Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 establishes the Drug Medi-Cal Treatment Program (Drug Medi-Cal), under which the department is authorized to enter into contracts with each county, or enter into contracts directly with certified providers, for the provision of various alcohol and drug use treatment services to Medi-Cal beneficiaries.

Existing law provides that in-person contact between a health care provider and a patient is not required under the Medi-Cal program for services appropriately provided through telehealth, as defined, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. Existing law, for purposes of payment for covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would, to the extent federal financial participation is available and any necessary federal approvals have been obtained, require that a Drug Medi-Cal certified provider receive reimbursement for individual counseling services provided through telehealth by a licensed practitioner of the healing arts or a registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid state plan. The bill would require the department to adopt regulations to implement these provisions by July 1, 2022, but would authorize the department to do so by means of provider bulletins, written guidelines, or similar instructions, until regulations are adopted.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 establishes the Drug Medi-Cal Treatment Program (Drug Medi-Cal), under which the department is authorized to enter into contracts with each county, or enter into contracts directly with certified providers, for the provision of various alcohol and drug use treatment services to Medi-Cal beneficiaries.

Existing law provides that in-person contact between a health care provider and a patient is not required under the Medi-Cal program for services appropriately provided through telehealth, as defined, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. Existing law, for purposes of payment for covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would, to the extent federal financial participation is available and any necessary federal approvals have been obtained, require that a Drug Medi-Cal certified provider receive reimbursement for individual counseling services provided through telehealth by a licensed practitioner of the healing arts or a registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid state plan. The bill would require the department to adopt regulations to implement these provisions by July 1, 2022, but would authorize the department to do so by means of provider bulletins, written guidelines, or similar instructions, until regulations are adopted.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 establishes the Drug Medi-Cal Treatment Program (Drug Medi-Cal), under which the department is authorized to enter into contracts with each county, or enter into contracts directly with certified providers, for the provision of various alcohol and drug use treatment services to Medi-Cal beneficiaries.

Existing law provides that in-person contact between a health care provider and a patient is not required under the Medi-Cal program for services appropriately provided through telehealth, as defined, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. Existing law, for purposes of payment for covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program program provisions.

Existing law provides that in-person contact between a health care provider and a patient is not required under the Medi-Cal program for services appropriately provided through telehealth, as defined, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. Existing law, for purposes of payment for covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would require, upon specific federal participation and approval, the department to allow a licensed practitioner of the healing arts or a certified substance use disorder counselor to receive Medi-Cal reimbursement for covered individual outpatient counseling services for substance use disorder services disorders provided through telehealth in accordance with the Medicaid state plan.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 in-person contact between a health care provider and a patient is not required under the Medi-Cal program for services appropriately provided through telehealth, as defined, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. Existing law, for purposes of payment for covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would require require, upon specific federal participation and approval, the department to allow a licensed practitioner of the healing arts or a certified substance use disorder counselor to receive Medi-Cal reimbursement for substance use disorder services provided through telehealth in accordance with the Medicaid state plan.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 in-person contact between a health care provider and a patient is not required under the Medi-Cal program for services appropriately provided through telehealth, as defined, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. Existing law, for purposes of payment for covered treatment or services provided through telehealth, prohibits the department from limiting the type of setting where services are provided for the patient or by the health care provider.

This bill would require the department to allow a licensed practitioner of the healing arts or a certified substance use disorder counselor to receive Medi-Cal reimbursement for substance use disorder services provided through telehealth in accordance with the Medicaid state plan.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2861

Author:(Salas)

As Amended Ver:August 6, 2018

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Requires a drug Medi-Cal certified provider to receive reimbursement for individual counseling services provided through telehealth, as defined, by a licensed practitioner of the healing arts or registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid state plan, to the extent federal financial participation is available and any necessary federal approvals have been obtained. Requires the Department of Health Care Services (DHCS) to adopt regulations by July 1, 2022, to implement this bill, as specified. Allows DHCS to implement, interpret, or make specific these provisions by means of provider bulletins, written guidelines, or similar instructions from DHCS, until regulations are adopted.

The Senate amendments:

1. Revise to require a drug Medi-Cal certified provider to receive reimbursement for individual counseling services provided through telehealth, as defined, by a licensed practitioner of the healing arts or registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid state plan.
2. Require DHCS to adopt regulations by July 1, 2022, to implement this bill, as specified.
3. Allow DHCS to implement, interpret, or make specific these provisions by means of provider bulletins, written guidelines, or similar instructions from DHCS, until regulations are adopted.

FISCAL EFFECT: According to the Senate Appropriations Committee, DHCS identifies total costs of $173,000 in fiscal year (FY) 2018-19, and $271,000 in FY 2019-20, and ongoing, for 2.0 personnel years (two new positions) to submit a State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS) and update state regulations (50 GF/50 federal funds):

1. Costs of $78,000 in FY 2018-19, and $118,000 for FY 2019-20 and ongoing, for 1.0 permanent, full-time associate governmental program analyst in the Substance Use Disorder Program, Policy, and Fiscal Division to promulgate regulations, bulletins, and program support.
2. Approximately $95,000 in FY 2018-19, and $153,000 for FY 2019-20 and ongoing for 1.0 permanent full-time, Attorney I position in the Office of Legal Services to develop the SPA, Information Notices, and regulations. This position would provide continued legal support including contract development, legal research, consultation, and written legal advice.

COMMENTS: According to the author, substance use disorder (SUD) is one of the greatest threats facing public health in the United States today. Drug overdose is now the leading cause of accidental death, surpassing both car accidents and gun violence. In 2015, 52,404 people in died from drug overdoses nationwide – more than 2.5 times higher than the rate in 2000. In California and across the nation, the public health concern posed by SUD disproportionately affects low income and rural communities. Many rural counties have drug overdose rates that are two to three times higher than the statewide average. Exacerbating the problem is the fact that the communities most affected by SUD also tend to have the least access to treatment. California suffers from a shortage of behavioral health care providers, especially in rural counties. A recent study conducted by the Healthforce Center at the University of California San Francisco highlighted the severe and growing shortage of behavioral health professionals and consequent difficulties in access to treatment, especially for people living in rural areas—the San Joaquin Valley and Inland Empire were found to have the lowest per capita ratios of behavioral health professionals in the state. Rural counties face a number of other barriers that contribute to the lack of treatment access, including fewer facilities, longer distances to those facilities, fewer public transportation options, and a lack of anonymity. SUD treatment provided by licensed substance abuse counselor via telehealth can increase access treatment by removing many of these barriers.

This bill would explicitly extend the benefits of telehealth services for SUDs to the residents of all California counties, thereby helping to ensure timely access to SUD treatment for those most in need.

1. Drug Medi-Cal. Responsibility for Drug Medi-Cal (DMC) services was realigned to the counties as part of 2011 Public Safety Realignment. Pursuant to Proposition 30, state requirements enacted after September 30, 2012, that have an overall effect of increasing the costs already borne by a local agency for programs or levels of service mandated by 2011 Realignment, applying to local agencies only to the extent that the state provides annual funding for the cost increase. The DMC program provides certain medically necessary SUD treatment services. These services are provided by certified providers under contract with the counties or with DHCS.
2. Under the state's Medicaid State Plan, the DMC program currently covers specified services including the following: a) Outpatient Drug Free Treatment Services; b) Intensive Outpatient Treatment (IOT); c) Residential Treatment Services (RTS) for pregnant and postpartum women; and d) Narcotic Treatment Program (NTP). Under the State Plan, face-to-face contact is required for group or individual counseling between a counselor/therapist and a beneficiary.
3. DMC Organized Delivery System. On August 13, 2015, DHCS received approval from the CMS to implement the DMC Organized Delivery System (DMC-ODS) waiver. The DMC-ODS is a pilot program for the organized delivery of health care services for Medicaid eligible individuals with an SUD. DMC-ODS waiver services will include the existing treatment modalities, and additional new and expanded services. New services in opt-in counties include specified withdrawal management, recovery services, case management, physician consultation, and expanded Medication Assisted Treatment (buprenorphine, naloxone, and disulfiram). Counties that opt­-in to participate in the DMC-ODS waiver are required to provide a continuum of care to all eligible beneficiaries modeled after the American Society of Addiction Medicine criteria. Counties were required to submit implementation plans and proposed interim rates for all county-covered SUD services, except for the NTP rates, which are set by DHCS. Participation in the waiver is voluntary for counties and will be implemented on a phase in basis. DMC-ODS waiver services for opt-in counties began in February 2017 on a phase-in basis. Four counties (San Mateo, Riverside, Marin, and Santa Clara) implemented the DMC-ODS waiver in FY 2016-17 with an anticipated 40 counties projected to implement by July 2019.

Under the Special Terms and Conditions (STCs) of the DMC-ODS waiver, outpatient services (counseling services are provided to beneficiaries up to nine hours a week for adults, and less than six hours a week for adolescents), IOT (structured programming services are provided to beneficiaries for a minimum of nine hours with a maximum of 19 hours a week for adults, and a minimum of six hours with a maximum of 19 hours a week for adolescents), recovery services, case management can be provided in-person, by telephone or by telehealth.

Unlike the restriction in the State Plan that requires individual and group counseling to be done face-to-face, the STCs of the waiver authorize services to be provided through telehealth. The practical effect of this bill is to align the State Plan with the services in the waiver, thereby allowing DMC counties that choose not to opt into the DMC-ODS to utilize telehealth.

This bill is supported by health care providers, counties and mental health advocates. The County Behavioral Health Directors Association writes in support that telehealth services are an invaluable tool for increasing treatment capacity across the state at a time when drug overdose is the leading cause of accidental death in the United States. There is no known, registered opposition to this bill.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0004278

 THIRD READING  

Bill No: AB 2861

Author:

Amended: 8/6/18 in Senate

Vote:

SENATE HEALTH COMMITTEE: 9-0, 6/27/18

AYES: Pan, Nguyen, Beall, Hernandez, Leyva, Mitchell, Monning, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/16/18

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

ASSEMBLY FLOOR: 78-0, 5/30/18 - See last page for vote

SUBJECT:

SOURCE: Author

DIGEST:

This bill requires a Drug Medi-Cal certified provider to receive Drug Medi-Cal reimbursement for individual counseling services provided through telehealth, as defined, by a licensed practitioner of the healing arts or a registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid State Plan.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS) and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
   
2. Establishes a schedule of benefits in the Medi-Cal program, which includes substance use disorder (SUD) services included in the essential health benefits package adopted by the state pursuant to the federal Affordable Care Act, known as the Kaiser Small Group Product. [HSC §1367.005, WIC §14132.03]
   
3. Prohibits in-person contact between a health care provider and a patient from being required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by DHCS to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. [WIC §14132.72]
   
4. Defines, “telehealth” as the means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. [BPC §2290.5]
   

This bill:

1. Requires a Drug Medi-Cal certified provider to receive Drug Medi-Cal reimbursement for individual counseling services provided through telehealth, as defined, by a licensed practitioner of the healing arts or a registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid State Plan.
   
2. Implements this bill only to the extent federal financial participation is available and only if any necessary federal approvals have been obtained.
   
3. Requires DHCS to adopt regulations by July 1, 2022, to implement this bill in accordance with the Administrative Procedure Act (APA). Permits DHCS, notwithstanding the rulemaking provisions of the APA, if it deems it appropriate, implement, interpret, or make specific this bill by means of provider bulletins, written guidelines, or similar instructions from DHCS, until regulations are adopted.

Comments

1. Author’s statement. According to the author, SUD is one of the greatest threats facing public health in the United States today. Drug overdose is now the leading cause of accidental death, surpassing both car accidents and gun violence. In 2015, 52,404 people in died from drug overdoses nationwide—more than 2.5 times higher than the rate in 2000. In California and across the nation, the public health concern posed by SUD disproportionately affects low income and rural communities. Many rural counties have drug overdose rates that are two to three times higher than the statewide average. Exacerbating the problem is the fact that the communities most affected by SUD also tend to have the least access to treatment. California suffers from a shortage of behavioral health care providers, especially in rural counties. A recent study conducted by the Healthforce Center at the University of California San Francisco highlighted the severe and growing shortage of behavioral health professionals and consequent difficulties in access to treatment, especially for people living in rural areas—the San Joaquin Valley and Inland Empire were found to have the lowest per capita ratios of behavioral health professionals in the state. Rural counties face a number of other barriers that contribute to the lack of treatment access, including fewer facilities, longer distances to those facilities, fewer public transportation options, and a lack of anonymity. SUD treatment provided by licensed substance abuse counselor via telehealth can increase access treatment by removing many of these barriers.
   
   This bill explicitly extends the benefits of telehealth services for SUDs to the residents of all California counties, thereby helping to ensure timely access to SUD treatment for those most in need.
2. Drug Medi-Cal. Responsibility for Drug Medi-Cal (DMC) services was realigned to the counties as part of 2011 Public Safety Realignment. Pursuant to Proposition 30, state requirements enacted after September 30, 2012, that have an overall effect of increasing the costs already borne by a local agency for programs or levels of service mandated by 2011 Realignment, applying to local agencies only to the extent that the state provides annual funding for the cost increase. The DMC program provides certain medically necessary SUD treatment services. These services are provided by certified providers under contract with the counties or with DHCS.
   
   Under the state’s Medicaid State Plan, the DMC program currently covers specified services including the following: a) Outpatient Drug Free Treatment Services (ODF); b) Intensive Outpatient Treatment (IOT); c) Residential Treatment Services (RTS) for pregnant and postpartum women; and d) Narcotic Treatment Program (NTP). Under the State Plan, face-to-face contact is required for group or individual counseling between a counselor/therapist and a beneficiary.
3. DMC Organized Delivery System. On August 13, 2015, DHCS received approval from the Centers for Medicare and Medicaid Services (CMS) to implement the DMC Organized Delivery System (DMC-ODS) waiver. The DMC-ODS is a pilot program for the organized delivery of health care services for Medicaid eligible individuals with an SUD. DMC-ODS waiver services will include the existing treatment modalities, and additional new and expanded services. New services in opt-in counties include specified withdrawal management, recovery services, case management, physician consultation, and expanded Medication Assisted Treatment (MAT) (buprenorphine, naloxone, and disulfiram). Counties that opt­-in to participate in the DMC-ODS waiver are required to provide a continuum of care to all eligible beneficiaries modeled after the American Society of Addiction Medicine (ASAM) criteria. Counties were required to submit implementation plans and proposed interim rates for all county-covered SUD services, except for the NTP rates, which are set by DHCS. Participation in the waiver is voluntary for counties and will be implemented on a phase in basis. DMC-ODS waiver services for opt-in counties began in February 2017 on a phase-in basis. Four counties (San Mateo, Riverside, Marin, and Santa Clara) implemented the DMC-ODS waiver in FY 2016-17 with an anticipated 40 counties projected to implement by July 2019.

Under the Special Terms and Conditions (STCs) of the DMC-ODS waiver, outpatient services (counseling services are provided to beneficiaries up to nine hours a week for adults, and less than six hours a week for adolescents), IOT (structured programming services are provided to beneficiaries for a minimum of nine hours with a maximum of 19 hours a week for adults, and a minimum of six hours with a maximum of 19 hours a week for adolescents), recovery services, case management can be provided in-person, by telephone or by telehealth.

Unlike the restriction in the Medicaid State Plan that requires individual and group counseling to be done face-to-face, the STCs of the waiver authorize services to be provided through telehealth. The practical effect of this bill is to align the Medicaid State Plan with the services in the waiver, thereby allowing DMC counties that choose not to opt into the DMC-ODS to utilize telehealth.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee, DHCS identifies total costs of $173,000 in fiscal year 2018-19, and $271,000 in fiscal year 2019-20, and ongoing, for 2.0 PYs to submit a State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services and update state regulations (50 General Fund/50 federal fund):

• $78,000 in FY 2018/19, and $118,000 for FY 2019/20 and ongoing, for 1.0 permanent, full-time associate governmental program analyst in the Substance Use Disorder Program, Policy, and Fiscal Division to promulgate regulations, bulletins, and program support.
• $95,000 in Fiscal Year (FY) 2018/19, and $153,000 for FY 2019/20 and ongoing for 1.0 permanent full-time, Attorney I position in the Office of Legal Services (OLS) to develop the SPA, Information Notices, and regulations. This position would provide continued legal support including contract development, legal research, consultation, and written legal advice.

SUPPORT: (Verified 8/13/18)

American Academy of Pediatrics, California

Association of California Healthcare Districts

California Access Coalition

California Academy of Family Physicians

California Chapter of the American College of Emergency Physicians

California Council of Community Behavioral Health Agencies

California State Association of Counties

California Society of Addiction Medicine

Community Clinic of Los Angeles County

County Behavioral Health Directors Association

County of San Diego

Depression and Bipolar Support Alliance

Silicon Valley Leadership Group

OPPOSITION: (Verified 8/13/18)

None received

ARGUMENTS IN SUPPORT: This bill is supported by health care providers, counties and mental health advocates. The County Behavioral Health Directors Association writes in support that telehealth services are an invaluable tool for increasing treatment capacity across the state at a time when drug overdose is the leading cause of accidental death in the United States. Effective addiction treatment relies on behavioral therapy delivered by qualified professionals. Unfortunately, California and the nation suffer from a shortage of behavioral health care providers, a challenge that is particularly acute in rural counties. Counseling by telehealth is an evidence-based approach that can increase access to care by reducing barriers of time and distance, effectively bringing the counselor to the client. Studies have shown little or no difference in patient satisfaction compared to traditional in-person counseling sessions. Telehealth is already widely used to treat Medi-Cal mental health clients in California, and is a component of the DMC-ODS pilot program under the state’s Section 1115 Waiver, which allows for telehealth services to be provided by Licensed Practitioners of the Healing Arts and by Certified SUD Counselors. This bill would explicitly extend the benefits of telehealth services for SUDs to residents of all California counties, thereby helping to ensure timely access to SUD treatment.

ASSEMBLY FLOOR: 78-0, 5/30/18

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

Prepared by:

8/18/18 14:55:25

**** END ****

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2017 - 2018 Regular Session

AB 2861 (Salas) - Medi-Cal: telehealth: substance use disorders

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

Bill Summary:

Requires the Department of Health Care Services (DHCS) to allow a licensed practitioner of the healing arts or a certified substance use disorder counselor to receive Medi-Cal reimbursement for covered individual outpatient counseling services for substance use disorders provided through telehealth, in accordance with the Medicaid state plan, to the extent federal financial participation is available and any necessary federal approvals have been obtained.

Fiscal Impact:

The DHCS identifies total costs of $173,000 in fiscal year 2018-19, and $271,000 in fiscal year 2019-20, and ongoing, for 2.0 PYs to submit a State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services and update state regulations (50 General Fund/50 federal fund):

• $78,000 in FY 2018/19, and $118,000 for FY 2019/20 and ongoing, for 1.0 permanent, full-time associate governmental program analyst in the Substance Use Disorder Program, Policy, and Fiscal Division to promulgate regulations, bulletins, and program support.
• $95,000 in Fiscal Year (FY) 2018/19, and $153,000 for FY 2019/20 and ongoing for 1.0 permanent full-time, Attorney I position in the Office of Legal Services (OLS) to develop the SPA, Information Notices, and regulations. This position would provide continued legal support including contract development, legal research, consultation, and written legal advice.

Background:

The DHCS administers the Medi-Cal program, which provides health care services to qualified individuals who are low-income. As part of 2011 public safety realignment, Drug Medi-Cal program (DMC) administration was realigned to the counties. Under the state’s Medicaid State Plan, the DMC program currently covers specified services including the following: a) Outpatient Drug Free Treatment Services (ODF); b) Intensive Outpatient Treatment (IOT); c) Residential Treatment Services (RTS) for pregnant and postpartum women; and d) Narcotic Treatment Program (NTP). Under the State Plan, face-to-face contact is required for group or individual counseling between a counselor/therapist and a beneficiary.

On August 13, 2015, DHCS received approval from the Centers for Medicare and Medicaid Services (CMS) to implement the DMC Organized Delivery System (DMC-ODS) waiver. The DMC-ODS is a pilot program for the organized delivery of health care services for Medicaid eligible individuals with an SUD. Four counties (San Mateo, Riverside, Marin, and Santa Clara) implemented the DMC-ODS waiver in fiscal year 2016-17 with an anticipated 40 counties projected to implement by July 2019. Unlike the restriction in the State Plan that requires individual and group counseling to be done face-to-face, the STCs of the waiver authorize services to be provided through telehealth. Telehealth is broadly defined by the federal Health Resources and Services Administration as the “use of telecommunications and information technologies to share information, and provide clinical care, education, public health, and administrative services at a distance.”

Proposed Law:

Assembly Bill 2861 includes the following provisions, among others:

• Requires a Drug Medi-Cal certified provider to receive Medi-Cal reimbursement for covered individual counseling services provided through telehealth, as defined, by a licensed practitioner of the healing arts or a registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid state plan.
  
• Implements this bill only to the extent federal financial participation is available and only if any necessary federal approvals have been obtained.
• Requires the department to adopt regulations, by July 1, 2022, to implement the bill in accordance with the Administrative Procedure Act.
• Authorizes the department, if it deems appropriate, to implement, interpret, or make specific the bill’s provisions by provider bulletins, written guidelines, or similar instructions, until regulations are adopted.

Related Legislation:

• AB 205 (Wood, Chapter 738, Statutes of 2017), among other provisions, authorizes the use of clinically appropriate telecommunications technology, including telehealth, as a means of determining annual compliance with the time and distance standards for Medi-Cal managed care or the DHCS’s approval of a request for alternative access standards.
• SB 171 (Hernandez, Chapter 768, Statutes of 2017) requires DHCS to ensure that all covered mental health benefits and SUD benefits are provided in compliance with federal mental health parity regulations for Medicaid, and any subsequent amendment to those regulations, and any associated federal policy guidance issued by the federal Centers for Medicare and Medicaid Services.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 2861

SUBJECT: Medi-Cal: telehealth: substance use disorders.

SUMMARY:

Requires the Department of Health Care Services to allow a licensed practitioner of the healing arts or a certified substance use disorder counselor to receive Medi-Cal reimbursement for covered individual outpatient counseling services for substance use disorders provided through telehealth, in accordance with the Medicaid state plan, to the extent federal financial participation is available and any necessary federal approvals have been obtained.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS) and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
   
2. Establishes a schedule of benefits in the Medi-Cal program, which includes substance use disorder services included in the essential health benefits package adopted by the state pursuant to the federal Affordable Care Act, known as the Kaiser Small Group Product. [HSC §1367.005, WIC §14132.03]
   
3. Prohibits in-person contact between a health care provider and a patient from being required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by DHCS to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program. [WIC §14132.72]
   
4. Defines, “telehealth” as the means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. [BPC §2290.5]
   

This bill:

1. Requires DHCS to allow a licensed practitioner of the healing arts or a certified substance use disorder (SUD) counselor to receive Medi-Cal reimbursement for covered individual outpatient counseling services for SUDs provided through telehealth, in accordance with the Medicaid state plan.
   
2. Implements this bill only to the extent federal financial participation is available and only if any necessary federal approvals have been obtained.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. This bill does not add coverage for a new service, but to the extent reimbursement for services delivered through telehealth increases utilization, costs for drug treatment counseling as well as medication-assisted treatment could increase. A 1% increase in utilization of outpatient drug treatment, intensive outpatient therapy and narcotic treatment program services delivered outside the Drug Medi-Cal Organized Delivery System waiver (explained further below) would be slightly over $2 million statewide annually (General Fund/GF) or county realignment funds/federal).
2. Pursuant to Proposition 30, if reimbursement for telehealth services is considered a state requirement that has the overall effect of increasing local costs for Drug Medi-Cal, this requirement may only be operative to the extent funding is provided for the purpose by the state. It is unclear whether this provision would apply in this case, but if a large spike in utilization and commensurate cost was shown to be associated with the use of telehealth, it seems plausible reimbursement for these services could be a state responsibility.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, SUD is one of the greatest threats facing public health in the United States today. Drug overdose is now the leading cause of accidental death, surpassing both car accidents and gun violence. In 2015, 52,404 people in died from drug overdoses nationwide—more than 2.5 times higher than the rate in 2000. In California and across the nation, the public health concern posed by SUD disproportionately affects low income and rural communities. Many rural counties have drug overdose rates that are two to three times higher than the statewide average. Exacerbating the problem is the fact that the communities most affected by SUD also tend to have the least access to treatment. California suffers from a shortage of behavioral health care providers, especially in rural counties. A recent study conducted by the Healthforce Center at the University of California San Francisco highlighted the severe and growing shortage of behavioral health professionals and consequent difficulties in access to treatment, especially for people living in rural areas—the San Joaquin Valley and Inland Empire were found to have the lowest per capita ratios of behavioral health professionals in the state. Rural counties face a number of other barriers that contribute to the lack of treatment access, including fewer facilities, longer distances to those facilities, fewer public transportation options, and a lack of anonymity. SUD treatment provided by licensed substance abuse counselor via telehealth can increase access treatment by removing many of these barriers.
   
   This bill would explicitly extend the benefits of telehealth services for SUDs to the residents of all California counties, thereby helping to ensure timely access to SUD treatment for those most in need.
2. Drug Medi-Cal. Responsibility for Drug Medi-Cal (DMC) services was realigned to the counties as part of 2011 Public Safety Realignment. Pursuant to Proposition 30, state requirements enacted after September 30, 2012, that have an overall effect of increasing the costs already borne by a local agency for programs or levels of service mandated by 2011 Realignment, applying to local agencies only to the extent that the state provides annual funding for the cost increase. The DMC program provides certain medically necessary SUD treatment services. These services are provided by certified providers under contract with the counties or with DHCS.
   
   Under the state’s Medicaid State Plan, the DMC program currently covers specified services including the following: a) Outpatient Drug Free Treatment Services (ODF); b) Intensive Outpatient Treatment (IOT); c) Residential Treatment Services (RTS) for pregnant and postpartum women; and d) Narcotic Treatment Program (NTP). Under the State Plan, face-to-face contact is required for group or individual counseling between a counselor/therapist and a beneficiary.
3. DMC Organized Delivery System. On August 13, 2015, DHCS received approval from the Centers for Medicare and Medicaid Services (CMS) to implement the DMC Organized Delivery System (DMC-ODS) waiver. The DMC-ODS is a pilot program for the organized delivery of health care services for Medicaid eligible individuals with an SUD. DMC-ODS waiver services will include the existing treatment modalities, and additional new and expanded services. New services in opt-in counties include specified withdrawal management, recovery services, case management, physician consultation, and expanded Medication Assisted Treatment (MAT) (buprenorphine, naloxone, and disulfiram). Counties that opt­-in to participate in the DMC-ODS waiver are required to provide a continuum of care to all eligible beneficiaries modeled after the American Society of Addiction Medicine (ASAM) criteria. Counties were required to submit implementation plans and proposed interim rates for all county-covered SUD services, except for the NTP rates, which are set by DHCS. Participation in the waiver is voluntary for counties and will be implemented on a phase in basis. DMC-ODS waiver services for opt-in counties began in February 2017 on a phase-in basis. Four counties (San Mateo, Riverside, Marin, and Santa Clara) implemented the DMC-ODS waiver in FY 2016-17 with an anticipated 40 counties projected to implement by July 2019.

Under the Special Terms and Conditions (STCs) of the DMC-ODS waiver, outpatient services (counseling services are provided to beneficiaries up to nine hours a week for adults, and less than six hours a week for adolescents), IOT (structured programming services are provided to beneficiaries for a minimum of nine hours with a maximum of 19 hours a week for adults, and a minimum of six hours with a maximum of 19 hours a week for adolescents), recovery services, case management can be provided in-person, by telephone or by telehealth.

Unlike the restriction in the State Plan that requires individual and group counseling to be done face-to-face, the STCs of the waiver authorize services to be provided through telehealth. The practical effect of this bill is to align the State Plan with the services in the waiver, thereby allowing DMC counties that choose not to opt into the DMC-ODS to utilize telehealth.

1. Related legislation. AB 2576 (Aguiar-Curry) provides, only to the extent that federal financial participation is available, that neither face-to-face contact nor a patient’s physical presence on the premises of an enrolled community clinic, is required for services provided by the clinic to a Medi-Cal beneficiary during or immediately following a state of emergency, as specified. Requires that telehealth services, telephonic services, and other specified services be reimbursable when provided by an enrolled community clinic during a state of emergency. AB 2576 passed the Senate Health Committee by a vote of 9-0 on June 20, 2018.
   

SB 1023 (Hernandez) requires the Family Planning, Access, Care, and Treatment (Family PACT) program to cover services provided by a Family PACT provider through direct video and telephonic communications with a provider and direct or asynchronous care provided through a smart phone application that is appropriate to be delivered remotely based on current clinical guidelines. SB 1023 is set for hearing on June 26, 2018 in the Assembly Health Committee.

1. Prior legislation. AB 205 (Wood, Chapter 738, Statutes of 2017) among other provisions, authorizes the use of clinically appropriate telecommunications technology, including telehealth, as a means of determining annual compliance with the time and distance standards for Medi-Cal managed care (including DMC), or the DHCS’s approval of a request for alternative access standards.

SB 171 (Hernandez, Chapter 768, Statutes of 2017) requires DHCS to ensure that all covered mental health benefits and SUD benefits are provided in compliance with federal mental health parity regulations for Medicaid, and any subsequent amendment to those regulations, and any associated federal policy guidance issued by the federal Centers for Medicare and Medicaid Services.

AB 2507 (Gordon of 2016) would have added video communications and telephone communications to the definition of telehealth and would have provided that the required prior consent for telehealth services may be digital, oral, or written. AB 2507 was held in the Assembly Appropriations Committee.

SB 289 (Mitchell of 2015) would have required health plans or health insurers to cover telephonic and electronic patient management services provided by a physician or non-physician health care provider and to reimburse those services based on their complexity and time expenditure. SB 289 was held on the Senate Appropriations Committee suspense file.

AB 1771 (V. Manuel Pérez, of 2014) would have required health plans and health insurers, with respect to plan contracts and insurance policies issued, amended, or renewed on or after January 1, 2016, to cover telephone visits provided by a physician. AB 1771 was held on the Senate Appropriations Committee suspense file.

AB 809 (Logue, Chapter 404, Statutes of 2014) revises the informed consent requirements relating to the delivery of health care via telehealth by permitting consent to be made verbally or in writing, and by deleting the requirement that the health care provider who obtains the consent be at the originating site where the patient is physically located.

AB 1733 (Logue, Chapter 782, Statutes of 2012) specifies that the prohibition on requiring in-person contact also applies to other health care service plan contracts with DHCS for services under the Medi-Cal program, and publicly supported programs other than Medi-Cal, as well as to the organizations implementing Programs of All-Inclusive Care for the Elderly.

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

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

1. Support. This bill is supported by health care providers, counties and mental health advocates. The County Behavioral Health Directors Association writes in support that telehealth services are an invaluable tool for increasing treatment capacity across the state at a time when drug overdose is the leading cause of accidental death in the United States. Effective addiction treatment relies on behavioral therapy delivered by qualified professionals. Unfortunately, California and the nation suffer from a shortage of behavioral health care providers, a challenge that is particularly acute in rural counties. Counseling by telehealth is an evidence-based approach that can increase access to care by reducing barriers of time and distance, effectively bringing the counselor to the client. Studies have shown little or no difference in patient satisfaction compared to traditional in-person counseling sessions. Telehealth is already widely used to treat Medi-Cal mental health clients in California, and is a component of the DMC-ODS pilot program under the state’s Section 1115 Waiver, which allows for telehealth services to be provided by Licensed Practitioners of the Healing Arts and by Certified SUD Counselors. This bill would explicitly extend the benefits of telehealth services for SUDs to residents of all California counties, thereby helping to ensure timely access to SUD treatment.
   

SUPPORT AND OPPOSITION:

Support: American Academy of Pediatrics, California

California Access Coalition

California Academy of Family Physicians

California Chapter of the American College of Emergency Physicians

California Council of Community Behavioral Health Agencies

California State Association of Counties

California Society of Addiction Medicine

Community Clinic of Los Angeles County

County Behavioral Health Directors Association

County of San Diego

Depression and Bipolar Support Alliance

Silicon Valley Leadership Group

Oppose: None received

ASSEMBLY THIRD READING

ATR Bill Id:

Author:(Salas)

As Amended Ver:May 25, 2018

Majority vote

SUMMARY: Requires the Department of Health Care Services (DHCS) to allow a licensed practitioner of the healing arts or a certified substance use disorder (SUD) counselor to receive Medi-Cal reimbursement for covered individual outpatient counseling services for SUD services provided through telehealth, as defined, in accordance with the Medicaid state plan.

FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill does not add coverage for a new service, but to the extent reimbursement for services delivered through telehealth increases utilization, costs for drug treatment counseling as well as medication-assisted treatment could increase. A 1% increase in utilization of narcotic treatment program, outpatient drug treatment, and intensive outpatient therapy services delivered outside the Drug Medi-Cal Organized Delivery System (DMC-ODS) waiver (explained further below) would be slightly over $2 million statewide annually (general fund or county realignment funds/federal).   

Pursuant to Proposition 30, if reimbursement for telehealth services is considered a state requirement that has the overall effect of increasing local costs for Drug Medi-Cal, this requirement may only be operative to the extent funding is provided for the purpose by the state. It is unclear whether this provision would apply in this case, but if a large spike in utilization and commensurate cost was shown to be associated with the use of telehealth, it seems plausible reimbursement for these services could be a state responsibility. 

COMMENTS: According to the author, this bill removes barriers to SUD treatment provided via telehealth to ensure timely and effective patient access. At a time when the nation is suffering from an opioid epidemic and drug overdose rates have become the leading cause of accidental death, it is critical that those suffering from SUD have access to treatment. Furthermore, the public health concern posed by SUD disproportionately affects low income and rural communities. Many rural counties have drug overdose rates that are two to three times higher than the statewide average. At the same time, these communities also have the greatest barriers to access. Rural counties face a number of barriers that contribute to the lack of treatment access, including a behavioral health professional shortage, fewer facilities, longer distances to those facilities, fewer public transportation options, and a lack of anonymity. Telehealth can increase access to SUD treatment by removing many of these barriers by using modern technology. This bill would explicitly extend the benefits of telehealth services for SUD to the residents of all California counties, thereby helping to ensure access to SUD treatment for those most in need.

1. DMC-ODS. The DMC-ODS is a voluntary pilot program that offers California counties the opportunity to expand access to high-quality care for Medi-Cal enrollees with SUD, with some counties including telehealth services. The goal of the DMC-ODS is to demonstrate how organized SUD care improves beneficiary health outcomes, while decreasing system-wide health care costs. Counties that choose to participate in the DMC-ODS are required to provide access to a full continuum of SUD benefits modeled after the American Society of Addiction Medicine (ASAM) Criteria. Counties must opt-in to participate in the program. While there is a list of required services participating counties must provide, the medication assisted therapy (MAT) services are optional (MAT also has as a part of it counseling services). Currently, 19 counties have had their plans approved by DHCS, with 16 incorporating telehealth into their county plans primarily for counseling and care coordinating purposes. However, group counseling cannot be conducted via telehealth. This approach is expected to provide eligible enrollees with access to the care and services they need for a sustainable and successful recovery. The DMC-ODS is a pilot program to test a new type of health care services delivery system for SUD and is meant to make improvements over the current DMC system. Critical elements of the DMC-ODS are:
   1. Provides a continuum of care modeled after the ASAM Criteria for SUD treatment services;
   2. Increases local control and accountability with greater administrative oversight;
   3. Creates utilization controls to improve care and efficient use of resources;
   4. Increases program oversight and integrity;
   5. Provides more intensive services for the criminal justice population;
   6. Requires evidence-based practices in substance abuse treatment; and,
   7. Increases coordination with other systems of care including physical and mental health.
   8. MAT Expansion Project. In 2017, under the 21st Century Cures Act, California was allocated $89 million for a two year State Targeted Response to the Opioid Crisis Grant that is administered by Substance Abuse and Mental Health Administration. California is using this funding for a project called the MAT Expansion. The focus of the project will be on populations with limited MAT access including rural areas, American Indian and Native Alaskan tribal communities and statewide access to buprenorphine. The two projects are:
      1. The California Hub and Spoke System (CA H&SS); and,
      2. Tribal MAT Project.

The CA H&SS is based on a hub and spoke model from Vermont. Nineteen applicants were selected to act as “hubs” and will cover 32 counties, seven of which are in the top 10 counties with the highest opioid overdose rates. The hubs are opioid treatment programs that will provide care for complex patients, all MAT options, and consultative support to “spokes,” which are primary care or other practices able to prescribe buprenorphine.

1. Telehealth. Access to providers and health care services is an ongoing concern among stakeholders and policymakers throughout the state. In an effort to ensure quality services are accessible to patients, health reform policies have focused on innovative methods, such as telehealth, to deliver care. Telehealth uses telecommunication tools and technologies to connect providers to patients who may otherwise have limited access to care. In doing so, it provides a means of delivering care and services, including diagnosis, treatment, and patient education. The California HealthCare Foundation reports that health plans, providers, and information technology vendors are currently using telehealth applications to increase quality of care, reduce costs, and increase access for the underserved, and that studies have demonstrated telehealth services have improved outcomes and continuity of care for patients, particularly in rural settings. AB 415 (Logue), Chapter 547, Statutes of 2011, established the Telehealth Advancement Act to revise and update existing law to facilitate the advancement of telehealth as a service delivery mode in managed care and the Medi-Cal program.

The California State Association of Counties (CSAC) states that California suffers from a shortage of behavioral health care providers, and is particularly acute in rural counties. According to CSAC, this bill would extend the benefits of telehealth services for SUDs to residents of all California counties to help ensure timely access to critically needed SUD treatment. There is no opposition to this bill.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0003350

Date of Hearing: May 23, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 2861

Author:(Salas) – As Amended Ver:April 26, 2018

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

SUMMARY:

This bill requires the Department of Health Care Services (DHCS) to allow a licensed practitioner of the healing arts or a certified substance use disorder (SUD) counselor to receive Medi-Cal reimbursement for SUD services provided through telehealth, as defined, in accordance with the Medicaid state plan.

FISCAL EFFECT:

This bill does not add coverage for a new service, but to the extent reimbursement for services delivered through telehealth increases utilization, costs for drug treatment counseling as well as medication-assisted treatment could increase. A 1% increase in utilization of outpatient drug treatment, intensive outpatient therapy and narcotic treatment program services delivered outside the Drug Medi-Cal Organized Delivery System waiver (explained further below) would be slightly over $2 million statewide annually (GF or county realignment funds/federal).

Pursuant to Proposition 30, if reimbursement for telehealth services is considered a state requirement that has the overall effect of increasing local costs for Drug Medi-Cal, this requirement may only be operative to the extent funding is provided for the purpose by the state. It is unclear whether this provision would apply in this case, but if a large spike in utilization and commensurate cost was shown to be associated with the use of telehealth, it seems plausible reimbursement for these services could be a state responsibility.

COMMENTS:

1. Purpose. This bill is intended to increase access to Medi-Cal drug counseling services reimbursed through telehealth. The author explains this change would help people in rural communities gain access to drug counseling services.
2. Drug Medi-Cal. Local delivery systems for Medi-Cal drug treatment services vary by county. Forty counties have opted into a relatively new "Drug Medi-Cal Organized Delivery System" (DMC-ODS) waiver, whereby counties have developed a network of providers and use standardized criteria to provide an appropriate level of services. The federal-state agreement on the parameters of the waiver, called the Special Terms and Conditions (STCs), for this DMC-ODS waiver is explicit that individual counseling services may be provided through telehealth. However, such reimbursement is not explicitly allowed in the counties that are not participating in the waiver.

Core Medi-Cal drug treatment services include individual and group counseling, intensive outpatient treatment, perinatal residential treatment, and methadone therapy through the narcotic treatment program. DMC-ODS counties, which account for over 97% of the state's population, will also offer a suite of additional services, including expanded medication-assisted treatments, non-perinatal residential treatment, recovery services, case management, and more.

Many rural counties have significantly higher rates of drug addiction and overdose deaths than do more urban counties. Around 1 million people in the state, largely in rural areas, live outside of a DMC-ODS waiver county and are unlikely to be able to access drug treatment services through telehealth. Current law requires reimbursement for psychiatry delivered through telehealth, but not for counseling delivered by the SUD counselors who commonly provide this service.

1. Effectiveness of services. The California Health Benefits Review Program (CHBRP) reviewed the medical effectiveness of mental health services provided through telehealth. According to CHBRP, telehealth is increasingly being used to overcome barriers to care, especially geographical barriers. Rural communities face greater challenges in accessing mental health and substance use treatment services as a result of difficulty recruiting and obtaining qualified professionals. Telehealth services offer the potential benefit of increasing access to care in these communities. CHBRP reports there is a large body of evidence on the effects of telehealth, specifically videoconferencing, on health outcomes for the treatment of mental health conditions. In 2016, CHBRP identified four randomized controlled trials and a systematic review that reported that outcomes for psychiatry and counseling delivered by live videoconferencing did not differ from in-person care.
2. Funding for Drug Medi­Cal services. Responsibility for Drug Medi-Cal was realigned to the counties in 2011. Pursuant to Proposition 30, state requirements enacted after September 30, 2012, that have the overall effect of increasing the costs already borne by a local agency for programs or levels of service mandated by 2011 realignment shall apply to local agencies only to the extent that the state provides annual funding for the increase.
3. Staff Comments. A number of counties are in some level of DMC-ODS waiver implementation, while most have not yet launched. It is unclear whether this bill will, or is intended to, apply in those counties prior to implementation. The author may wish to be more explicit on this point.

In addition, there are some substance use disorder services that are not appropriately delivered through telehealth. The author may wish to narrow this bill to focus on services that are appropriate for delivery through telehealth.

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

Date of Hearing: April 24, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2861

Author:(Salas) – As Introduced Ver:February 16, 2018

SUBJECT: Medi-Cal: telehealth: substance use disorder services.

SUMMARY: Requires the Department of Health Care Services (DHCS) to allow a licensed practitioner of the healing arts (LPHA) or a certified substance use disorder (SUD) counselor to receive Medi-Cal reimbursement for SUD services provided through telehealth, as defined, in accordance with the Medicaid state plan.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services.
2. Requires the DHCS to ensure that all covered mental health benefits and substance use disorder benefits, as defined, are provided in compliance with federal regulations governing mental health parity requirements to address the application of certain mental health parity requirements under a specified federal law to certain Medicaid managed care plans, Medicaid benchmark and benchmark-equivalent plans, and the Children’s Health Insurance Program.
3. Provides that in-person contact between a health care provider and a patient is not required under the Medi-Cal program for services appropriately provided through telehealth, as defined, subject to reimbursement policies adopted by DHCS to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed under the Medi-Cal program. Prohibits, for purposes of payment for covered treatment or services provided through telehealth, DHCS from limiting the type of setting where services are provided for the patient or by the health care provider.
4. Defines telehealth as the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. States that telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.
5. Defines originating site as a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.
6. Prohibits providers from prescribing or dispensing dangerous drugs or dangerous devices on the internet without an appropriate prior examination and medical indication.
7. Establishes various health arts boards within the Department of Consumer Affairs, including boards for physicians and surgeons, nurses, dentists, acupuncturists, etc.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill removes barriers to SUD treatment provided via telehealth to ensure timely and effective patient access. At a time when the nation is suffering from an opioid epidemic and drug overdose rates have become the leading cause of accidental death, it is critical that those suffering from SUD have access to treatment. Furthermore, the public health concern posed by SUD disproportionately affects low income and rural communities. Many rural counties have drug overdose rates that are two to three times higher than the statewide average. At the same time, these communities also have the greatest barriers to access. Rural counties face a number of barriers that contribute to the lack of treatment access, including a behavioral health professional shortage, fewer facilities, longer distances to those facilities, fewer public transportation options, and a lack of anonymity. Telehealth can increase access to SUD treatment by removing many of these barriers by using modern technology. This bill would explicitly extend the benefits of telehealth services for SUD to the residents of all California counties, thereby helping to ensure access to SUD treatment for those most in need.
2. BACKGROUND.
   1. Drug Medi-Cal Organized Delivery System Waiver (DMC-ODS). The DMC-ODS is a voluntary pilot program that offers California counties the opportunity to expand access to high-quality care for Medi-Cal enrollees with SUD, with some counties including telehealth services. The goal of the DMC-ODS is to demonstrate how organized SUD care improves beneficiary health outcomes, while decreasing system-wide health care costs. Counties that choose to participate in the DMC-ODS are required to provide access to a full continuum of SUD benefits modeled after the American Society of Addiction Medicine (ASAM) Criteria. Counties must opt-in to participate in the program. While there is a list of required services participating counties must provide, the medication assisted therapy (MAT) services are optional (MAT also has as a part of it counseling services). Currently, 19 counties have had their plans approved by DHCS, with 16 incorporating telehealth into their county plans primarily for counseling and care coordinating purposes. However, group counseling cannot be conducted via telehealth. This approach is expected to provide eligible enrollees with access to the care and services they need for a sustainable and successful recovery. The DMC-ODS is a pilot program to test a new type of health care services delivery system for SUD and is meant to make improvements over the current DMC system. Critical elements of the DMC-ODS are:
      1. Provides a continuum of care modeled after the ASAM Criteria for SUD treatment services;
      2. Increases local control and accountability with greater administrative oversight;
      3. Creates utilization controls to improve care and efficient use of resources;
      4. Increases program oversight and integrity;
      5. Provides more intensive services for the criminal justice population;
      6. Requires evidence-based practices in substance abuse treatment; and,
      7. Increases coordination with other systems of care including physical and mental health.
   2. MAT Expansion Project. In 2017, under the 21^st Century Cures Act, California was allocated $89 million for a two year State Targeted Response to the Opioid Crisis Grant that is administered by Substance Abuse and Mental Health Administration (SAMHSA). California is using this funding for a project called the MAT Expansion. The focus of the project will be on populations with limited MAT access including rural areas, American Indian and Native Alaskan tribal communities and statewide access to buprenorphine. The two projects are:
      1. The California Hub and Spoke System (CA H&SS); and,
      2. Tribal MAT Project.

The CA H&SS is based on a hub and spoke model from Vermont. Nineteen applicants were selected to act as “hubs” and will cover 32 counties, seven of which are in the top 10 counties with the highest opioid overdose rates. The hubs are opioid treatment programs that will provide care for complex patients, all MAT options, and consultative support to “spokes,” which are primary care or other practices able to prescribe buprenorphine.

• 1. Telehealth. Access to providers and health care services is an ongoing concern among stakeholders and policymakers throughout the state. In an effort to ensure quality services are accessible to patients, health reform policies have focused on innovative methods, such as telehealth, to deliver care. Telehealth uses telecommunication tools and technologies to connect providers to patients who may otherwise have limited access to care. In doing so, it provides a means of delivering care and services, including diagnosis, treatment, and patient education. The California HealthCare Foundation reports that health plans, providers, and information technology vendors are currently using telehealth applications to increase quality of care, reduce costs, and increase access for the underserved, and that studies have demonstrated telehealth services have improved outcomes and continuity of care for patients, particularly in rural settings. AB 415 (Logue), Chapter 547, Statutes of 2011, established the Telehealth Advancement Act to revise and update existing law to facilitate the advancement of telehealth as a service delivery mode in managed care and the Medi-Cal program.
  2. Modalities. According to the Center for Connected Health Policy, there are four traditional modalities of telehealth in which services can be delivered:
     1. Live Video is the use of video technology where patients and providers (or in some cases provider to provider) interact in real time (synchronous). This is the modality most frequently used in delivering services and also the most commonly reimbursed by both public and private payers.
     2. Store and Forward is the capturing and relaying of information to a provider when the patient is not immediately involved. The information is not looked at in “real time” so it is an asynchronous interaction. For example, an image of a skin condition is captured in a high-resolution photograph and then sent over a secure system to a dermatologist who will reply to the primary care provider with a diagnosis or further instructions. Electronic consultation, or eConsult, an asynchronous dialogue initiated by a physician or other qualified health care professional seeking a specialist consultant's expert opinion, and includes a written report to the initiator, is also a form of this modality.
     3. Remote Patient Monitoring (RPM) is the continuous monitoring of a patient by a provider from a distance. This can take place in real time (for example when an intensivist monitors an Intensive Care Unit patient form another location) or not in real time (for example, when a patient has hypertension and sends to his/her provider daily blood pressure readings who may look at the week’s information at the end of the week). Studies have shown potential health benefits and savings, especially in treating chronic diseases where issues could be identified before they deteriorate into more serious and costly episodes. RPM is not as widely used partly due to the limited reimbursement available.
     4. mHealth refers to the use of a mobile device to receive either some health service or education/information many times using an application. mHealth encompasses all three of the previous modalities, but it is how those services are accessed that makes it different. This is the modality with the least amount of specific established policy for it, either in California or in other states and federally.
  3. California Health Benefits Review Program (CHBRP) analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes of 2015, added an impact assessment on essential health benefits, and legislation that impacts health insurance benefit designs, cost sharing, premiums, and other health insurance topics. The Committee requested CHBRP to conduct a review of available literature on Medi-Cal covered telehealth treatments for substance use disorders.
     
     According to CHBRP, this bill requires DHCS to allow a LPHA or a certified substance use disorder counselor to receive Medi-Cal reimbursement for substance use disorder services provided through telehealth in accordance with the Medicaid state plan. Definitions of a LPHA vary by state. In California, the following providers meet the requirements of a LPHA:
     
     1. Psychiatrist, Medical Doctor, Psychiatric Resident (Licensed or Unlicensed);
     2. Licensed Clinical Psychologist;
     3. Licensed Clinical Social Worker;
     4. Licensed Marriage and Family Therapist;
     5. Licensed Professional Clinical Counselor I;
     6. Licensed Professional Clinical Counselor II;
     7. Registered Nurse, Nurse Practitioner, Nurse Practitioner Intern; and,
     8. Physician Assistant.

SUDs occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment. According to SAMHSA’s National Survey on Drug Use and Health, 20.2 million adults (8.4%) had a substance use disorder. SAMHSA classifies the most common substance use disorder in the United States into the following categories: alcohol use disorder, tobacco use disorder, cannabis use disorder, stimulant use disorder, hallucinogen use disorder, and opioid use disorder.

According to the National Institute on Drug Abuse, behavioral therapies help engage people in drug abuse treatment, increase abstinence, and help modify their behaviors and coping mechanisms related to drug abuse. A number of evidence-based therapies have been shown to be effective in treating substance use disorders, including Cognitive Behavioral Therapy, Motivational Enhancement Therapy, MAT, and Contingency Management Interventions. These treatments often involve mental health and specific substance use treatment providers, ranging from psychiatrists, psychologists, therapists, counselors, and substance abuse counselors to peer providers.

According to CHBRP, telehealth is being used increasingly to overcome barriers to care, especially geographical barriers. Rural communities face greater challenges in accessing mental health and substance use treatment services as a result of difficulty recruiting and obtaining qualified professionals. Telehealth services offer the potential benefit of increasing access to care in these communities. There is a large body of evidence on the effects of telehealth, specifically videoconferencing, on health outcomes for the treatment of mental health conditions. In 2016, CHBRP identified four randomized controlled trials and a systematic review that reported that outcomes for psychiatry and counseling delivered by live videoconferencing did not differ from in-person care.

According to CHBRP, the medical effectiveness review for this report summarized the available literature on Medi-Cal covered telehealth treatments for substance use disorders. Though there is a larger body of literature on telehealth treatments for other areas, such as mental health treatment, there is limited high-quality literature available specifically examining treatment for substance use disorders. It should be noted that a grading of insufficient evidence is given when there is an absence of robust, high-quality studies available in the literature, it does not mean there is no effect; it means that the effect is unknown. Additional research is needed to definitively examine the potential for telehealth to improve substance use disorder treatment in the Medi-Cal population.

1. SUPPORT. The California State Association of Counties (CSAC) states that California suffers from a shortage of behavioral health care providers, and is particularly acute in rural counties. According to CSAC, this bill would extend the benefits of telehealth services for SUDs to residents of all California counties to help ensure timely access to critically needed SUD treatment.
2. RELATED LEGISLATION.
   1. AB 2576 (Aguiar-Curry) provides, only to the extent that federal financial participation is available, that neither face-to-face contact nor a patient’s physical presence on the premises of an enrolled community clinic, is required for services provided by the clinic to a Medi-Cal beneficiary during or immediately following a state of emergency, as specified. Requires that telehealth services, telephonic services, and other specified services be reimbursable when provided by an enrolled community clinic during a state of emergency. AB 2576 is pending in Assembly Appropriations.
   2. SB 1023 (Ed Hernandez) requires the Family Planning, Access, Care, and Treatment (PACT) program to cover services provided by a Family PACT provider through direct video and telephonic communications with a provider and direct or asynchronous care provided through a smart phone application that is appropriate to be delivered remotely based on current clinical guidelines. SB 1023 is pending in Senate Health Committee.
3. PREVIOUS LEGISLATION.
   1. AB 205 (Wood), Chapter 738, Statutes of 2017, authorizes the use of clinically appropriate telecommunications technology, including telehealth, as a means of determining annual compliance with the time and distance standards established in the bill or the DHCS’s approval of a request for alternative access standards.
   2. SB 171 (Hernandez) Chapter 768, Statutes of 2017 requires DHCS to ensure that all covered mental health benefits and substance use disorder benefits are provided in compliance with federal mental health parity regulations for Medicaid, and any subsequent amendment to those regulations, and any associated federal policy guidance issued by the federal Centers for Medicare and Medicaid Services.
   3. AB 2507 (Gordon) of 2016 would have added video communications and telephone communications to the definition of telehealth. AB 2507 would have provided that the required prior consent for telehealth services may be digital as well as oral or written. AB 2507 was held in the Assembly Appropriations Committee.
   4. SB 289 (Mitchell) of 2015, would have required health plans or health insurers to cover telephonic and electronic patient management services provided by a physician or non-physician health care provider and reimburse those services based on their complexity and time expenditure. SB 289 was held in the Senate Appropriations Committee.
   5. AB 1771 (V. Manuel Pérez), of 2014, would have required health plans and health insurers, with respect to plan contracts and insurance policies issued, amended, or renewed on or after January 1, 2016, to cover telephone visits provided by a physician. AB 1771 was held in the Senate Appropriations Committee.
   6. AB 809 (Logue), Chapter 404, Statutes of 2014, revises the informed consent requirements relating to the delivery of health care via telehealth by permitting consent to be made verbally or in writing, and by deleting the requirement that the health care provider who obtains the consent be at the originating site where the patient is physically located.
   7. AB 1733 (Logue), Chapter 782, Statutes of 2012, specifies that the prohibition on requiring in-person contact also applies to other health care service plan contracts with the DHCS for services under the Medi-Cal program, and publicly supported programs other than Medi-Cal, as well as to the organizations implementing Programs of All-Inclusive Care for the Elderly.
   8. AB 415 (Logue), Chapter 547, Statutes of 2011, among other provisions, prohibits DHCS from requiring that a health care provider document a barrier to an in-person visit prior to paying for services provided via telehealth to a Medi-Cal beneficiary. Repeals the prohibition of paying for a service provided by telephone or facsimile and would instead prohibit DHCS from limiting the type of setting where services are provided for the patient. Prohibits health plans and insurers from requiring that in-person contact occur between a health care provider and a patient before payment is made for the services appropriately provided through telehealth, subject to the terms of the relevant contract. Repeals the prohibition for paying for a service provided by telephone or facsimile and would instead prohibit health plans and insurers from limiting the type of setting where services are provided for the patient or by the health care provider.
   9. SB 1665 (Thompson), Chapter 864, Statutes of 1996, established the Telemedicine Development Act (TDA) to set standards for the use of telemedicine by health care practitioners and insurers. TDA specifies, in part, that face-to-face contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telemedicine, when those services are otherwise covered by the Medi-Cal program, and requires a health care practitioner to obtain verbal and written consent prior to providing services through telemedicine.
4. SUGGESTED AMENDMENTS. As drafted, this bill requires DHCS to allow specified providers to receive Medi-Cal reimbursement for SUD telehealth services. The DMC-ODS waiver currently offers some counties this option. Forty counties submitted implementation plans to DHCS. There are 19 counties with plans approved, of which 16 counties incorporate telehealth services. As such, since most counties may already include the provisions of this bill as part of their waiver submission, the author may wish to consider narrowing this bill as a pilot project and apply to Kern and Kings Counties.

REGISTERED SUPPORT / OPPOSITION:

Support

California Access Coalition

California Association of Family Physicians

California State Association of Counties

County of San Diego

Depression and Bipolar Support Alliance

Silicon Valley Leadership Group

Opposition

None on file.

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