p)The department shall implement this section only to the extent that federal financial participation is obtained. available.
(q)Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific subdivisions (l) and (m) by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of subdivisions (l) and (m), including all of the following:
(1)Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days prior to the meeting described in paragraph (2).
(2)Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.
(3)Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4)Providing at least 60 days advance notice of the effective date of the proposed action or change.
SEC. 2.Section 1.5 of this bill incorporates amendments to Section 14132.100 of the Welfare and Institutions Code proposed by both this bill and Senate Bill 323. That section shall only become operative if (1) both bills are enacted and become effective on or before January 1, 2018, (2) each bill amends Section 14132.100 of the Welfare and Institutions Code, and (3) this bill is enacted after Senate Bill 323, in which case Section 1 of this bill shall not become operative.
(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)No change in costs shall, in and of itself, be considered a scope-of-service change unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, physician shall be interpreted in a manner consistent with the Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist. therapist, or a licensed professional clinical counselor.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals professionals, licensed professional clinical counselors, or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, licensed professional clinical counselor, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist. therapist or a licensed professional clinical counselor, as applicable.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity (as entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)An entity that first qualifies as an FQHC or RHC in the year 2001 or later, a newly licensed facility at a new location added to an existing FQHC or RHC, and any entity that is an existing FQHC or RHC that is relocated to a new site shall each have its reimbursement rate established in accordance with one of the following methods, as selected by the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(2)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(3)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, or in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, shall be billed by and reimbursed at the same rate as the FQHC or RHC establishing the intermittent clinic site or the mobile unit, subject to the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(m)The department shall, no later than March 30, 2008, promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(n)The department shall implement this section only to the extent that federal financial participation is obtained.
SECTION 1.Section 14132.100 of the Welfare and Institutions Code is amended to read:14132.100.(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.(B)A change in service due to amended regulatory requirements or rules.(C)A change in service resulting from relocating or remodeling an FQHC or RHC.(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).(3)No change in costs shall, in and of itself, be considered a scope-of-service change unless all of the following apply:(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.(4)A request shall be submitted for each affected year.(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.(6)The department shall notify the provider of the departments discretionary decision in writing.(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, physician shall be interpreted in a manner consistent with the Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist.(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals, licensed professional clinical counselors, or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, licensed professional clinical counselor services, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity (as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.(i)(1)An entity that first qualifies as an FQHC or RHC in the year 2001 or later, a newly licensed facility at a new location added to an existing FQHC or RHC, and any entity that is an existing FQHC or RHC that is relocated to a new site shall each have its reimbursement rate established in accordance with one of the following methods, as selected by the FQHC or RHC:(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.(2)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.(3)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.(j)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, or in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, shall be billed by and reimbursed at the same rate as the FQHC or RHC establishing the intermittent clinic site or the mobile unit, subject to the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).(l)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.(m)The department shall, no later than March 30, 2008, promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.(n)The department shall implement this section only to the extent that federal financial participation is obtained.(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)No change in costs shall, in and of itself, be considered a scope-of-service change unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, physician shall be interpreted in a manner consistent with the Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals professionals, licensed professional clinical counselors, or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, a licensed professional clinical counselor, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, licensed professional clinical counselor services, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity (as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)An entity that first qualifies as an FQHC or RHC in the year 2001 or later, a newly licensed facility at a new location added to an existing FQHC or RHC, and any entity that is an existing FQHC or RHC that is relocated to a new site shall each have its reimbursement rate established in accordance with one of the following methods, as selected by the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(2)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(3)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, or in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, shall be billed by and reimbursed at the same rate as the FQHC or RHC establishing the intermittent clinic site or the mobile unit, subject to the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(m)The department shall, no later than March 30, 2008, promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(n)The department shall implement this section only to the extent that federal financial participation is obtained.
SECTION 1.Section 1785.1 of the Civil Code is amended to read:1785.1.The Legislature finds and declares as follows:(a)An elaborate mechanism has been developed for investigating and evaluating the credit worthiness, credit standing, credit capacity, and general reputation of consumers.(b)Consumer credit reporting agencies have assumed a vital role in assembling and evaluating consumer credit and other information on consumers.(c)There is a need to insure that consumer credit reporting agencies exercise their grave responsibilities with fairness, impartiality, and a respect for the consumers right to privacy.(d)It is the purpose of this title to require that consumer credit reporting agencies adopt reasonable procedures for meeting the needs of commerce for consumer credit, personnel, insurance, hiring of a dwelling unit, and other information in a manner that is fair and equitable to the consumer, with regard to the confidentiality, accuracy, relevancy, and proper utilization of the information in accordance with the requirements of this title.(e)The Legislature hereby intends to regulate consumer credit reporting agencies pursuant to this title in a manner that will best protect the interests of the people of the State of California.(f)The extension of credit is a privilege and not a right. Nothing in this title shall preclude a creditor from denying credit to any applicant providing the denial is based on factors not inconsistent with present law.(g)Any clauses in contracts that prohibit any action required by this title are not in the public interest and shall be considered unenforceable. This shall not invalidate the other terms of the contract.The Legislature finds and declares as follows:
(a)An elaborate mechanism has been developed for investigating and evaluating the credit worthiness, credit standing, credit capacity, and general reputation of consumers.
(b)Consumer credit reporting agencies have assumed a vital role in assembling and evaluating consumer credit and other information on consumers.
(c)There is a need to insure that consumer credit reporting agencies exercise their grave responsibilities with fairness, impartiality, and a respect for the consumers right to privacy.
(d)It is the purpose of this title to require that consumer credit reporting agencies adopt reasonable procedures for meeting the needs of commerce for consumer credit, personnel, insurance, hiring of a dwelling unit, and other information in a manner which that is fair and equitable to the consumer, with regard to the confidentiality, accuracy, relevancy, and proper utilization of such the information in accordance with the requirements of this title.
(e)The Legislature hereby intends to regulate consumer credit reporting agencies pursuant to this title in a manner which that will best protect the interests of the people of the State of California.
(f)The extension of credit is a privilege and not a right. Nothing in this title shall preclude a creditor from denying credit to any applicant providing such the denial is based on factors not inconsistent with present law.
(g)Any clauses in contracts which that prohibit any action required by this title are not in the public interest and shall be considered unenforceable. This shall not invalidate the other terms of such a the contract.
|
Date
|
Status
|
|---|---|
| Jan 12, 2018 | Stricken from file. |
| Jan 3, 2018 | Consideration of Governor's veto pending. |
| Oct 7, 2017 | Vetoed by Governor. |
| Sep 25, 2017 | Enrolled and presented to the Governor at 12 p.m. |
| Sep 14, 2017 | Senate amendments concurred in. To Engrossing and Enrolling. |
| Sep 14, 2017 | Ordered to special consent calendar. |
| Sep 14, 2017 | Read third time. Passed. Ordered to the Assembly. |
| Sep 12, 2017 | Ordered to special consent calendar. |
| Sep 11, 2017 | Read second time. Ordered to third reading. |
| Sep 8, 2017 | Read third time and amended. Ordered to second reading. |
| Sep 5, 2017 | Read second time. Ordered to third reading. |
| Sep 1, 2017 | From committee: Amend, and do pass as amended. (Ayes 7. Noes 0.) (September 1). |
| Jul 10, 2017 | In committee: Referred to APPR. suspense file. |
| Jun 14, 2017 | From committee: Do pass and re-refer to Com. on APPR. with recommendation: To Consent Calendar. (Ayes 9. Noes 0.) (June 14). Re-referred to Com. on APPR. |
| Jun 8, 2017 | Referred to Com. on HEALTH. |
| May 30, 2017 | In Senate. Read first time. To Com. on RLS. for assignment. |
| May 30, 2017 | Read third time. Passed. Ordered to the Senate. (Ayes 76. Noes 0. Page 1846.) |
| May 26, 2017 | From committee: Do pass. (Ayes 17. Noes 0.) (May 26). |
| May 3, 2017 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| Apr 19, 2017 | From committee: Do pass and re-refer to Com. on APPR. with recommendation: To Consent Calendar. (Ayes 15. Noes 0.) (April 18). Re-referred to Com. on APPR. |
| Mar 29, 2017 | Re-referred to Com. on HEALTH. |
| Mar 28, 2017 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 27, 2017 | Referred to Com. on HEALTH. |
| Feb 19, 2017 | From printer. May be heard in committee March 21. |
| Feb 17, 2017 | Read first time. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Sep 14, 2017 | AB 1591 Berman Special Consent Calendar 1st Day Regular Session | Assembly Floor |
Passed |
|
| Sep 14, 2017 | Special Consent Calendar # AB1591 | Senate Floor |
Passed |
|
| Sep 1, 2017 | Do pass as amended | Senate Standing Committee on Appropriations |
Passed |
|
| Jul 10, 2017 | Placed on suspense file | Senate Standing Committee on Appropriations |
Passed |
|
| Jun 14, 2017 | Do pass, but first be re-referred to the Committee on [Appropriations] with the recommendation: To Consent Calendar | Senate Standing Committee on Health |
Passed |
|
| May 30, 2017 | AB 1591 BERMAN Assembly Third Reading | Assembly Floor |
Passed |
|
| May 26, 2017 | Do pass. | Assembly Standing Committee on Appropriations |
Passed |
|
| Apr 18, 2017 | Do pass and be re-referred to the Committee on [Appropriations] with recommendation: To Consent Calendar | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| APLA Health | ** Support | Sep 9, 2017 |
| Association of California Healthcare Districts | ** Support | Sep 9, 2017 |
| Board of Behavioral Sciences | ** Support | Sep 9, 2017 |
| California Association for Licensed Professional Clinical Counselors | ** Support | Sep 9, 2017 |
| California Association Of Marriage And Family Therapists | ** Support | Sep 9, 2017 |
| California Council Of Community Behavioral Health Agencies | ** Support | Sep 9, 2017 |
| CaliforniaHealth+ Advocates | ** Support | Sep 9, 2017 |
| County Health Executives Association Of California | ** Support | Sep 9, 2017 |
| Department Of Finance | ** Against | Sep 9, 2017 |
| Department of Health Care Services | ** Against | Sep 9, 2017 |
| North Coast Clinics Network | ** Support | Sep 9, 2017 |
GOVERNOR'S VETO
GV Bill Id:AB 1591
Author:(Berman)
As Enrolled Ver:September 15, 2017
2/3 vote
ASSEMBLY: | 76-0 | (May 30, 2017) | SENATE: | 40-0 | (September 14, 2017) |
ASSEMBLY: | 79-0 | (September 14, 2017) |
Original Committee Reference: HEALTH
SUMMARY: Adds, no later than July 1, 2018, licensed professional clinical counselors (LPCCs) to the list of healthcare professionals that qualify for a face-to-face encounter with a patient at Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) for purposes of a per-visit Medi-Cal payment under the prospective payment system (PPS).
The Senate amendments add the July 1, 2018 effective date for this bill, add language to avoid chaptering out this bill and SB 323 (Mitchell), Chapter 540, Statutes of 2017, and make other technical and conforming changes.
FISCAL EFFECT: According to the Senate Appropriations Committee:
- One-time costs, potentially in the hundreds of thousands to low millions, for the Department of Health Care Services (DHCS) to recalculate the PPS rate for clinics that are providing LPCC services or wish to add those services (General Fund and federal funds). This bill allows clinics that are currently including LPCC services in the costs used to calculate their PPS rate to seek a recalculation of the rate to allow the clinic to bill for face-to-face visits. The process for recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, the cost of performing such a review is historically about $20,000 and assuming that 10% of clinics that currently employ LPCCs seek a recalculation, the administrative costs to DHCS would be about $800,000.
However, there are reasons to think that actual costs to DHCS may not be significant. First, because the process of recalculating the PPS rate is administratively costly for clinics, it is not likely that a very large share of clinics that employ LPCCs or would like to would seek authority to bill for face-to-face visits for licensed professional clinical counsellors. Second, a recently enacted law allows clinics to bill Medi-Cal for a face-to-face visit performed by a licensed marriage and family therapists (MFTs). Any clinic that employs LPCCs is also likely to employ MFTs. It is likely that such clinics would only adjust their PPS rate to include LPCCs if they are also going to do so for MFTs. In that case, the overall number of additional PPS rate adjustments under this bill may not be significantly higher than those that would occur under current law.
- No significant increase in costs is expected for LPCC services currently being provided in eligible clinics. Under the current system for calculating the PPS rate paid by Medi-Cal to FQHC and RHC, the total amount of eligible services (including mental health services) provided to Medi-Cal beneficiaries is divided by the number of eligible face-to-face visits (e.g. a visit with a physician or clinical psychologist). Because this bill requires a recalculation of the PPS to account for the fact that LPCCs would be eligible for face-to-face billing before a clinic can bill for such an encounter, the Medi-Cal program is not expected to pay more for services currently being provided. (In other words, a clinic employing LPCCs would be able to bill for more face-to-face encounters, but the PPS rate would be lower to account for those visits.)
- It is not likely that there would be a substantial overall increase in Medi-Cal paid visits to eligible clinics. Under current law, a Medi-Cal beneficiary who visits a FQHC or RHC must be seen by certain types of providers (not including LPCCs) in order for the clinic to bill Medi-Cal for the visit. In theory, the bill could allow clinics to bill Medi-Cal for more overall visits, because it may be easier to hire LPCCs than other practitioners, such as physicians or psychologists. However, under current practice, clinics can already qualify a patient visit by having the patient see seven categories of health care providers. In addition, there are only about 2,000 LPCCs in the state. The actual impact on overall visitations to qualifying clinics is likely to be small, given that clinics can already use a variety of practitioners to qualify the patient visit for payment from Medi-Cal.
COMMENTS: According to the author, with mental health and substance abuse services having been deemed essential health benefits under the Patient Protection and Affordable Care Act and the expansion of Medi-Cal to over 12 million beneficiaries, demand for Medi-Cal providers has increased. California's approximately 600 FQHCs and 350 RHCs serve a significant portion of the uninsured and underinsured and rely on funding from Medi-Cal to provide critical mental health services. Under current law, psychologists, licensed clinical social workers (LCSWs) and licensed MFTs are eligible for Medi-Cal reimbursement for services they provide at FQHCs and RHCs. This bill would add LPCCs to those providers that qualify for reimbursement. LPCCs are fully qualified and trained masters-level mental health professionals who have the education, background and training equivalent to LMFTs and LCSWs, and authorizing them to be reimbursed in these settings will provide greater access to patients who utilize the services of FQHCs and RHCs. Adding LPCCs will help span gaps in workforce capacity by providing clinics with funding to employ these counselors, and also help to meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers.
FQHCs and RHCs serve a significant portion of the uninsured and Medi-Cal. Reimbursement to FQHCs and RHCs is governed by state and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a per-visit rate which is known as PPS. For Medi-Cal managed care plan patients, DHCS reimburses FQHCs and RHCs for the difference between its per-visit PPS rate and the payment made by the plan. This payment is known as a "wrap around" payment. The Medi-Cal managed care wrap around rate was established to reimburse providers for the difference between their PPS rate and their Medi-Cal managed care reimbursement rate.
DHCS' policy on same day visits, as stated in its State Plan Amendment, is that encounters with more than one health professional and/or multiple encounters with the same health professional, which take place on the same day and at a single FQHC or RHC location, constitute a single visit, except that more than one visit may be counted on the same day: 1) when the clinic patient, after the first visit, suffers illness or injury requiring another diagnosis or treatment; or, 2) when the clinic patient has a face-to-face encounter with a dentist or dental hygienist and then also has a face-to-face encounter with another health professional or comprehensive perinatal services practitioner on the same date. Mental health visits are treated for Medi-Cal billing purposes as a same day visit, and separate billing on the same day for a medical visits and a mental health visit is not allowed.
The California Association for Licensed Professional Clinical Counselors (CALPCC), the sponsor of this bill, indicates that LPCCs are billable and recognized providers under the Medi-Cal program but not in FQHC and RHC settings. CALPCC believes that this bill brings parity throughout Medi-Cal program and allows for the utilization of all qualified mental health providers, and provides greater access to mental health services by broadening the pool of providers at these settings.
The Department of Finance writes in opposition, arguing this bill will result in ongoing, potentially significant General Fund costs in the Medi-Cal Program. DHCS writes in opposition that this bill continues the piecemeal approach of making changes to the FQHC PPS that creates significant workload for DHCS while not addressing the fundamental issues with the PPS reimbursement structure. DHCS argues its efforts should be focused on implementing a capitated payment model authorized by legislation in 2015 which would allow FQHCs and RHCs to use LPCCs without having to complete the administrative processes associated with adding them as separately billable providers.
This bill adds Licensed Professional Clinical Counselors to the list of health care professionals whose services are reimbursable by Medi-Cal on a per visit basis at Federally Qualified Health Centers and Rural Health Clinics.
The Department of Health Care Services is developing a new payment model for these health clinics that will eliminate the need to add specific providers to an approved list. Consequently, this bill is unnecessary.
Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0002455
CONCURRENCE IN SENATE AMENDMENTS
CSA1 Bill Id:AB 1591
Author:(Berman)
As Amended Ver:September 8, 2017
Majority vote
ASSEMBLY: | 76-0 | (May 30, 2017) | SENATE: | 40-0 | (September 14, 2017) |
Original Committee Reference: HEALTH
SUMMARY: Adds, no later than July 1, 2018, licensed professional clinical counselors (LPCCs) to the list of healthcare professionals that qualify for a face-to-face encounter with a patient at Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) for purposes of a per-visit Medi-Cal payment under the prospective payment system (PPS).
The Senate amendments add the July 1, 2018 effective date for this bill, add language to avoid chaptering out this bill and SB 323 (Mitchell) of the current legislative session, and make other technical and conforming changes.
FISCAL EFFECT: According to the Senate Appropriations Committee:
- One-time costs, potentially in the hundreds of thousands to low millions, for the Department of Health Care Services (DHCS) to recalculate the PPS rate for clinics that are providing LPCC services or wish to add those services (General Fund and federal funds). This bill allows clinics that are currently including LPCC services in the costs used to calculate their PPS rate to seek a recalculation of the rate to allow the clinic to bill for face-to-face visits. The process for recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, the cost of performing such a review is historically about $20,000 and assuming that 10% of clinics that currently employ LPCCs seek a recalculation, the administrative costs to DHCS would be about $800,000.
However, there are reasons to think that actual costs to DHCS may not be significant. First, because the process of recalculating the PPS rate is administratively costly for clinics, it is not likely that a very large share of clinics that employ LPCCs or would like to would seek authority to bill for face-to-face visits for licensed professional clinical counsellors. Second, a recently enacted law allows clinics to bill Medi-Cal for a face-to-face visit performed by a licensed marriage and family therapists (MFTs). Any clinic that employs LPCCs is also likely to employ MFTs. It is likely that such clinics would only adjust their PPS rate to include LPCCs if they are also going to do so for MFTs. In that case, the overall number of additional PPS rate adjustments under this bill may not be significantly higher than those that would occur under current law.
- No significant increase in costs is expected for LPCC services currently being provided in eligible clinics. Under the current system for calculating the PPS rate paid by Medi-Cal to FQHC and RHC, the total amount of eligible services (including mental health services) provided to Medi-Cal beneficiaries is divided by the number of eligible face-to-face visits (e.g. a visit with a physician or clinical psychologist). Because this bill requires a recalculation of the PPS to account for the fact that LPCCs would be eligible for face-to-face billing before a clinic can bill for such an encounter, the Medi-Cal program is not expected to pay more for services currently being provided. (In other words, a clinic employing LPCCs would be able to bill for more face-to-face encounters, but the PPS rate would be lower to account for those visits.)
- It is not likely that there would be a substantial overall increase in Medi-Cal paid visits to eligible clinics. Under current law, a Medi-Cal beneficiary who visits a FQHC or RHC must be seen by certain types of providers (not including LPCCs) in order for the clinic to bill Medi-Cal for the visit. In theory, the bill could allow clinics to bill Medi-Cal for more overall visits, because it may be easier to hire LPCCs than other practitioners, such as physicians or psychologists. However, under current practice, clinics can already qualify a patient visit by having the patient see seven categories of health care providers. In addition, there are only about 2,000 LPCCs in the state. The actual impact on overall visitations to qualifying clinics is likely to be small, given that clinics can already use a variety of practitioners to qualify the patient visit for payment from Medi-Cal.
COMMENTS: According to the author, with mental health and substance abuse services having been deemed essential health benefits under the Patient Protection and Affordable Care Act and the expansion of Medi-Cal to over 12 million beneficiaries, demand for Medi-Cal providers has increased. California's approximately 600 FQHCs and 350 RHCs serve a significant portion of the uninsured and underinsured and rely on funding from Medi-Cal to provide critical mental health services. Under current law, psychologists, licensed clinical social workers (LCSWs) and licensed MFTs are eligible for Medi-Cal reimbursement for services they provide at FQHCs and RHCs. This bill would add LPCCs to those providers that qualify for reimbursement. LPCCs are fully qualified and trained masters-level mental health professionals who have the education, background and training equivalent to LMFTs and LCSWs, and authorizing them to be reimbursed in these settings will provide greater access to patients who utilize the services of FQHCs and RHCs. Adding LPCCs will help span gaps in workforce capacity by providing clinics with funding to employ these counselors, and also help to meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers.
FQHCs and RHCs serve a significant portion of the uninsured and Medi-Cal. Reimbursement to FQHCs and RHCs is governed by state and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a per-visit rate which is known as PPS. For Medi-Cal managed care plan patients, DHCS reimburses FQHCs and RHCs for the difference between its per-visit PPS rate and the payment made by the plan. This payment is known as a "wrap around" payment. The Medi-Cal managed care wrap around rate was established to reimburse providers for the difference between their PPS rate and their Medi-Cal managed care reimbursement rate.
DHCS' policy on same day visits, as stated in its State Plan Amendment, is that encounters with more than one health professional and/or multiple encounters with the same health professional, which take place on the same day and at a single FQHC or RHC location, constitute a single visit, except that more than one visit may be counted on the same day: 1) when the clinic patient, after the first visit, suffers illness or injury requiring another diagnosis or treatment; or, 2) when the clinic patient has a face-to-face encounter with a dentist or dental hygienist and then also has a face-to-face encounter with another health professional or comprehensive perinatal services practitioner on the same date. Mental health visits are treated for Medi-Cal billing purposes as a same day visit, and separate billing on the same day for a medical visits and a mental health visit is not allowed.
The California Association for Licensed Professional Clinical Counselors (CALPCC), the sponsor of this bill, indicates that LPCCs are billable and recognized providers under the Medi-Cal program but not in FQHC and RHC settings. CALPCC believes that this bill brings parity throughout Medi-Cal program and allows for the utilization of all qualified mental health providers, and provides greater access to mental health services by broadening the pool of providers at these settings.
The Department of Finance writes in opposition, arguing this bill will result in ongoing, potentially significant General Fund costs in the Medi-Cal Program. DHCS writes in opposition that this bill continues the piecemeal approach of making changes to the FQHC PPS that creates significant workload for DHCS while not addressing the fundamental issues with the PPS reimbursement structure. DHCS argues its efforts should be focused on implementing a capitated payment model authorized by legislation in 2015 which would allow FQHCs and RHCs to use LPCCs without having to complete the administrative processes associated with adding them as separately billable providers.
Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN 0002204
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB 1591 |
THIRD READING
Bill No: AB 1591
Amended: 9/8/17 in Senate
SENATE HEALTH COMMITTEE: 9-0, 6/14/17
AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth
SENATE APPROPRIATIONS COMMITTEE: 7-0, 9/1/17
AYES: Lara, Bates, Beall, Bradford, Hill, Nielsen, Wiener
ASSEMBLY FLOOR: 76-0, 5/30/17 - See last page for vote
SUBJECT: Medi-Cal: federally qualified health centers and rural health centers: licensed professional clinical counselor
SOURCE: California Association for Licensed Professional Clinical Counselors
DIGEST:
This bill adds licensed professional clinical counselors to the list of health care professionals that qualify for a face-to-face encounter with a patient at Federally Qualified Health Centers or Rural Health Clinics for purposes of a per-visit Medi-Cal payment under the prospective payment system.
Senate Floor Amendments of 9/8/17 add language to prevent chaptering out SB 323 (Mitchell).
Existing law:
- Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), which provides comprehensive health care coverage for low-income individuals. Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services are covered benefits under the Medi-Cal program.
- Requires FQHCs and RHCs to be reimbursed on a per-visit basis. Defines a “visit” as a face-to-face encounter between an FQHC or RHC patient and the following health care providers: a physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker (LCSW), marriage and family therapist (MFT), visiting nurse, podiatrist, dentist, dental hygienist, dental hygienist in alternative practice optometrist, chiropractor, comprehensive perinatal services practitioner providing comprehensive perinatal services, a four-hour day of attendance at an Adult Day Health Care Center; and, any other provider identified in the state plan’s definition of an FQHC or RHC visit. The reimbursement structure for FQHCs and RHCs is known as the prospective payment system (PPS).
- Permits FQHC or RHC to apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Requires rate changes based on a change in the scope of services provided by an FQHC or RHC to be evaluated in accordance with Medicare reasonable cost principles.
This bill:
- Adds licensed professional clinical counselors (LPCC) to the list of health care professionals that qualify for a face-to-face encounter with a patient at FQHCs and RHCs for purposes of a per-visit Medi-Cal payment under PPS.
- Permits an FQHC or RHC that applies for an adjustment to its rate to continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a LPCC has been approved.
- Requires an FQHC or RHC that does not provide LPCC and later elects to add these services and bill these services as a separate visit, to process the addition of these services as a change in its scope of service.
Background
- FQHCs and RHCs are federally designated clinics that provide primary care services that are required to serve medically underserved populations. Medi-Cal reimbursement to FQHCs and RHCs is governed by state and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a per-visit rate which is known as the PPS. The list of providers who are billable by an FQHC and RHC is in statute. Each FQHC and RHC has a specific PPS Medi-Cal rate for each face-to-face encounter, irrespective of the reason for the visit. For Medi-Cal managed care plan patients, DHCS reimburses FQHCs and RHCs for the difference between its per-visit PPS rate and the payment made by the plan. This payment is known as a “wrap around” payment. The Medi-Cal managed care wrap-around rate was established to reimburse providers for the difference between their PPS rate and their Medi-Cal managed care reimbursement rate.
- LPCCs. The Board of Behavioral Sciences (BBS) licenses and regulates LPCCs. The LPCC licensure category was created in 2009 by SB 788 (Wyland, Chapter 619, Statutes of 2009). As of April 20, 2017, BBS indicates it licensed 1,486 LPCCs and 2,601 professional counselor interns).
LPCCs are authorized to provide professional clinical counseling, defined as the application of counseling interventions and psychotherapeutic techniques to identify and remediate cognitive, mental, and emotional issues, including personal growth, adjustment to disability, crisis intervention, and psychosocial and environmental problems, and the use, application, and integration of the coursework and training required under existing law. Professional clinical counseling also includes conducting assessments for the purpose of establishing counseling goals and objectives to empower individuals to deal adequately with life situations, reduce stress, experience growth, change behavior, and make well-informed, rational decisions.
In Medi-Cal, DHCS indicates LPCCs cannot bill Medi-Cal fee-for-service, and services rendered by an LPCC are not eligible for federal financial participation in Medicaid. LPCCs are qualified providers of Medi-Cal county mental health plans to provide Targeted Case Management, Mental Health Services, Day Treatment Intensive, Day Rehabilitation, Crisis Intervention, Adult Residential, Crisis Residential, and Psychiatric Health Facility services.
- Author’s statement. According to the author, with mental health and substance abuse services having been deemed essential health care benefits under the Affordable Care Act and the expansion of Medi-Cal to over 12 million beneficiaries, demand for Medi-Cal providers has increased. Approximately 600 FQHCs and 350 RHCs serve a significant portion of California’s uninsured and underinsured and rely on funding from Medi-Cal to employ mental health care providers. Under current law, psychologists, LCSWs, and MFTs are eligible for Medi-Cal reimbursement for services they provide at FQHCs and RHCs.
This bill adds LPCCs to those providers that qualify for reimbursement. LPCCs are fully qualified and trained masters-level mental health professionals who have the education, background and training equivalent to LCSWs and MFTs. Adding LPCCs will help span gaps in workforce capacity by providing FQHCs and RHCs with funding to employ LPCCs and meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No
According to the Senate Appropriations Committee:
- One-time costs, potentially in the hundreds of thousands to low millions, for DHCS to recalculate the PPS rate for clinics that are providing LPCC services or wish to add those services (General Fund and federal funds). The bill allows clinics that are currently including LPCC services in the costs used to calculate their PPS rate to seek a recalculation of the rate to allow the clinic to bill for face-to-face visits. The process for recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, the cost of performing such a review is historically about $20,000 and assuming that 10% of clinics that currently employ LPCCs seek a recalculation, the administrative costs to DHCS would be about $800,000.
However, there are reasons to think that actual costs to DHCS may not be significant. First, because the process of recalculating the PPS rate is administratively costly for clinics, it is not likely that a very large share of clinics that employ LPCCs or would like to would seek authority to bill for face-to-face visits for licensed professional clinical counsellors. Second, a recently enacted law allows clinics to bill Medi-Cal for a face-to-face visit performed by a licensed MFT. Any clinic that employs LPCCs is also likely to employ MFTs. It is likely that such clinics would only adjust their PPS rate to include LPCCs if they are also going to do so for MFTs. In that case, the overall number of additional PPS rate adjustments under this bill may not be significantly higher than those that would occur under current law.
- No significant increase in costs is expected for LPCC services currently being provided in eligible clinics. Under the current system for calculating the PPS rate paid by Medi-Cal to FQHC and RHC, the total amount of eligible services (including mental health services) provided to Medi-Cal beneficiaries is divided by the number of eligible face-to-face visits (e.g. a visit with a physician or clinical psychologist). Because the bill requires a recalculation of the PPS to account for the fact that LPCCs would be eligible for face-to-face billing before a clinic can bill for such an encounter, the Medi-Cal program is not expected to pay more for services currently being provided. (In other words, a clinic employing LPCCs would be able to bill for more face-to-face encounters, but the PPS rate would be lower to account for those visits.)
- It is not likely that there would be a substantial overall increase in Medi-Cal paid visits to eligible clinics. Under current law, a Medi-Cal beneficiary who visits a FQHC or RHC must be seen by certain types of providers (not including LPCCs) in order for the clinic to bill Medi-Cal for the visit. In theory, the bill could allow clinics to bill Medi-Cal for more overall visits, because it may be easier to hire LPCCs than other practitioners, such as physicians or psychologists. However, under current practice, clinics can already qualify a patient visit by having the patient see seven categories of health care providers. In addition, there are only about 2,000 LPCCs in the state. The actual impact on overall visitations to qualifying clinics is likely to be small, given that clinics can already use a variety of practitioners to qualify the patient visit for payment from Medi-Cal.
California Association for Licensed Professional Clinical Counselors (source)
APLA Health
Association of California Healthcare Districts
Board of Behavioral Sciences
California Association of Marriage and Family Therapists
California Council of Community Behavioral Health Agencies
CaliforniaHealth+ Advocates
County Health Executives Association of California
North Coast Clinics Network
OPPOSITION: (Verified 8/30/17)
Department of Finance
Department of Health Care Services
ARGUMENTS IN SUPPORT: This bill is sponsored by the California Association for Licensed Professional Clinical Counselors (CALPCC), which indicates that LPCCs are not billable under the Medi-Cal program in FQHC and RHC settings. CALPCC believes that this bill brings parity throughout Medi-Cal program and allows for the utilization of all qualified mental health providers, and provides greater access to mental health services by broadening the pool of providers at these settings. CaliforniaHealth+ Advocates writes in support that allowing LPCCs to serve Medi-Cal patients in health centers will address serious gaps in behavioral health care and bring the state one step closer to addressing the behavioral health crisis in California.
ARGUMENTS IN OPPOSITION: The Department of Finance writes in opposition, arguing this bill will result in ongoing, potentially significant
General Fund costs in the Medi-Cal Program. DHCS writes in opposition that this bill continues the piecemeal approach of making changes to the FQHC PPS that creates significant workload for DHCS while not addressing the fundamental issues with the PPS reimbursement structure. DHCS argues its efforts should be focused on implementing a capitated payment model authorized by legislation in 2015 which would allow FQHCs and RHCs to use LPCCs without having to complete the administrative processes associated with adding them as separately billable providers.
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, 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, Mathis, 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, Cunningham, Eggman
Prepared by: Scott Bain / HEALTH / (916) 651-4111
9/9/17 16:13:42
**** END ****
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB 1591 |
THIRD READING
Bill No: AB 1591
Amended: 9/1/17 in Senate
SENATE HEALTH COMMITTEE: 9-0, 6/14/17
AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth
SENATE APPROPRIATIONS COMMITTEE: 7-0, 9/1/17
AYES: Lara, Bates, Beall, Bradford, Hill, Nielsen, Wiener
ASSEMBLY FLOOR: 76-0, 5/30/17 - See last page for vote
SUBJECT: Medi-Cal: federally qualified health centers and rural health centers: licensed professional clinical counselor
SOURCE: California Association for Licensed Professional Clinical Counselors
DIGEST:
This bill adds licensed professional clinical counselors to the list of health care professionals that qualify for a face-to-face encounter with a patient at Federally Qualified Health Centers or Rural Health Clinics for purposes of a per-visit Medi-Cal payment under the prospective payment system.
Existing law:
- Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), which provides comprehensive health care coverage for low-income individuals. Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services are covered benefits under the Medi-Cal program.
- Requires FQHCs and RHCs to be reimbursed on a per-visit basis. Defines a “visit” as a face-to-face encounter between an FQHC or RHC patient and the following health care providers: a physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker (LCSW), marriage and family therapist (MFT), visiting nurse, podiatrist, dentist, dental hygienist, dental hygienist in alternative practice optometrist, chiropractor, comprehensive perinatal services practitioner providing comprehensive perinatal services, a four-hour day of attendance at an Adult Day Health Care Center; and, any other provider identified in the state plan’s definition of an FQHC or RHC visit. The reimbursement structure for FQHCs and RHCs is known as the prospective payment system (PPS).
- Permits FQHC or RHC to apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Requires rate changes based on a change in the scope of services provided by an FQHC or RHC to be evaluated in accordance with Medicare reasonable cost principles.
This bill:
- Adds licensed professional clinical counselors (LPCC) to the list of health care professionals that qualify for a face-to-face encounter with a patient at FQHCs and RHCs for purposes of a per-visit Medi-Cal payment under PPS.
- Permits an FQHC or RHC that applies for an adjustment to its rate to continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a LPCC has been approved.
- Requires an FQHC or RHC that does not provide LPCC and later elects to add these services and bill these services as a separate visit, to process the addition of these services as a change in its scope of service.
Background
- FQHCs and RHCs are federally designated clinics that provide primary care services that are required to serve medically underserved populations. Medi-Cal reimbursement to FQHCs and RHCs is governed by state and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a per-visit rate which is known as the PPS. The list of providers who are billable by an FQHC and RHC is in statute. Each FQHC and RHC has a specific PPS Medi-Cal rate for each face-to-face encounter, irrespective of the reason for the visit. For Medi-Cal managed care plan patients, DHCS reimburses FQHCs and RHCs for the difference between its per-visit PPS rate and the payment made by the plan. This payment is known as a “wrap around” payment. The Medi-Cal managed care wrap-around rate was established to reimburse providers for the difference between their PPS rate and their Medi-Cal managed care reimbursement rate.
- LPCCs. The Board of Behavioral Sciences (BBS) licenses and regulates LPCCs. The LPCC licensure category was created in 2009 by SB 788 (Wyland, Chapter 619, Statutes of 2009). As of April 20, 2017, BBS indicates it licensed 1,486 LPCCs and 2,601 professional counselor interns).
LPCCs are authorized to provide professional clinical counseling, defined as the application of counseling interventions and psychotherapeutic techniques to identify and remediate cognitive, mental, and emotional issues, including personal growth, adjustment to disability, crisis intervention, and psychosocial and environmental problems, and the use, application, and integration of the coursework and training required under existing law. Professional clinical counseling also includes conducting assessments for the purpose of establishing counseling goals and objectives to empower individuals to deal adequately with life situations, reduce stress, experience growth, change behavior, and make well-informed, rational decisions.
In Medi-Cal, DHCS indicates LPCCs cannot bill Medi-Cal fee-for-service, and services rendered by an LPCC are not eligible for federal financial participation in Medicaid. LPCCs are qualified providers of Medi-Cal county mental health plans to provide Targeted Case Management, Mental Health Services, Day Treatment Intensive, Day Rehabilitation, Crisis Intervention, Adult Residential, Crisis Residential, and Psychiatric Health Facility services.
- Author’s statement. According to the author, with mental health and substance abuse services having been deemed essential health care benefits under the Affordable Care Act and the expansion of Medi-Cal to over 12 million beneficiaries, demand for Medi-Cal providers has increased. Approximately 600 FQHCs and 350 RHCs serve a significant portion of California’s uninsured and underinsured and rely on funding from Medi-Cal to employ mental health care providers. Under current law, psychologists, LCSWs, and MFTs are eligible for Medi-Cal reimbursement for services they provide at FQHCs and RHCs.
This bill adds LPCCs to those providers that qualify for reimbursement. LPCCs are fully qualified and trained masters-level mental health professionals who have the education, background and training equivalent to LCSWs and MFTs. Adding LPCCs will help span gaps in workforce capacity by providing FQHCs and RHCs with funding to employ LPCCs and meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No
According to the Senate Appropriations Committee:
- One-time costs, potentially in the hundreds of thousands to low millions, for DHCS to recalculate the PPS rate for clinics that are providing LPCC services or wish to add those services (General Fund and federal funds). The bill allows clinics that are currently including LPCC services in the costs used to calculate their PPS rate to seek a recalculation of the rate to allow the clinic to bill for face-to-face visits. The process for recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, the cost of performing such a review is historically about $20,000 and assuming that 10% of clinics that currently employ LPCCs seek a recalculation, the administrative costs to DHCS would be about $800,000.
However, there are reasons to think that actual costs to DHCS may not be significant. First, because the process of recalculating the PPS rate is administratively costly for clinics, it is not likely that a very large share of clinics that employ LPCCs or would like to would seek authority to bill for face-to-face visits for licensed professional clinical counsellors. Second, a recently enacted law allows clinics to bill Medi-Cal for a face-to-face visit performed by a licensed MFT. Any clinic that employs LPCCs is also likely to employ MFTs. It is likely that such clinics would only adjust their PPS rate to include LPCCs if they are also going to do so for MFTs. In that case, the overall number of additional PPS rate adjustments under this bill may not be significantly higher than those that would occur under current law.
- No significant increase in costs is expected for LPCC services currently being provided in eligible clinics. Under the current system for calculating the PPS rate paid by Medi-Cal to FQHC and RHC, the total amount of eligible services (including mental health services) provided to Medi-Cal beneficiaries is divided by the number of eligible face-to-face visits (e.g. a visit with a physician or clinical psychologist). Because the bill requires a recalculation of the PPS to account for the fact that LPCCs would be eligible for face-to-face billing before a clinic can bill for such an encounter, the Medi-Cal program is not expected to pay more for services currently being provided. (In other words, a clinic employing LPCCs would be able to bill for more face-to-face encounters, but the PPS rate would be lower to account for those visits.)
- It is not likely that there would be a substantial overall increase in Medi-Cal paid visits to eligible clinics. Under current law, a Medi-Cal beneficiary who visits a FQHC or RHC must be seen by certain types of providers (not including LPCCs) in order for the clinic to bill Medi-Cal for the visit. In theory, the bill could allow clinics to bill Medi-Cal for more overall visits, because it may be easier to hire LPCCs than other practitioners, such as physicians or psychologists. However, under current practice, clinics can already qualify a patient visit by having the patient see seven categories of health care providers. In addition, there are only about 2,000 LPCCs in the state. The actual impact on overall visitations to qualifying clinics is likely to be small, given that clinics can already use a variety of practitioners to qualify the patient visit for payment from Medi-Cal.
California Association for Licensed Professional Clinical Counselors (source)
APLA Health
Association of California Healthcare Districts
Board of Behavioral Sciences
California Association of Marriage and Family Therapists
California Council of Community Behavioral Health Agencies
CaliforniaHealth+ Advocates
County Health Executives Association of California
North Coast Clinics Network
OPPOSITION: (Verified 8/30/17)
Department of Finance
Department of Health Care Services
ARGUMENTS IN SUPPORT: This bill is sponsored by the California Association for Licensed Professional Clinical Counselors (CALPCC), which indicates that LPCCs are not billable under the Medi-Cal program in FQHC and RHC settings. CALPCC believes that this bill brings parity throughout Medi-Cal program and allows for the utilization of all qualified mental health providers, and provides greater access to mental health services by broadening the pool of providers at these settings. CaliforniaHealth+ Advocates writes in support that allowing LPCCs to serve Medi-Cal patients in health centers will address serious gaps in behavioral health care and bring the state one step closer to addressing the behavioral health crisis in California.
ARGUMENTS IN OPPOSITION: The Department of Finance writes in opposition, arguing this bill will result in ongoing, potentially significant
General Fund costs in the Medi-Cal Program. DHCS writes in opposition that this bill continues the piecemeal approach of making changes to the FQHC PPS that creates significant workload for DHCS while not addressing the fundamental issues with the PPS reimbursement structure. DHCS argues its efforts should be focused on implementing a capitated payment model authorized by legislation in 2015 which would allow FQHCs and RHCs to use LPCCs without having to complete the administrative processes associated with adding them as separately billable providers.
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, 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, Mathis, 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, Cunningham, Eggman
Prepared by: Scott Bain / HEALTH / (916) 651-4111
9/4/17 12:40:52
**** END ****
SENATE COMMITTEE ON
Senator Ricardo Lara, Chair
2017 - 2018 Regular Session
AB 1591 (Berman) - Medi-Cal: federally qualified health centers and rural health centers: licensed professional clinical counselor
Version: | Policy Vote: |
Urgency: | Mandate: |
Hearing Date: | Consultant: |
Bill Summary:
AB 1591 would add licensed professional clinical counsellors (LPCCs) to the list of health care providers that qualify for face-to-face encounter payments from the Medi-Cal program to federally qualified health centers and rural health clinics.
*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********
The following information is revised to reflect amendments
adopted by the committee on September 1, 2017
Fiscal Impact:
- One-time costs, potentially in the hundreds of thousands to low millions, for the Department of Health Care Services to recalculate the prospective payment system (PPS) rate for clinics that are providing licensed professional clinical counsellor services or wish to add those services (General Fund and federal funds). The bill allows clinics that are currently including licensed professional clinical counsellor services in the costs used to calculate their PPS rate to seek a recalculation of the rate to allow the clinic to bill for face-to-face visits. The process for recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, the cost of performing such a review is historically about $20,000 and assuming that 10% of clinics that currently employ licensed professional clinical counsellors seek a recalculation, the administrative costs to the Department of Health Care Services would be about $800,000.
However, there are reasons to think that actual costs to the Department may not be significant. First, because the process of recalculating the PPS rate is administratively costly for clinics, it is not likely that a very large share of clinics that employ licensed professional clinical counsellors or would like to would seek authority to bill for face-to-face visits for licensed professional clinical counsellors. Second, a recently enacted law allows clinics to bill Medi-Cal for a face-to-face visit performed by a licensed marriage and family therapist. Any clinic that employs LPCCs is also likely to employ marriage and family therapists. It is likely that such clinics would only adjust their PPS rate to include LPCCs if they are also going to do so for marriage and family therapists. In that case, the overall number of additional PPS rate adjustments under this bill may not be significantly higher than those that would occur under current law.
- No significant increase in costs is expected for licensed professional clinical counsellor services currently being provided in eligible clinics. Under the current system for calculating the PPS rate paid by Medi-Cal to federally qualified health centers and rural health clinics, the total amount of eligible services (including mental health services) provided to Medi-Cal beneficiaries is divided by the number of eligible face-to-face visits (e.g. a visit with a physician or clinical psychologist). Because the bill requires a recalculation of the PPS to account for the fact that licensed professional clinical counsellors would be eligible for face-to-face billing before a clinic can bill for such an encounter, the Medi-Cal program is not expected to pay more for services currently being provided. (In other words, a clinic employing licensed professional clinical counsellors would be able to bill for more face-to-face encounters, but the PPS rate would be lower to account for those visits.)
- It is not likely that there would be a substantial overall increase in Medi-Cal paid visits to eligible clinics. Under current law, a Medi-Cal beneficiary who visits a federally qualified health center or rural health clinic must be seen by certain types of providers (not including licensed professional clinical counsellors) in order for the clinic to bill Medi-Cal for the visit. In theory, the bill could allow clinics to bill Medi-Cal for more overall visits, because it may be easier to hire licensed professional clinical counsellors than other practitioners, such as physicians or psychologists. However, under current practice, clinics can already qualify a patient visit by having the patient see seven categories of health care providers. In addition, there are only about 2,000 licensed professional clinical counsellors in the state. The actual impact on overall visitations to qualifying clinics is likely to be small, given that clinics can already use a variety of practitioners to qualify the patient visit for payment from Medi-Cal.
Author Amendments:
revise the bill to avoid chaptering conflicts.
-- END --
SENATE COMMITTEE ON
Senator Ricardo Lara, Chair
2017 - 2018 Regular Session
AB 1591 (Berman) - Medi-Cal: federally qualified health centers and rural health centers: licensed professional clinical counselor
Version: | Policy Vote: |
Urgency: | Mandate: |
Hearing Date: | Consultant: |
This bill meets the criteria for referral to the Suspense File.
Bill Summary:
AB 1591 would add licensed professional clinical counsellors (LPCCs) to the list of health care providers that qualify for face-to-face encounter payments from the Medi-Cal program to federally qualified health centers and rural health clinics.
Fiscal Impact:
- One-time costs, potentially in the hundreds of thousands to low millions, for the Department of Health Care Services to recalculate the prospective payment system (PPS) rate for clinics that are providing licensed professional clinical counsellor services or wish to add those services (General Fund and federal funds). The bill allows clinics that are currently including licensed professional clinical counsellor services in the costs used to calculate their PPS rate to seek a recalculation of the rate to allow the clinic to bill for face-to-face visits. The process for recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, the cost of performing such a review is historically about $20,000 and assuming that 10% of clinics that currently employ licensed professional clinical counsellors seek a recalculation, the administrative costs to the Department of Health Care Services would be about $800,000.
However, there are reasons to think that actual costs to the Department may not be significant. First, because the process of recalculating the PPS rate is administratively costly for clinics, it is not likely that a very large share of clinics that employ licensed professional clinical counsellors or would like to would seek authority to bill for face-to-face visits for licensed professional clinical counsellors. Second, a recently enacted law allows clinics to bill Medi-Cal for a face-to-face visit performed by a licensed marriage and family therapist. Any clinic that employs LPCCs is also likely to employ marriage and family therapists. It is likely that such clinics would only adjust their PPS rate to include LPCCs if they are also going to do so for marriage and family therapists. In that case, the overall number of additional PPS rate adjustments under this bill may not be significantly higher than those that would occur under current law.
- No significant increase in costs is expected for licensed professional clinical counsellor services currently being provided in eligible clinics. Under the current system for calculating the PPS rate paid by Medi-Cal to federally qualified health centers and rural health clinics, the total amount of eligible services (including mental health services) provided to Medi-Cal beneficiaries is divided by the number of eligible face-to-face visits (e.g. a visit with a physician or clinical psychologist). Because the bill requires a recalculation of the PPS to account for the fact that licensed professional clinical counsellors would be eligible for face-to-face billing before a clinic can bill for such an encounter, the Medi-Cal program is not expected to pay more for services currently being provided. (In other words, a clinic employing licensed professional clinical counsellors would be able to bill for more face-to-face encounters, but the PPS rate would be lower to account for those visits.)
- It is not likely that there would be a substantial overall increase in Medi-Cal paid visits to eligible clinics. Under current law, a Medi-Cal beneficiary who visits a federally qualified health center or rural health clinic must be seen by certain types of providers (not including licensed professional clinical counsellors) in order for the clinic to bill Medi-Cal for the visit. In theory, the bill could allow clinics to bill Medi-Cal for more overall visits, because it may be easier to hire licensed professional clinical counsellors than other practitioners, such as physicians or psychologists. However, under current practice, clinics can already qualify a patient visit by having the patient see seven categories of health care providers. In addition, there are only about 2,000 licensed professional clinical counsellors in the state. The actual impact on overall visitations to qualifying clinics is likely to be small, given that clinics can already use a variety of practitioners to qualify the patient visit for payment from Medi-Cal.
Background:
Under current law, the Medi-Cal program provides health care coverage for certain low income and disabled individuals.
In the Medi-Cal fee-for-service system, federally qualified health centers and rural health clinics are paid a per-visit payment known as the prospective payment system rate (PPS). The PPS rate is based on a baseline rate that reflects a federally qualified health center’s costs to provide services in 1999-2000, adjusted for inflation. Those costs include the costs of eligible face-to-face visits (e.g. with a physician) and other services provided to Medi-Cal beneficiaries that are not eligible for billing as a face-to-face visit (e.g. visits with a registered nurse). When a Medi-Cal beneficiary in the managed care system receives care from a federally qualified health center, the managed care plan makes a per-visit payment to the center. Because the rates paid by managed care plans are significantly below the PPS rate, the state makes a supplemental “wrap-around” payment to the federally qualified health center to bring the total payment up to the PPS rate.
Under current law, clinics may bill Medi-Cal for face-to-face visits with several categories of health professionals, including physicians, nurse practitioners, clinical social workers, marriage and family therapists and others. Clinics cannot bill for face-to-face visits with licensed professional clinical counsellors. However, the cost to provide services to Medi-Cal beneficiaries by licensed professional clinical counsellors can be included in the calculation of the PPS rate.
Proposed Law:
AB 1591 would add licensed professional clinical counsellors (LPCCs) to the list of health care providers that qualify for face-to-face encounter payments from the Medi-Cal program to federally qualified health centers and rural health clinics.
The bill would authorize a federally qualified health center or a rural health clinic that currently includes the cost of licensed professional clinical counsellors services in its PPS rate to seek a recalculation of the PPS rate by the Department of Health Care Services. Once the rate adjustment has been approved, the bill would authorize an eligible clinic to bill for those services as a separate visit.
The bill would require a federally qualified health center or a rural health clinic that does not currently provide services by licensed professional clinical counsellors that wants to add such services and bill for them as face-to-face visits to do so by making a change in scope of service (which requires a recalculation of the PPS rate).
Related Legislation:
- SB 323 (Mitchell) would authorize federally qualified health centers (FQHCs) and rural health clinics (RHCs) to receive reimbursement from county mental health plans for specialty mental health services and through Drug Medi-Cal, outside of the regular reimbursement structure for paying these clinics in the Medi-Cal program. That bill is pending in the Assembly.
- SB 456 (Pan) would authorize an FQHC or RHC to enter into an agreement with specified entities to provide services that follow a patient. That bill is pending in the Assembly.
- AB 1863 (Wood, Statutes of 2016) added marriage and family therapists to the list of health care providers that can bill Medi-Cal for face-to-face visits in federally qualified health centers.
Staff Comments:
SB 97 (Committee on Budget and Fiscal Review) the health-related trailer bill associated with the 2017-18 budget delays the implementation of the authority for marriage and family therapists to bill for face-to-face visits in clinics to July 1, 2018. It is likely that any upfront administrative costs to the Department of Health Care Services related to this bill can be absorbed in the effort to implement AB 1863. In addition, the delay in implementation of AB 1863 makes it likely that any clinic seeking authorization for LPCCs to provide face-to-face visits would include such a request in their request to authorize marriage and family therapists.
-- END --
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1591
AUTHOR: | Berman | ||
VERSION: | March 28, 2017 | ||
HEARING DATE: | June 14, 2017 | ||
CONSULTANT: | Scott Bain | ||
SUBJECT: Medi-Cal: federally qualified health centers and rural health centers: licensed professional clinical counselor
SUMMARY:
Adds licensed professional clinical counselors to the list of healthcare professionals that qualify for a face-to-face encounter with a patient at Federally Qualified Health Centers or Rural Health Clinics for purposes of a per-visit Medi-Cal payment under the prospective payment system.
Existing law:
- Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), which provides comprehensive health care coverage for low-income individuals. Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services are covered benefits under the Medi-Cal program.
- Requires FQHCs and RHCs to be reimbursed on a per-visit basis. Defines a “visit” as a face-to-face encounter between an FQHC or RHC patient and the following health care providers: a physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker (LCSW), marriage and family therapist (MFT), visiting nurse, podiatrist, dentist, dental hygienist, dental hygienist in alternative practice optometrist, chiropractor, comprehensive perinatal services practitioner providing comprehensive perinatal services, a four-hour day of attendance at an Adult Day Health Care Center; and, any other provider identified in the state plan’s definition of an FQHC or RHC visit. The reimbursement structure for FQHCs and RHCs is known as the prospective payment system (PPS).
- Requires FQHC and RHC per-visit rates to be increased by the Medicare Economic Index (MEI) applicable to primary care services in the manner provided for in federal law.
- Permits FQHC or RHC to apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Requires rate changes based on a change in the scope of services provided by an FQHC or RHC to be evaluated in accordance with Medicare reasonable cost principles.
This bill:
- Adds licensed professional clinical counselors (LPCC) to the list of healthcare professionals that qualify for a face-to-face encounter with a patient at FQHCs and RHCs for purposes of a per-visit Medi-Cal payment under PPS.
- Permits an FQHC or RHC that applies for an adjustment to its rate to continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a LPCC has been approved.
- Requires an FQHC or RHC that does not provide LPCC and later elects to add these services and bill these services as a separate visit, to process the addition of these services as a change in scope of service.
FISCAL EFFECT:
According to the Assembly Appropriations Committee:
- Unknown one-time costs to recalculate the PPS rate for clinics that are providing LPCC services or wish to add those services (General Fund/federal). The bill requires clinics that currently include LPCC services in the costs used to calculate their PPS rate to seek a recalculation of the rate before the clinic is allowed to bill for visits. Recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, assuming the cost per review is about $10,000 and 20 clinics seek a recalculation, the administrative costs to DHCS would be about $200,000. However, a similar bill in 2016 also added MFTs as allowable providers. If clinics are submitting scope-of-service changes to add MFTs, they could add LPCCs simultaneously at no additional cost. This is a more likely scenario, as there are fewer than 2,000 LPCCs licensed in the state as compared to 40,000 MFTs. Although this bill would authorize it, it seems unlikely that a large number of scope-of-service changes would be requested solely to add LPCCs as providers.
- No significant increase in utilization of Medi-Cal clinic services is expected.
PRIOR VOTES:
Assembly Floor: | 76 - 0 |
Assembly Appropriations Committee: | 17 - 0 |
Assembly Health Committee: | 15 - 0 |
COMMENTS:
- Author’s statement. According to the author, with mental health and substance abuse services having been deemed essential health care benefits under the Affordable Care Act (ACA) and the expansion of Medi-Cal to over 12 million beneficiaries, demand for Medi-Cal providers has increased. Approximately 600 FQHCs and 350 RHCs serve a significant portion of California’s uninsured and underinsured and rely on funding from Medi-Cal to employ mental health care providers. Under current law psychologists, LCSWs, and MFTs are eligible for Medi-Cal reimbursement for services they provide at FQHCs and RHCs.
This bill would add LPCCs to those providers that qualify for reimbursement. LPCCs are fully qualified and trained masters-level mental health professionals who have the education, background and training equivalent to LCSWs and MFTs. Adding LPCCs will help span gaps in workforce capacity by providing FQHCs and RHCs with funding to employ LPCCs and meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers. - Background. FQHCs and RHCs are federally designated clinics that provide primary care services that are required to serve medically underserved populations. Medi-Cal reimbursement to FQHCs and RHCs is governed by state and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a per-visit rate which is known as the PPS. The list of providers who are billable by an FQHC and RHC is in statute. Each FQHC and RHC has a specific PPS Medi-Cal rate for each face-to-face encounter, irrespective of the reason for the visit. For Medi-Cal managed care plan patients, DHCS reimburses FQHCs and RHCs for the difference between its per-visit PPS rate and the payment made by the plan. This payment is known as a “wrap around” payment. The Medi-Cal managed care wrap-around rate was established to reimburse providers for the difference between their PPS rate and their Medi-Cal managed care reimbursement rate.
The average ($178.14) and median ($157.24) PPS rate paid to an FQHC and RHC in 2014-15 is considerably higher than the most common primary care visit reimbursement rates in Medi-Cal, but it also includes additional services not included in a primary care visit. The rationale for the enhanced reimbursement is to ensure that FQHCs and RHCs do not use federal grant funds intended for uninsured and special needs populations to back-fill for potentially below-cost Medicare or Medi-Cal rates. Because FQHCs are required to receive an MEI adjustment to their rates under federal law, and because of their role in providing primary care access to the Medi-Cal population, FQHCs have been exempted from the Medi-Cal rate reductions enacted in prior budget years. - Licensed professional clinical counselors. The Board of Behavioral Sciences (BBS) licenses and regulates LPCCs. The LPCC licensure category was created in 2009 by SB 788 (Wyland, Chapter 619, Statutes of 2009). As of April 20, 2017, BBS indicates it licensed 1,486 LPCCs and 2,601 professional counselor interns).
LPCCs are authorized to provide professional clinical counseling, defined as the application of counseling interventions and psychotherapeutic techniques to identify and remediate cognitive, mental, and emotional issues, including personal growth, adjustment to disability, crisis intervention, and psychosocial and environmental problems, and the use, application, and integration of the coursework and training required under existing law. Professional clinical counseling also includes conducting assessments for the purpose of establishing counseling goals and objectives to empower individuals to deal adequately with life situations, reduce stress, experience growth, change behavior, and make well-informed, rational decisions.
In Medi-Cal, DHCS indicates LPCCs cannot bill Medi-Cal fee-for-service, and services rendered by an LPCC are not eligible for federal financial participation in Medicaid. LPCCs are qualified providers of Medi-Cal county mental health plans to provide Targeted Case Management, Mental Health Services, Day Treatment Intensive, Day Rehabilitation, Crisis Intervention, Adult Residential, Crisis Residential, and Psychiatric Health Facility services.
4) Recent changes in Medi-cal coverage for mental health and substance use services. Mental health and substance use disorder services in Medi-Cal have been significantly changed since the implementation of the federal ACA. SB X1 1 (Hernandez and Steinberg, Chapter 4, Statutes of 2013) required Medi-Cal to cover the additional mental and substance use disorder benefits for both the newly eligible expansion population and the current Medi-Cal population. SB X1 1 requires mental health services included in the essential health benefit (EHB) package adopted by the state (the Legislature adopted the Kaiser Small Group Product [Kaiser Product] as the state’s EHB for the individual and small group health insurance market last session) to be covered under Medi-Cal, to the extent those services are not covered Medi-Cal benefits now. The additional mental health benefits required to be provided include group therapy and psychology (for non-specialty mental health program qualifying individuals). In addition, SB X1 1 required Medi-Cal to provide coverage for additional substance abuse disorder services included in the EHB adopted by the state. The additional substance use disorder services provided include:
- Intensive Outpatient Treatment (Day Care Rehabilitation) - For non-pregnant/postpartum beneficiaries (only pregnant women were eligible for this service under Drug Medi-Cal prior to this change);
- Residential Substance Use Disorder Services - For non-pregnant/postpartum beneficiaries (only pregnant women were eligible for this service under Drug Medi-Cal prior to this change); and,
- Elective Inpatient Detox – This benefit was made broadly available (prior to this change, individuals had to have an underlying physical medical condition in order to receive inpatient detoxification services).
SB X1 1 also required Medi-Cal managed care plans to provide coverage for “mental health benefits covered in the state plan, except for those benefits provided by county mental health plans under the Specialty Mental Health Services Waiver. This requirement is commonly referred to as requiring Medi-Cal managed care plans to cover “mild to moderate” mental health services. Under the previous system, Medi-Cal managed care plans covered mental health services within the scope of practice of a primary care physician under their contracts with DHCS, while county specialty mental health plans provided mental health services to individuals with severe mental illness, and Medi-Cal fee-for-service provided services to individuals who fell between those two plans. SB X1 1 effectively provided mid-level mental health services through the Medi-Cal managed care plan, instead of in fee-for-services, with the purpose of better care coordination and access to services.
- Related legislation. SB 323 (Mitchell) would authorize FQHCs and RHCs to receive reimbursement from county specialty mental health plans and through Drug Medi-Cal under the terms of a contract between the FQHC and RHC and either the county or DHCS and outside of the regular Medi-Cal reimbursement structure that applies to FQHCs and RHCs. SB 323 is pending in the Assembly.
SB 456 (Pan) would permit a FQHC or RHC to enter into an agreement with public or private entity willing and qualified to provide services that follow the patient, as defined. SB 456 is pending in the Assembly.
- Prior legislation. SB 147 (Hernandez, Chapter 760, Statutes of 2014) requires DHCS to authorize a three-year payment reform pilot project for FQHCs using an alternative payment methodology (APM) authorized under federal Medicaid law. SB 147 requires an FQHC participating in the pilot to receive a per member per month payment for each of its APM enrollees from a Medi-Cal managed care health plan, instead of the wrap around payment FQHCs currently receive from DHCS.
AB 1863 (Wood, Chapter 610, Statutes of 2016) added MFTs to the list of healthcare professionals that could bill Medi-Cal for purposes of an FQHC or RHC visit. The Administration has proposed delaying implementation of this bill to no sooner than July 1, 2018.
AB 858 (Wood of 2015) included a similar provision adding MFTs to the list of healthcare professionals that could bill Medi-Cal for purposes of an FQHC or RHC visit. SB 858 and five other bills were vetoed by Governor Brown who indicated that:
These bills unnecessarily codify certain existing health care benefits or require the expansion or development of new benefits and procedures in the Medi-Cal program. Taken together, these bills would require new spending at a time when there is considerable uncertainty in the funding of this program.
Until the fiscal outlook for Medi-Cal is stabilized, I cannot support any of these measures.
AB 690 (Wood of 2015) was substantially similar to the provisions of AB 858. AB 690 was held on the Assembly Appropriations suspense file.
AB 1785 (Lowenthal of 2012) would have added MFTs to the list of health care providers whose services are reimbursed through Medi-Cal on a per-visit basis by FQHCs and RHCs. AB 1785 was held on the Assembly Appropriations suspense file.
SB 260 (Steinberg of 2007) was substantially similar to AB 1863. SB 260 was vetoed by Governor Schwarzenegger who cited concerns about the fiscal impact of the bill.
- Support. This bill is sponsored by the California Association for Licensed Professional Clinical Counselors (CALPCC), which indicates that LPCCs are not billable under the Medi-Cal program in FQHC and RHC settings. CALPCC believes that this bill brings parity throughout Medi-Cal program and allows for the utilization of all qualified mental health providers, and provides greater access to mental health services by broadening the pool of providers at these settings. CaliforniaHealth+ Advocates writes in support that allowing LPCCs to serve Medi-Cal patients in health centers will address serious gaps in behavioral health care and bring the state one step closer to addressing the behavioral health crisis in California.
SUPPORT AND OPPOSITION:
Support: California Association for Licensed Professional Clinical Counselors (sponsor)
APLA Health
Association of California Healthcare Districts
Board of Behavioral Sciences
California Council of Community Behavioral Health Agencies
CaliforniaHealth+ Advocates
County Health Executives Association of California
North Coast Clinics Network
Oppose: None received
-- END --
ASSEMBLY THIRD READING
ATR Bill Id:AB 1591
Author:(Berman)
As Amended Ver:March 28, 2017
Majority vote
Committee | Votes | Ayes | Noes |
Health | 15-0 | Wood, Maienschein, Bonta, Burke, Gallagher, Limón, McCarty, Nazarian, Patterson, Quirk-Silva, Ridley-Thomas, Rodriguez, Santiago, Thurmond, Waldron | |
Appropriations | 17-0 | Gonzalez Fletcher, Bigelow, Bloom, Bocanegra, Bonta, Brough, Calderon, McCarty, Quirk, Fong, Friedman, Gallagher, Eduardo Garcia, Gray, Muratsuchi, Obernolte, Reyes |
|
SUMMARY: Adds licensed professional clinical counselors (LPCCs) to the list of healthcare professionals that qualify for a face-to-face encounter with a patient at Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) for purposes of a per-visit Medi-Cal payment under the prospective payment system (PPS).
FISCAL EFFECT: According to the Assembly Appropriations Committee:
- Unknown one-time costs to recalculate the PPS rate for clinics that are providing LPCC services or wish to add those services (General Fund/federal). The bill requires clinics that currently include LPCC services in the costs used to calculate their PPS rate to seek a recalculation of the rate before the clinic is allowed to bill for visits. Recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, assuming the cost per review is about $10,000 and 20 clinics seek a recalculation, the administrative costs to the Department of Health Care Services (DHCS) would be about $200,000. However, a similar bill in 2016 also added marriage and family therapists (MFTs) as allowable providers. If clinics are submitting scope-of-service changes to add MFTs, they could add LPCCs simultaneously at no additional cost. This is a more likely scenario, as there are fewer than 2,000 LPCCs licensed in the state as compared to 40,000 MFTs. Although this bill would authorize it, it seems unlikely that a large number of scope-of-service changes would be requested solely to add LPCCs as providers.
- No significant increase in utilization of Medi-Cal clinic services is expected.
COMMENTS: According to the author, with mental health and substance abuse services having been deemed essential health benefits under the Patient Protection and Affordable Care Act and the expansion of Medi-Cal to over 12 million beneficiaries, demand for Medi-Cal providers has increased. California's approximately 600 FQHCs and 350 RHCs serve a significant portion of the uninsured and underinsured and rely on funding from Medi-Cal to provide critical mental health services. Under current law, psychologists, licensed clinical social workers (LCSWs) and licensed MFTs are eligible for Medi-Cal reimbursement for services they provide at FQHCs and RHCs. This bill would add LPCCs to those providers that qualify for reimbursement. LPCCs are fully qualified and trained masters-level mental health professionals who have the education, background and training equivalent to LMFTs and LCSWs, and authorizing them to be reimbursed in these settings will provide greater access to patients who utilize the services of FQHCs and RHCs. Adding LPCCs will help span gaps in workforce capacity by providing clinics with funding to employ these counselors, and also help to meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers.
FQHCs and RHCs serve a significant portion of the uninsured and Medi-Cal. Reimbursement to FQHCs and RHCs is governed by state and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a per-visit rate which is known as PPS. For Medi-Cal managed care plan patients, DHCS reimburses FQHCs and RHCs for the difference between its per-visit PPS rate and the payment made by the plan. This payment is known as a "wrap around" payment. The Medi-Cal managed care wrap around rate was established to reimburse providers for the difference between their PPS rate and their Medi-Cal managed care reimbursement rate.
DHCS' policy on same day visits, as stated in its State Plan Amendment, is that encounters with more than one health professional and/or multiple encounters with the same health professional, which take place on the same day and at a single FQHC or RHC location, constitute a single visit, except that more than one visit may be counted on the same day: 1) when the clinic patient, after the first visit, suffers illness or injury requiring another diagnosis or treatment; or, 2) when the clinic patient has a face-to-face encounter with a dentist or dental hygienist and then also has a face-to-face encounter with another health professional or comprehensive perinatal services practitioner on the same date. Mental health visits are treated for Medi-Cal billing purposes as a same day visit, and separate billing on the same day for a medical visits and a mental health visit is not allowed.
The California Association for Licensed Professional Clinical Counselors (CALPCC), the sponsor of this bill, indicates that LPCCs are billable and recognized providers under the Medi-Cal program but not in FQHC and RHC settings. CALPCC believes that this bill brings parity throughout Medi-Cal program and allows for the utilization of all qualified mental health providers, and provides greater access to mental health services by broadening the pool of providers at these settings.
There is no opposition to this bill.
Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0000791
Date of Hearing: May 3, 2017
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez Fletcher, Chair
ABPCA Bill Id:AB 1591
Author:(Berman) – As Amended Ver:March 28, 2017
Policy Committee: | Health | Vote: | 15 - 0 |
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Urgency: No State Mandated Local Program: No Reimbursable: No
SUMMARY:
This bill adds licensed professional clinical counselors (LPCCs) to the list of health care professionals whose services are reimbursed through Medi-Cal on a per-visit basis to federally qualified health centers (FQHC) or rural health clinics (RHCs), and specifies procedures for adjusting rates for clinics who elect to bill Medi-Cal for these services.
FISCAL EFFECT:
- Unknown one-time costs to recalculate the prospective payment system (PPS) rate for clinics that are providing LPCC services or wish to add those services (GF/federal). The bill requires clinics that currently include LPCC services in the costs used to calculate their PPS rate to seek a recalculation of the rate before the clinic is allowed to bill for visits. Recalculating a PPS rate requires a detailed review of utilization and expenditures by clinics. For example, assuming the cost per review is about $10,000 and 20 clinics seek a recalculation, the administrative costs to the Department of Health Care Services (DHCS) would be about $200,000. However, a similar bill in 2016 also added marriage and family therapists (MFTs) as allowable providers. If clinics are submitting a scope-of-service changes to add MFTs, they could add LPCCs simultaneously at no additional cost. This is a more likley scenario, as there are fewer than 2,000 LPCCs licensed in the state as compared to 40,000 MFTs. Although this bill would authorize it, it seems unlikely that a large number of scope-of-service changes would be requested solely to add LPCCs as providers.
- No significant increase in utilization of Medi-Cal clinic services is expected.
COMMENTS:
- Purpose. According to the author, allowing clinics to bill for LPCC services will help to meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers. This bill is sponsored by the state association of LPCCs and has no opposition.
- LPCCs. LPCCs are masters-level mental health professionals who have a level of education, background and training similar to licensed MFTs and social workers. All professions are licensed by the Board of Behavioral Sciences within the Department of Consumer Affairs, but the LPCC is a fairly new license type.
- Clinic Reimbursement. Because of their unique role in providing health care to underserved communities and the uninsured, policymakers have historically attempted to ensure that community clinics remain financially viable. Federal law requires federally funded health programs, including Medicaid and Children's Health Insurance Program (CHIP), to pay clinics using a special reimbursement structure commonly called a prospective payment system (PPS). PPS rates are a clinic-specific per-visit rate, and are calculated by dividing costs for Medi-Cal-reimbursable services by Medi-Cal reimbursable visits. PPS rates are also adjusted by a growth rate to account for inflation. In addition, clinics can request a recalculation of their PPS rates based on a change in their scope of services. All clinics must provide at least a defined scope of primary care and mental health services, but may provide additional services as well. If clinics are paid by managed care plans in amounts less than their PPS rates, there is a reconciliation performed to ensure clinics get paid the full PPS rate through a wrap-around payment paid by DCHS. For Medi-Cal, current PPS rates vary from around $80 to over $650 per visit, depending on the mix of services provided at each clinic.
Only certain services and provider types are reimbursable at the PPS rate. This bill would add the cost of LPCC services into the PPS rate, and allow clinics to bill Medi-Cal for an LPCC visit.
- FQHC Payment Reform. The PPS system has been criticized as encouraging a higher volume of services rather than rewarding quality and efficiency, as well as limiting innovation by restricting provider types and care delivery settings. SB 147 (Hernández), Chapter 760, Statutes of 2015, authorizes a three-year payment reform pilot project for federally qualified health centers (FQHCs) using an alternative payment methodology (APM) authorized under federal Medicaid law, but not all clinics will participate. Theoretically, if clinic payment methodology was reformed on a permanent and statewide basis in a way that allowed clinics flexibility to choose provider types, a bill like this, specifying payment for a certain provider type, would not be necessary. But although this possibility is on the horizon, a wholesale change to clinic billing does not appear imminent.
- Prior Legislation. AB 1863 (Wood), Chapter 610, Statutes of 2016 allows MFTs as billable providers for FQHCs and RHCs, similar to what this bill does for LPCCs.
- Related Governor's Budget Proposal. The Governor's budget proposal includes a delayed implementation, to July 1, 2018, of the addition of MFTs pursuant to AB 1836. This budget proposal is pending action in the Legislature.
- Staff Comments. Given that current state law recently authorized the addition of MFTs for inclusion in PPS billing, for the sake of efficiency and consistency, it appears reasonable to allow clinics to also add LPCCs as allowable provider types. If the addition of MFTs and LPCCs was done at the same time, with a single scope-of-service change, this could streamline the addition of these two mental health provider types and reduce potential administrative costs of adding them separately.
Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081
Date of Hearing: April 18, 2017
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
ABPCA Bill Id:AB 1591
Author:(Berman) – As Amended Ver:March 28, 2017
SUBJECT: Medi-Cal: federally qualified health centers and rural health centers: licensed professional clinical counselor.
SUMMARY: Adds licensed professional clinical counselors (LPCCs) to the list of healthcare professionals that qualify for a face-to-face encounter with a patient at Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) for purposes of a per-visit Medi-Cal payment under the prospective payment system (PPS).
EXISTING LAW:
- Establishes the Medi-Cal program to provide comprehensive health benefits to low-income persons administered by the Department of Health Care Services (DHCS).
- Establishes a statutory structure for Medi-Cal payments being made under the PPS. States that these payments are for services provided by FQHCs and RHCs on a per-visit basis with rates determined prospectively.
- Identifies those services that may be reimbursed as services identified in federal law as covered benefits for FQHCs and RHCs.
- Defines visit as a face-to-face encounter with a physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker (LCSW), visiting nurse, dentist, dental hygienist, marriage and family therapist (MFT), optometrist, chiropractor, comprehensive perinatal services practitioner, or adult day health care center. Authorizes other providers if identified in the state plan.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, with mental health and substance abuse services having been deemed essential health benefits (EHBs) under the Patient Protection and Affordable Care Act (ACA) and the expansion of Medi-Cal to over 12 million beneficiaries, demand for Medi-Cal providers has increased. California’s approximately 600 FQHCs and 350 RHCs serve a significant portion of the uninsured and underinsured and rely on funding from Medi-Cal to provide critical mental health services. Under current law, psychologists, LCSWs) and licensed MFTs are eligible for Medi-Cal reimbursement for services they provide at FQHCs and RHCs. This bill would add LPCCs to those providers that qualify for reimbursement. LPCCs are fully qualified and trained masters-level mental health professionals who have the education, background and training equivalent to LMFTs and LCSWs, and authorizing them to be reimbursed in these settings will provide greater access to patients who utilize the services of FQHCs and RHCs. Adding LPCCs will help span gaps in workforce capacity by providing clinics with funding to employ these counselors, and also help to meet the demand for mental health services, particularly in rural or remote areas that have difficulty attracting and retaining health care providers.
- BACKGROUND.
- FQHCs and RHCs. FQHCs and RHCs serve a significant portion of the uninsured and underinsured in California. They are open-door providers that treat patients on a sliding scale fee structure and make their services available regardless of a patient's ability to pay. There are approximately 600 FQHCs and 350 RHCs in California. All FQHCs, and a majority of the RHCs, are either nonprofit community clinics or government entities. Because clinics are safety net providers, their continued survival depends heavily on the stability and adequacy of revenues from the Medi-Cal program. FQHCs and RHCs are paid by Medi-Cal on a "per visit" basis in an amount equal to the clinic's cost of delivering services. Essentially, DHCS calculates the annual cost of care provided by each clinic and divides the total by the number of visits to determine a per visit rate.
Community clinics and health centers provide health care to 14% of Californians. This figure is even higher in rural or remote areas that struggle to attract and retain health care providers. Mental health and substance abuse services are part of the EHBs under the ACA. As such they are a part of Medi-Cal. Along with the expansion of these benefits, the expansion of the Medi-Cal program overall has increased the number of beneficiaries to over 12 million, placing even greater demands on Medi-Cal providers. - Medi-Cal Reimbursement to FQHCs and RHCs. Reimbursement to FQHCs and RHCs is governed by state and federal law. FQHCs and RHCs are reimbursed by Medi-Cal on a per-visit rate which is known as the PPS. For Medi-Cal managed care plan patients, DHCS reimburses FQHCs and RHCs for the difference between its per-visit PPS rate and the payment made by the plan. This payment is known as a “wrap around” payment. The Medi-Cal managed care wrap-around rate was established to reimburse providers for the difference between their PPS rate and their Medi-Cal managed care reimbursement rate.
- Same day visits. DHCS’ policy on same day visits, as stated in its State Plan Amendment, is that encounters with more than one health professional and/or multiple encounters with the same health professional, which take place on the same day and at a single FQHC or RHC location, constitute a single visit, except that more than one visit may be counted on the same day: i) when the clinic patient, after the first visit, suffers illness or injury requiring another diagnosis or treatment; or, ii) when the clinic patient has a face-to-face encounter with a dentist or dental hygienist and then also has a face-to-face encounter with another health professional or comprehensive perinatal services practitioner on the same date. Mental health visits are treated for Medi-Cal billing purposes as a same day visit, and separate billing on the same day for a medical visits and a mental health visit is not allowed.
- Governor’s Budget Proposal. As part of the 2017-18 Budget, the Governor is proposing a July 1, 2018 delayed implementation of AB 1863 (Wood), Chapter 610, Statutes of 2016, which allows MFTs as billable providers for FQHCs and RHCs, similar to what this bill is trying to do for LPCCs. This budget proposal is pending action in the Legislature.
- FQHCs and RHCs. FQHCs and RHCs serve a significant portion of the uninsured and underinsured in California. They are open-door providers that treat patients on a sliding scale fee structure and make their services available regardless of a patient's ability to pay. There are approximately 600 FQHCs and 350 RHCs in California. All FQHCs, and a majority of the RHCs, are either nonprofit community clinics or government entities. Because clinics are safety net providers, their continued survival depends heavily on the stability and adequacy of revenues from the Medi-Cal program. FQHCs and RHCs are paid by Medi-Cal on a "per visit" basis in an amount equal to the clinic's cost of delivering services. Essentially, DHCS calculates the annual cost of care provided by each clinic and divides the total by the number of visits to determine a per visit rate.
- SUPPORT. The California Association for Licensed Professional Clinical Counselors (CALPCC), the sponsor of this bill, indicates that LPCCs are billable and recognized providers under the Medi-Cal program but not in FQHC and RHC settings. CALPCC believes that this bill brings parity throughout Medi-Cal program and allows for the utilization of all qualified mental health providers, and provides greater access to mental health services by broadening the pool of providers at these settings.
- RELATED LEGISLATION. SB 323 (Mitchell), pending in Senate Health Committee, would authorize, if federal financial participation is available, FQHCs and RHCs to elect to enroll as a Drug Medi-Cal certified provider to provide Drug Medi-Cal services pursuant to the terms of a mutually agreed upon contract entered into between the FQHC or RHC and the county or department, as specified, and would set forth the reimbursement requirements for these services.
- PREVIOUS LEGISLATION.
- AB 1863 adds MFTs to the list of healthcare professionals that qualify for a face-to-face encounter with a patient at FQHCs or RHCs for purposes of a per-visit Medi-Cal payment under the PPS.
- SB 1335 (Mitchell) of 2016, would have authorized FQHCs and RHCs to elect to have Drug Medi-Cal and specialty mental health services to be reimbursed on a fee-for-service basis, according to the same criteria that applies to pharmacy and dental services. SB 1335 was held on the Assembly inactive file.
- AB 858 (Wood) of 2015 included a similar provision adding MFTs to the list of healthcare professionals that could bill Medi-Cal for purposes of an FQHC or RHC visit. AB 858 and five other bills were vetoed by Governor Brown who indicated that
such “bills unnecessarily codify certain existing health care benefits or require the expansion or development of new benefits and procedures in the Medi-Cal program. Taken together, these bills would require new spending at a time when there is considerable uncertainty in the funding of this program. Until the fiscal outlook for Medi-Cal is stabilized, I cannot support any of these measures.” - AB 690 (Wood) of 2015 was substantially similar to the provisions of AB1863 but was held in the Assembly Appropriations suspense file.
- SB 260 (Steinberg) of 2007 would have allowed FQHCs to be reimbursed by Medi-Cal for multiple visits by a patient with a single or different health care professional on the same day at a single location, and specifically allows for billing for two visits when a patient has a medical visit and an additional visit with a mental health practitioner or a dental professional. SB 260 was vetoed by Governor Schwarzenegger who cited concerns about the fiscal impact of the bill.
- COMMENT. As indicated above, the Governor is proposing to delay the implementation date of AB 1863 to July 1, 2018. If this budget proposal is signed and implemented, the Committee recommends also delaying implementation of this bill to July 1, 2018, for consistency.
REGISTERED SUPPORT / OPPOSITION:
Support
California Association for Licensed Professional Clinical Counselors (sponsor)
APLA Health
Association of California Healthcare Districts
North Coast Clinics Network
Opposition
None on file.
Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097
Discussed in Hearing
1H
Senate Standing Committee on Appropriations
1MIN
Assembly Floor
1H
Assembly Standing Committee on Appropriations
Bill Author
Bill Co-Author(s):