Date of Hearing: May 16, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1524

Author:(Chiu) – As Amended Ver:April 2, 2019

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

SUMMARY:

This bill shortens the Department of Health Care Services’(DHCS) approval timeline for provider enrollment of student health centers at institutes of higher education for the Medi-Cal and Family Planning Access Care and Treatment program (Family PACT), from 180 to 30 days, and requires DHCS to grant of provisional provider status on the 31^st day of a Medi-Cal application.

FISCAL EFFECT:

Unknown, potentially significant costs to the Medi-Cal provider enrollment division. There is currently a high volume and large backlog of provider enrollment applications. Processing new applications within a short time frame without worsening the existing problem will necessitate additional resources. If DHCS requires two additional positions to process these enrollments, it would be a cost of $175,000 total annually (GF/federal).

COMMENTS:

1. Purpose. The author notes a student health center’s Medi-Cal enrollment can often take up to a year to complete and that this prolonged enrollment process discourages many student health centers from participating in Medi-Cal and other related programs. The author states this bill puts student health centers on par with the approval time window for affiliate primary care clinics by requiring student health center’s application be approved within 30 days of submission for both Medi-Cal enrollment and the Family PACT program.
2. Background. During the enrollment process, providers are screened to identify and reject potentially fraudulent providers from admission into the Medi-Cal FFS program and safeguard program integrity. DHCS must complete an application review for a new physician or new physician group, which comprises the majority of applications, within 90 days. Most others must be approved within 180 days. Affiliate primary care clinics, which have a 30-day time frame for FPACT enrollment, are affiliated with clinics that are existing Medi-Cal providers.
3. Administration Proposal. DHCS submitted an April 1, 2019, budget change proposal to the Legislature requesting two-year limited-term funding equivalent to 23 positions and associated expenditure authority to address an increase in workload due to an increase in provider enrollment applications, as well as an existing backlog. DHCS’ total expenditure authority request is $3.2 million ($795,000 General Fund (GF) and $2.4 million in federal funds for 2019-20 and $2.9 million ($744,000 GF and $2.2 million federal funds) for 2020-21.
4. Staff Comment. It is unclear why the enrollment time frame for student health centers should be shorter than that of other providers. Badly needed specialists, for example, could make a similarly compelling argument for a shortened time frame.
   

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

Date of Hearing: April 23, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1524

Author:(Chiu) – As Amended Ver:April 2, 2019

SUBJECT: Medi-Cal: provider enrollment.

SUMMARY: Shortens the timeframe for the Department of Health Care Services (DHCS) to act upon an application package to enroll in Medi-Cal from a student health center operated by public institutions of higher education (student health center) and a clinic operated by, or affiliated with, any institution of learning that teaches a recognized healing art (institution of learning clinic) by requiring DHCS to act within 30 days of receiving an application, instead of 180 days in existing law. Requires applications for enrollment in the Family Planning, Access, Care, and Treatment (Family PACT) Program from student health centers and institution of learning clinics to be acted upon within 30 calendar days of receiving a complete application. Specifically, this bill:

1. Expedites the Medi-Cal application processing timeframe for an institution of learning clinic or a student health center by requiring DHCS to give the institution of learning clinic or student health center written notice either granting the clinic or student health center provider provisional provider status on the 31^st day for a period no longer than 12 months, effective from the 31st day, or (under existing law requirements), to take one of specified actions, such as telling the applicant if the application is incomplete, denying the application, or informing the applicant that DHCS intends to perform background checks or an on-site visit to the provider.
   
2. Requires DHCS, for purposes of enrollment into the Family PACT Program from a student health center or an institution of learning clinic, within 30 calendar days of receiving a complete application for enrollment into the Family PACT Program, to do one of the following:
   1. Approve the provider’s Family PACT Program application, provided the applicant meets the Family PACT Program provider enrollment requirements;
   2. If the provider is an enrolled Medi-Cal provider in good standing, notify the applicant in writing of any discrepancies in the Family PACT Program enrollment application. Requires the applicant to have 30 days from the date of written notice to correct any identified discrepancies, and upon receipt of all requested corrections, requires DHCS to approve the application within 30 calendar days; or,
   3. Not proceed, if the provider is not an enrolled Medi-Cal provider in good standing, until DHCS receives confirmation of good standing and enrollment as a Medi-Cal provider.
      
3. Requires, pursuant to existing law, the effective date of enrollment into the Family PACT Program to be the later of the date DHCS receives confirmation of enrollment as a Medi-Cal provider, or the date the applicant meets all Family PACT Program provider enrollment requirements.
   

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services.
   
2. Establishes the Family PACT Program to provide comprehensive clinical family planning services to individuals who meet specified income requirements.
   
3. Requires specified providers who are not currently enrolled in the Medi-Cal program, a provider applying for continued enrollment (upon written notification from DHCS), or, a provider not currently enrolled at a location where the provider intends to provide services, goods, supplies, or merchandise to a Medi-Cal beneficiary, to submit a complete application package for enrollment, continuing enrollment, or enrollment at a new location or a change in location. These requirements and process are known as “provider enrollment.”
   
4. Requires DHCS, within 180 days after receiving an application package submitted by a provider, or from the date of the notice to an applicant or provider that the applicant or provider does not qualify as a preferred provider, to give written notice to the applicant or provider that any of the following applies, or on the 181st day grant the applicant or provider provisional provider status pursuant to this section for a period no longer than 12 months, effective from the 181st day:
   1. The applicant or provider is being granted provisional provider status for a period of 12 months, effective from the date on the notice;
   2. The application package is incomplete, with the notice identifying additional information or documentation that is needed to complete the application package;
   3. DHCS is conducting background checks, pre-enrollment inspections, or unannounced visits; or,
   4. The application package is denied for specified reasons.
      
5. Requires physician applicants or providers meeting specified criteria to be considered a preferred provider and to be granted preferred provisional provider status for a period of no longer than 18 months, effective from the date on the notice from DHCS.
   
6. Requires DHCS, within 90 days after receiving an application package from a physician or physician group, to give written notice to the applicant or provider that the criteria in 4) b) through d) applies, or to grant the applicant on the 91st day provisional provider status for a period no longer than 12 months, effective from the 91st day.
   
7. Requires DHCS, within 30 calendar days of receiving confirmation of certification for enrollment as a Medi-Cal provider for an affiliate primary care clinic, to provide written notice to the applicant informing the applicant that its Medi-Cal enrollment is approved, and requires DHCS to enroll the affiliate primary care clinic retroactive to the date of certification.
   
8. Requires DHCS, within 30 calendar days of receiving a complete application for enrollment into the Family PACT Program from an affiliate primary care clinic, to do one of the following:
   1. Approve the provider’s Family PACT Program application, provided the applicant meets the Family PACT Program provider enrollment requirements; or,
   2. Notify, if the provider is an enrolled Medi-Cal provider in good standing, the applicant in writing of any discrepancies in the Family PACT Program enrollment application (the applicant is required to have 30 days from the date of written notice to correct any identified discrepancies, and upon receipt of all requested corrections, DHCS is required to approve the application within 30 calendar days.
9. Makes specified clinics exempt from licensure by the Department of Public Health (DPH), including both of the following:
   1. A clinic operated by, or affiliated with, any institution of learning that teaches a recognized healing art and is approved by the state board or commission vested with responsibility for regulation of the practice of that healing art; and,
   2. Student health centers operated by public institutions of higher education.
      

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, in California, about half of all children and one out of every three adults is covered by Medi-Cal. Although student health centers provide preventative services and other primary care services to children and young adults like any other primary care clinic, they are excluded from the same fast-tracked enrollment process that affiliate primary care clinics can use to enroll in Medi-Cal. In fact, a student health center’s Medi-Cal enrollment can often take up to a year to complete. This prolonged enrollment process discourages many student health centers from participating in other safety net programs that require providers to first be enrolled in Medi-Cal, including programs that cover prenatal and pregnancy-related care and mental health services. This in turn means that student health centers, which provide these time-sensitive services anyway at no or low cost, are leaving badly needed reimbursement dollars on the table. This bill simply puts student health centers on par with affiliate primary care clinics by requiring that their applications be approved within 30 days of submission for both Medi-Cal enrollment and the Family PACT program.
   
2. MEDI-CAL PROVIDER ENROLLMENT. State law governing Medi-Cal and federal law and regulations contain provisions to address fraud in the Medicaid program. For example, existing state law requires an applicant or provider seeking to provide services in the Medi-Cal program, to submit a complete application package for enrollment, continuing enrollment, enrollment at a new location or a change in location. DHCS’ Provider Enrollment Division (PED) is responsible for the enrollment and re-enrollment of most eligible fee-for-service (FFS) health care providers in the Medi-Cal program. DHCS indicates its review of a provider’s application package is a complex process that requires assessment of many elements of the application, including a review of the required supporting documentation, to determine eligibility for enrollment into the Medi-Cal program. DHCS may conduct a background check of an applicant or provider for the purpose of verifying information. This background check may include an unannounced on-site inspection, a review of business records, and data searches to ensure that the applicant or provider meets enrollment criteria. There are currently 185,000 providers enrolled in the Medi-Cal FFS program, and DHCS indicates the number grows each year. As of December 31, 2018, PED had a backlog of 19,000 applications, which represents a 200% increase when compared to the previous calendar year.
   
   In November 2016, DHCS began initial implementation of the Provider Application and Validation for Enrollment (PAVE) system, an enrollment portal and associated business processes to automate provider enrollment and management activities to comply with provider integrity mandates under the federal Patient Protection and Affordable Care Act (ACA). Prior to PAVE, provider enrollment utilized a paper-based process. With the initial implementation of PAVE in November 2016, 80% of Medi-Cal FFS providers have the option to enroll and/or update their enrollment through a web-based, interactive, and secure portal.
   
   Family PACT also has an enrollment process for providers. Providers must be enrolled in the Medi-Cal program to be a Family PACT provider. The Family PACT statute does not have application processing timeframes for DHCS except for affiliate clinics (described further below).
   
3. APPLICATION PROCESSING TIMEFRAMES. Existing law establishes notification requirement and timeframes for DHCS application processing that vary depending upon the type of provider, such as whether the application is from a physician, an affiliated clinic, a clinic exempt from licensure or another health care provider. For example, for physicians and physician groups, DHCS provides an "acknowledgment of receipt letter" for an application package from a within 15 days. For applications from provider types other than physicians or physician groups, a written notice confirming receipt is mailed within 30 days. Physician and physician group applicants are notified in writing of one of the four actions listed below, within 90 days of receipt of an application. Notification of DHCS action to applicants other than a physician or physician group (such as psychologists, physician assistants, nurse practitioners, podiatrists, licensed midwives and unlicensed clinics) remains at 180 days. Notification from DHCS is one of four responses:
4. The application is approved for enrollment as a provisional provider;
5. The application is incomplete and additional information is required;
6. The application is referred for a comprehensive review and background check; or,
7. The application is denied with the reason(s) for denial.
   

There is also a “preferred provider” designation for physicians that was enacted in the early 2000s to establish a shorter statutory timeframe for DHCS to enroll physicians than then-180 day timeframe for all applicants. AB 1226 (Hayashi), Chapter 693, Statutes of 2007, further shortened the statutory timeframe for DHCS to enroll a preferred provider, from 90 days to 60 days, and shortened the timeframe for enrollment action on all physician and physician group applications to 90 days, making the only enrollment timeframe difference between “preferred” providers and regular applications for physician 30 days.

SB 442 (Ducheny), Chapter 502, Statutes of 2010, established an expedited licensure process for an affiliate primary care clinic or a mobile health care unit operated as a primary care clinic. Under SB 442, a primary care clinic that has held a valid, unrevoked, and unsuspended license for at least the immediately preceding five years, with no demonstrated history of repeated or uncorrected violations that pose immediate jeopardy to a patient, and that has no pending action to suspend or revoke its license, is authorized to file an affiliate clinic application to establish a primary care clinic at an additional site or a mobile health care unit (referred to as an “affiliate clinic”). In order to be an affiliate clinic, the parent clinic and the affiliate have to have to have the same corporate officers, the parent and affiliate clinics must be owned and operated by the same nonprofit organization with the same board of directors, and the parent and affiliate clinics have the same medical director or directors and medical policies, procedures, protocols, and standards. DPH is required to issue a clinic license under these provisions within 30 days of receipt of a completed affiliate clinic application.

AB 2051 (Gonzalez-Fletcher and Bocanegra), Chapter 356, Statutes of 2014, requires DHCS, within 30 calendar days of receiving confirmation of certification for enrollment as a Medi-Cal provider for an applicant that is an affiliate primary care clinic, to provide specified written notice to the applicant informing the applicant that its Medi-Cal enrollment is approved. In addition, AB 2051 would require DHCS, with respect to an application for enrollment into the Family PACT Program from an affiliate primary care clinic, to either approve the provider’s Family PACT Program application, provided the applicant meets the Family PACT Program provider enrollment requirements, or if the provider is an enrolled Medi-Cal provider in good standing, notify the applicant in writing of any discrepancies in the Family PACT Program enrollment application.

1. DHCS SPRING BUDGET CHANGE PROPOSAL. DHCS submitted an April 1, 2019 Budget Change Proposal (BCP) to the Legislature requesting two-year limited-term (LT) funding equivalent to 23 positions and associated expenditure authority. The resources are needed to address an increase in workload due to an increase in provider enrollment applications, including applications from Drug Medi-Cal and Medi-Cal managed care health plan providers. In addition, these positions would be used to address the backlog of approximately 19,000 applications due to an increase in applications received. DHCS’ total expenditure authority request is $3.2 million ($795,000 General Fund (GF) and $2.4 million in federal funds for fiscal year (FY) 2019-20 and $2.9 million ($744,000 GF and $2.2 million federal funds) for FY 2020-21.
   
2. SUPPORT. This bill is sponsored by Health Services Association California Community Colleges (HSACCC) and supported by civil rights, women’s organizations, specified health care providers, and reproductive rights groups to increase access to primary care and preventive health services for children and young adults by creating a fast-tracked enrollment process for qualified clinics by allowing student health centers that choose to participate in the Medi-Cal and Family PACT programs to have their enrollments processed in about 30 days. HSACCC writes that providing Medi-Cal and Family PACT health services on school campuses, whether at a high school, community college, or four-year institution, is extremely effective because it delivers vital and often time-sensitive health care services directly to students in need. Half of all children and one in three of all adults in California rely on Medi-Cal services. Despite this fact, only a small percentage of student health centers are enrolled Medi-Cal providers, thus posing barriers to students, especially in rural communities, who are forced off campus to seek care. The benefits are multi-fold: student health centers enrolled in Medi-Cal and Family PACT can provide students with access to indispensable primary care and preventative services - especially pregnancy-related and family planning services, and take advantage of essential reimbursement opportunities for our student health centers. HSACCC writes that this bill puts student health centers on par with affiliate primary care clinics by requiring that their enrollment applications be approved within 30 days of submission for both Medi-Cal and Family PACT. By fast-tracking the enrollment process, more student health centers can participate in critical and cost-effective programs that are designed to provide immediate access to young people in need of timely health services.
   
3. RELATED LEGISLATION. SB 24 (Leyva) requires clinics located on a campus within the University of California (UC) or California State University (CSU) that provide primary health care services to students, after January 1, 2023, to offer abortion by medication techniques onsite. Requires the California Commission on the Status of Women and Girls to administer the College Student Health Center Sexual and Reproductive Health Preparation Fund established by SB 24 for the purposes of providing private moneys to public university student health centers for medication abortion readiness. SB 24 passed the Senate Health Committee on April 4, 2019 by a 7-2 vote and is pending in the Senate Education Committee.
   
4. PREVIOUS LEGISLATION. SB 1529 (Alquist), Chapter 797, Statutes of 2012, revises screening, enrollment, disenrollment, suspensions, and other sanctions for fee-for-service Medi-Cal providers and suppliers to conform to the ACA.
   

SB 857 (Speier), Chapter 601, Statutes of 2003, made numerous changes to the Medi-Cal program intended to address provider fraud, including establishing new Medi-Cal application requirements for new providers, existing providers at new locations, and providers applying for continued enrollment.

1. POLICY QUESTIONS:
   
   1. Are student health centers not enrolling in Medi-Cal because of the time it takes to complete the Medi-Cal Provider Enrollment process? The author argues the prolonged and laborious enrollment process discourages many student health centers from participating in other safety net programs that require providers to first be enrolled in Medi-Cal, including Family PACT (which receives a nine to one federal match) and presumptive eligibility (which covers prenatal and pregnancy-related care), and that this results in student health centers – which provide these time-sensitive services anyway at no or low cost - leaving badly needed reimbursement dollars on the table.

However, 25 of the 93 community colleges with health centers are Medi-Cal/Family PACT providers, approximately half of CSU student health centers are already enrolled as Family PACT providers, and other student health centers do not accept insurance (other than the university-provided student health insurance) and are typically funded through student assessments. For example, UC does not accept public or private insurance generally (other than the UC-provided Student Health Insurance Plan). It is not clear that the provider enrollment process is the main reason why student health centers do not participate in Medi-Cal or Family PACT, or if an expedited enrollment process will result in student health centers participating in Medi-Cal or contracting with Medi-Cal managed care plans.

• 1. Should student health centers have a shorter provider enrollment timeframe than other health care providers? The author argues that, by fast-tracking student health center enrollment into Medi-Cal, more student health centers can participate in Medi-Cal and Family PACT, which are cost-effective programs designed to provide immediate access to patients in need of time-sensitive reproductive health services. In addition, the author argues this bill puts student health centers on par with affiliate primary care clinics by requiring that their applications be approved within 30 days of submission for both Medi-Cal enrollment and the Family PACT program. Although affiliate clinics do have a shorter timeframe, this provision is limited to non-profit parent clinics who have a common board of directors, a common medical director with an affiliate site (which reduce PED workload in reviewing the application), and it is not clear that same fact set is true for student health centers or other clinics. In addition, many Medi-Cal providers could also make compelling arguments for an expedited enrollment process based on the services they provide to Medi-Cal beneficiaries.
     
  2. Should the current statutory enrolment timeframes be re-visited generally with the implementation of PAVE? PAVE was intended to be a “TurboTax-like” enrollment process that would expedite the application processing and reduce errors upon submission that result in delays and the need to resubmit material or information. However, since PAVE was implemented, the provider enrollment application timeframes in existing law have not changed, and checking on the status of provider enrollment applications is a frequent source of inquiry from providers, legislative staff and advocates to DHCS. However, as indicated by the Spring Budget Change proposal request, PED continues to have a high volume and an increased backlog of applications. While this bill would provide an expedited process for a subset of providers, the committee may wish to consider whether the current timeframes should be shortened, and (alternatively), whether the current backlog means this bill should have a later effective date.

REGISTERED SUPPORT / OPPOSITION:

Support

Health Services Association of California Community Colleges (sponsor)
Access Women's Health Justice
Act for Women And Girls
American Civil Liberties Union of California
American Medical Women's Association
Business and Professional Women of Nevada County
California United for a Responsible Budget
Center for Reproductive Rights
Citizens for Choice
Feminist Majority Foundation
Medical Billing Technologies
NARAL Pro-Choice California 
National Association of Social Workers, California Chapter
National Health Law Program
National Women's Health Network
Rhedi/Reproductive Health Education in Family Medicine
The Women's Foundation of California
Training in Early Abortion for Comprehensive Health
Women's Health Specialists

Opposition

None on file.

Analysis Prepared by: Scott Bain / HEALTH / (916) 319-2097