CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 678

Author:(Flora)

As Amended Ver:July 8, 2019

Majority vote

SUMMARY:

Prohibits a doctor of podiatric medicine (podiatrist) from being required to submit a request for prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician providing the same services would not be required to submit prior authorization to the Department of Health Care Services (DHCS). Subjects a podiatrist providing services to the same Medi-Cal billing and services policies as required for a physician, including but not limited to, a maximum numerical service limitation in any one calendar month.

The Senate Amendments:

Delete the proposed permanent restoration of podiatry as a Medi-Cal benefit.

COMMENTS:

PRIOR AUTHORIZATION CHANGE. This bill prohibits a podiatrist from being required to submit a prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician providing the same services would not be required to submit prior authorization to DHCS. This change replaces the narrower language in existing law that prohibits prior authorization on an outpatient or inpatient service from being required when all of the specified conditions are met, including that:

1. The services are related to trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage; and,
2. An urgent or emergency need for services exists at the time the service is provided.

Prior authorization in Medi-Cal is done by requiring providers to fill out and submit a Treatment Authorization Requests (TARs). TARs are a form of utilization control, and require DHCS approval in order for a provider to receive payment for the service.

Medicaid optional and mandatory benefits AND PODIATRY. States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. States are required to cover certain "mandatory benefits," and can choose to provide other "optional benefits" through the Medicaid program, for which they can receive federal financial participation (federal "matching funds"). Children are entitled to all Medicaid benefit under the federal Early and Periodic Screening Diagnosis and Treatment Program benefit.

During the budget deficit in 2009, the Legislature and Governor enacted AB 5 X3 (Evans), Chapter 20, Statutes of 2009, which eliminated some optional benefits for adults that had been covered under Medi-Cal under a trigger mechanism, including podiatry. Medi-Cal optional benefits, including acupuncture, audiology, chiropractic, adult dental services, incontinence washes and creams, optician and optical lab services, podiatric services, psychology services, and speech therapy. Optional benefits continued to be provided for certain beneficiaries, such as those receiving services under Early and Periodic Screening Diagnosis Treatment. Since the elimination of optional benefits in 2009, the Legislature has restored a number of services, including acupuncture, adult dental and, beginning on January 1, 2020, optical benefits.

The 2019-20 Budget and trailer bill legislation [SB 78 (Committee on Budget and Fiscal Review)], Chapter 38, Statutes of 2019 restores a number of optional benefits, including podiatric services, for two years, effective no sooner than January 1, 2020. After December 31, 2021, the restoration of services would be subject to the availability of General Fund revenues.

According to the Author:

According to the author, the 2009 budget cuts eliminated podiatry services in the state's Medi-Cal program. This elimination removed Medicaid coverage by a podiatrist. The restrictions on podiatric services in Medi-Cal have exacerbated an already acute access problem for the low-income and disabled population. This bill ensures that more patients within Med-Cal have access to treatment, providing better health outcomes for California's most vulnerable populations.

Arguments in Support:

This bill is sponsored by the California Podiatric Medical Association (CPMA) which writes that podiatrists perform physician services and have full medical staff admitting and surgical privileges in hospitals and surgery centers. However, they are prohibited from providing podiatric services to patients in the Medi-Cal system unless certain conditions are met or the treatment is providing in a specific setting. For example, podiatrists may be reimbursed only if the treatment was performed in a federally qualified health center, rural health clinic, emergency room, or in-patient hospital setting. They argue that the restrictions on podiatric services in Medi-Cal have exacerbated an already acute access problem for the low income and disabled population.

Arguments in Opposition:

There is no known opposition.

FISCAL COMMENTS:

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

ASSEMBLY FLOOR: 78-0-2

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, O'Donnell, Obernolte, Patterson, Petrie‑Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

ABS, ABST OR NV: Cooley, Eduardo Garcia

SENATE FLOOR: 37-0-3

YES: Allen, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

ABS, ABST OR NV: Archuleta, Hueso, Portantino

UPDATED:

VERSION: July 8, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0001403

 CONSENT  

Bill No: AB 678

Author: Flora (R)

Amended: 7/8/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 7/3/19

AYES: Pan, Stone, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 78-0, 5/23/19 - See last page for vote

SUBJECT: Medi-Cal: podiatric services

SOURCE: California Podiatric Medical Association

DIGEST:

This bill aligns prior authorization and visit limitations for podiatric services provided by podiatrists in the Medi-Cal program with those that apply to physicians providing the same services.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes benefits required under federal law and benefits provided at state option but for which federal financial participation through Medicaid is available. [WIC §14132]
3. Excludes the following optional benefits from being covered in the Medi-Cal program:
   1. Audiology services;
   2. Chiropractic services;
   3. Incontinence creams and washes products;
   4. Podiatric services; and,
   5. Speech therapy services. [WIC §14131.10]
4. Authorizes optional benefits excluded under existing law to remain covered if the services are provided under the following circumstances:
   1. Pregnancy-related services and services for other conditions that might complicate the pregnancy;
   2. Services under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) Program;
   3. Continuing services for beneficiaries after the age of 21 if the course of treatment for an acute episode began prior to turning 21; and
   4. Services for residents in a skilled nursing facility and Intermediate Care Facility for the Developmentally Disabled, as defined. [WIC §14131.10]
5. Requires, on January 1, 2020, and contingent on the availability of General Fund revenues in subsequent years, optometric, optician, audiology, speech therapy, and podiatric services and incontinence creams and washes to be a covered benefit in the Medi-Cal program. [WIC §14131.10]
6. Authorizes DHCS to implement provisions of the optional benefits exclusion by means of all-county letters, provider bulletins, or similar instructions, without taking further regulatory action. [WIC §14131.10]
7. Authorizes podiatric services to be provided without prior authorization by a doctor of podiatric medicine acting within their scope of practice, on an outpatient or inpatient basis, only when all of the following conditions are met:
   1. Services are related to a trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage;
   2. Services are medically necessary;
   3. An urgent or emergency need for services exists at the time the service is provided;
   4. The patient was referred to the doctor of podiatric medicine by a physician; and,
   5. Prior authorization is not required for a physician providing the same services. [WIC §14133.07]

This bill:

1. Deletes existing requirements for a doctor of podiatric medicine to provide podiatric services without prior authorization. Instead, authorizes a doctor of podiatric medicine, acting within their scope of practice, to provide podiatric services without prior authorization, on outpatient or inpatient basis, if a physician and surgeon may provide the same services without prior authorization.
2. Requires a doctor of podiatric medicine providing podiatric services without prior authorization, as specified by this bill, to be subject to the same billing, service policies, and numerical service limitation rules as a physician and surgeon providing the same services under Medi-Cal.

Comments

1. Author’s statement. According to the author, the 2009 budget cuts eliminated podiatry services in the state’s Medi-Cal program. This elimination removed Medicaid coverage by a podiatrist. The restrictions on podiatric services in Medi-Cal have exacerbated an already acute access problem for the low-income and disabled population. This bill ensures that more patients within Med-Cal have access to treatment, providing better health outcomes for California’s most vulnerable populations.
2. Medi-Cal optional benefits. Medi-Cal, the state’s Medicaid program, provides health care coverage to over 13 million low-income residents. Medicaid, as a program, is administered by the states, according to federal requirements. States establish and determine the type, amount, duration and scope of services within those guidelines. Federal law mandates all Medicaid programs to provide certain mandatory benefits and authorizes states to cover other services, known as optional benefits. Podiatric services is one of the optional benefits.

During the budget deficit in 2009, ABX3-5 (Evans, Chapter 20, Statutes of 2009-10, Third Extraordinary Session) reduced reimbursement rates and benefits in the Medi-Cal program. Medi-Cal optional benefits, including acupuncture, audiology, chiropractic, adult dental services, incontinence washes and creams, optician and optical lab services, podiatric services, psychology services, and speech therapy. Optional benefits continued to be provided for certain beneficiaries, such as those receiving services under EPSDT. Since the elimination of optional benefits in 2009, the Legislature has restored a number of services, including acupuncture, adult dental and, beginning on January 1, 2020, optical benefits.

The 2019-20 Budget restores a number of optional benefits, including podiatric services, for two years, beginning on January 1, 2020. After December 31, 2021, the restoration of services would be suspended and subject to the availability of GF revenues.

1. Podiatric services in Medi-Cal. In addition to the exceptions included in 2009, there have been exceptions adopted to allow podiatric services provided by a podiatrist in certain settings. According to All Plan Letter 15-003 issued on January 26, 2015, pursuant to the Ninth United States Circuit Court of Appeals ruling in California Rural Health Clinics v. Douglas, medically necessary podiatric services are covered by Medi-Cal when provided in federally qualified health center and rural health clinic settings. The services remain subject to a Treatment Authorization Request (TAR) and the two-visit monthly limit. In January 2017, DHCS released a provider bulletin and updated the provider manual to clarify additional circumstances in which podiatrists may provide services. The bulletin noted that podiatrists may provide services to all beneficiaries in emergency rooms, inpatient hospitals, hospital outpatient departments, and hospital outpatient clinics, subject to a TAR and two-visit monthly limit.

Podiatrists are exempted from receiving prior authorization if all of the following conditions are met:

• 1. Services are medically necessary and related to a trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage;
  2. An urgent or emergency need for services exists at the time the service is provided;
  3. The patient was referred to the doctor of podiatric medicine by a physician; and,
  4. Prior authorization is not required for a physician providing the same services.

Related/Prior Legislation

AB 1868 (Gomez, 2014) would have restored Medi-Cal coverage of medical and surgical services provided by a podiatrist within his or her scope of practice that, if provided by a physician, would be considered physician services, for services which can be provided by either a physician or a podiatrist. AB 1868 was held on the Senate Appropriations Committee suspense file.

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

SUPPORT: (Verified 8/13/19)

California Podiatric Medical Association (source)

Association of California Healthcare Districts

Association of Regional Center Agencies

Board of Podiatric Medicine

California Medical Association
CaliforniaHealth+ Advocates

Osteopathic Physicians and Surgeons of California

Western Center on Law & Poverty

OPPOSITION: (Verified 8/13/19)

None received

ARGUMENTS IN SUPPORT: This bill is sponsored by the California Podiatric Medical Association, which writes that podiatrists perform physician services and have full medical staff admitting and surgical privileges in hospitals and surgery centers. However, they are prohibited from providing podiatric services to patients in the Medi-Cal system unless certain conditions are met or the treatment is providing in a specific setting. For example, podiatrists may be reimbursed only if the treatment was performed in a federally qualified health center, rural health clinic, emergency room, or in-patient hospital setting. They argue that the restrictions on podiatric services in Medi-Cal have exacerbated an already acute access problem for the low income and disabled population. Western Center on Law & Poverty writes in support of this bill, as well, arguing that podiatry services are critical for many diabetics who often need more expensive services from complications if they do not get the podiatric services, including amputations. Association of California Healthcare Districts, also in support of this bill, states that making access to podiatry care via a podiatrist available eases the existing burdens to access treatment by a physician or surgeon.

ASSEMBLY FLOOR: 78-0, 5/23/19

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, 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, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Cooley, Eduardo Garcia

Prepared by: Kimberly Chen / HEALTH / (916) 651-4111

8/14/19 15:11:25

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 678

SUBJECT: Medi-Cal: podiatric services

SUMMARY:

Requires podiatric services to be a covered optional benefit in the Medi-Cal program, beginning January 1, 2020, or the effective date of any necessary federal approval, whichever is later. Aligns prior authorization and visit limitations for podiatrists with those that apply to physicians providing the same services.

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes benefits required under federal law and benefits provided at state option but for which Federal financial participation (FFP) through Medicaid is available. [WIC §14132]
3. Excludes the following optional benefits from being covered in the Medi-Cal program:
   1. Audiology services;
   2. Chiropractic services;
   3. Incontinence creams and washes products;
   4. Podiatric services; and,
   5. Speech therapy services. [WIC §14131.10]
4. Authorizes optional benefits excluded under existing law to remain covered if the services are provided under the following circumstances:
   1. Pregnancy-related services and services for other conditions that might complicate the pregnancy;
   2. Services under the Early and Periodic Screening Diagnosis and Treatment (EPSTD) Program;
   3. Continuing services for beneficiaries after the age of 21 if the course of treatment for an acute episode began prior to turning 21;
   4. Services for residents in a skilled nursing facility (SNF) and Intermediate Care Facility for the Developmentally Disabled (ICF/DD), as defined. [WIC §14131.10]
5. Requires, on January 1, 2020 and contingent on an appropriation of funds in state budget process, optometric and optician services to be a covered benefit in the Medi-Cal program. [WIC §14131.10]
6. Authorizes DHCS to implement provisions of the optional benefits exclusion by means of all-county letters, provider bulletins, or similar instructions, without taking further regulatory action. [WIC §14131.10]
7. Authorizes podiatric services to be provided without prior authorization by a doctor of podiatric medicine acting within their scope of practice, on an outpatient or inpatient basis, only when all of the following conditions are met:
   1. Services are related to a trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage;
   2. Services are medically necessary;
   3. An urgent or emergency need for services exists at the time the service is provided;
   4. The patient was referred to the doctor of podiatric medicine by a physician; and,
   5. Prior authorization is not required for a physician providing the same services. [WIC §14133.07]

This bill:

1. Requires podiatric services to be a covered optional benefit in the Medi-Cal program, beginning January 1, 2020, or the effective date of any necessary federal approval, whichever is later. Implements this provision only to the extent that all necessary federal approvals are obtained.
2. Deletes existing requirements for a doctor of podiatric medicine to provide podiatric services without prior authorization. Instead, authorizes a doctor of podiatric medicine, acting within their scope of practice, to provide podiatric services without prior authorization, on outpatient or inpatient basis, if a physician and surgeon may provide the same services without prior authorization.
3. Requires a doctor of podiatric medicine providing podiatric services without prior authorization, as specified by this bill, to be subject to the same billing, service policies, and numerical service limitation rules as a physician and surgeon providing the same services under Medi-Cal.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, projected costs to Medi-Cal of at least $4.6 million General Fund (GF) ($15.2 million total funds) to restore podiatric services as a benefit. Costs may be slightly higher based on the removal of podiatric-specific visit limitations and prior authorization requirements. To the extent this increases access to podiatric services among individuals with diabetes, it may prevent more costly complications in some cases.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, the 2009 budget cuts eliminated podiatry services in the state’s Medi-Cal program. This elimination removed Medicaid coverage by a podiatrist. The restrictions on podiatric services in Medi-Cal have exacerbated an already acute access problem for the low-income and disabled population. This bill would ensure that more patients within Med-Cal have access to treatment, providing better health outcomes for California’s most vulnerable populations.
2. Medi-Cal optional benefits. Medi-Cal, the state’s Medicaid program, provides health care coverage to over 13 million low-income residents. Medicaid, as a program, is administered by the states, according to federal requirements. States establish and determine the type, amount, duration and scope of services within those guidelines. Federal law mandates all Medicaid programs to provide certain mandatory benefits and authorizes states to cover other services, known as optional benefits. Podiatric services is one of the optional benefits.

During the budget deficit in 2009, AB 5 X3 (Evans, Chapter 20, Statutes of 2009) reduced reimbursement rates and benefits in the Medi-Cal program. Medi-Cal optional benefits, including acupuncture, audiology, chiropractic, adult dental services, incontinence washes and creams, optician and optical lab services, podiatric services, psychology services, and speech therapy. Optional benefits continued to be provided for certain beneficiaries, such as those receiving services under EPSDT. Since the elimination of optional benefits in 2009, the Legislature has restored a number of services, including acupuncture, adult dental and, beginning on January 1, 2020, optical benefits.

The 2019-20 budget restores a number of optional benefits, including podiatric services, for two years, beginning on January 1, 2020. After December 31, 2021, the restoration of services would be suspended and subject to the availability of GF revenues.

1. Podiatric Services in Medi-Cal. In addition to the exceptions included in 2009, there have been exceptions adopted to allow podiatric services provided by a podiatrist in certain settings. According to All Plan Letter 15-003 issued on January 26, 2015, pursuant to the Ninth United States Circuit Court of Appeals ruling in California Rural Health Clinics v. Douglas, medically necessary podiatric services are covered by Medi-Cal when provided in Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) settings. The services remain subject to a Treatment Authorization Request (TAR) and the two-visit monthly limit. In January 2017, DHCS released a provider bulletin and updated the provider manual to clarify additional circumstances in which podiatrists may provide services. The bulletin noted that podiatrists may provide services to all beneficiaries in emergency rooms, inpatient hospitals, hospital outpatient departments, and hospital outpatient clinics, subject to a TAR and two-visit monthly limit.

Podiatrists are exempted from receiving prior authorization if all of the following conditions are met:

1. Services are medically necessary and related to a trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage;
2. An urgent or emergency need for services exists at the time the service is provided;
3. The patient was referred to the doctor of podiatric medicine by a physician; and,
4. Prior authorization is not required for a physician providing the same services.
5. Prior legislation. AB 1868 (Gomez of 2014) would have restored Medi-Cal coverage of medical and surgical services provided by a podiatrist within his or her scope of practice that, if provided by a physician, would be considered physician services, for services which can be provided by either a physician or a podiatrist. AB 1868 was held on the Senate Appropriations Committee suspense file.
6. Support. This bill is sponsored by the California Podiatric Medical Association, which writes that podiatrists perform physician services and have full medical staff admitting and surgical privileges in hospitals and surgery centers. However, they are prohibited from providing podiatric services to patients in the Medi-Cal system unless certain conditions are met or the treatment is providing in a specific setting. For example, podiatrists may be reimbursed only if the treatment was performed in a federally qualified health center, rural health clinic, emergency room, or in-patient hospital setting. They argue that the restrictions on podiatric services in Medi-Cal have exacerbated an already acute access problem for the low income and disabled population and support the reinstatement of treatments performed by podiatrists in the Medi-Cal system and eliminate the unnecessary authorizations, billing, and service policies that apply to them, but not physicians, within the Medi-Cal system.

Western Center on Law & Poverty writes in support of this bill, as well, arguing that podiatry services are critical for many diabetics who often need more expensive services from complications if they do not get the podiatric services, including amputations. Association of California Healthcare Districts, also in support of the bill, states that making access to podiatry care via a podiatrist available eases the existing burdens to access treatment by a physician or surgeon.

1. Amendments. The author is proposing amendments to delete provisions of this bill that restore podiatric services, so that only the prior authorization and service and billing provisions remain.

SUPPORT AND OPPOSITION:

Support: California Podiatric Medical Association (sponsor)

Association of California Healthcare Districts

Association of Regional Center Agencies

Board of Podiatric Medicine

California Medical Association
CaliforniaHealth+ Advocates

Osteopathic Physicians and Surgeons of California

Western Center on Law & Poverty

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 678

Author:(Flora)

As Amended Ver:April 9, 2019

Majority vote

SUMMARY:

Requires podiatric services to be covered under the Medi-Cal program. Prohibits a doctor of podiatric medicine (podiatrist) from being required to submit a request for prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician providing the same services would not be required to submit prior authorization to the Department of Health Care Services (DHCS). Subjects a podiatrist providing services to the same Medi-Cal billing and services policies as required for a physician, including but not limited to, a maximum numerical service limitation in any one calendar month.

Major Provisions

COMMENTS:

Medicaid optional and mandatory benefits. States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. States are required to cover certain "mandatory benefits," and can choose to provide other "optional benefits" through the Medicaid program, for which they can receive federal financial participation (federal "matching funds"). Children are entitled to all Medicaid benefit under the federal Early and Periodic Screening Diagnosis and Treatment Program benefit.

Background on Medi-Cal optional benefit elimination. In 2009, the Legislature and Governor enacted AB 5 X3 (Evans), Chapter 20, Statutes of 2009, which eliminated some optional benefits for adults that had been covered under Medi-Cal under a trigger mechanism, including podiatry. The Legislative Analyst's Office estimates the annual cost of restoration of podiatry as a Medi-Cal benefit would have a total funds cost of $15.3 million ($4.6 million General Fund (GF)). This estimate does not include the change to the prior authorization and elimination of the two a month limit for podiatry services.

PRIOR AUTHORIZATION CHANGE. This bill prohibits a podiatrist from being required to submit a prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician providing the same services would not be required to submit prior authorization to DHCS. This change replaces the narrower language in existing law that prohibits prior authorization on an outpatient or inpatient service from being required when all of the specified conditions are met, including that:

1. The services are related to trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage; and,
2. An urgent or emergency need for services exists at the time the service is provided.

Prior authorization in Medi-Cal is done by requiring providers to fill out and submit a Treatment Authorization Requests (TARs). TARs are a form of utilization control, and require DHCS approval in order for a provider to receive payment for the service.

According to the Author:

Eliminating podiatric services from Medi-Cal has made an access problem worse for low-income and disabled populations. This bill would ensure that Medi-Cal patients have access to essential services and would provide for better health outcomes for already vulnerable populations.

Arguments in Support:

This bill is sponsored by the California Podiatric Medical Association (CPMA) to reinstate full foot and ankle care by podiatrists in Medi-Cal. CPMA states this elimination removed Medi-Cal coverage by podiatrists, but not the services themselves as the same services provided by a physician are covered in Medi-Cal. CPMA argues eliminating coverage of services provided by podiatrists has resulted in much more expensive complications down the road as podiatrists perform physician services and have full medical staff admitting and surgical privileges in hospitals and surgery centers. However, CPMA indicates hospital podiatrists are prohibited from providing on-call services to emergency patients in the Medi-Cal system. This has led to a delay in care in cases of diabetic foot care, traumatic foot, and ankle injuries as patients attempt to find a provider. It has also placed an increased burden on emergency room providers who are now tasked with providing essential foot and ankle services for these Medi-Cal patients.

Arguments in Opposition:

There is no known opposition.

FISCAL COMMENTS:

According to the Assembly Appropriation Committee, projected costs to Medi-Cal of at least $4.6 million GF ($15.2 million total funds) to restore podiatric services as a benefit. Costs may be slightly higher based on the removal of podiatric-specific visit limitations and prior authorization requirements. To the extent this increases access to podiatric services among individuals with diabetes, it may prevent more costly complications in some cases.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

UPDATED:

VERSION: April 9, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0000643

Date of Hearing: April 24, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 678

Author:(Flora) – As Amended Ver:April 9, 2019

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

SUMMARY:

This bill restores Medi-Cal coverage of podiatric services and aligns prior authorizations and visit limitations for podiatrists with those that apply to physicians providing the same services.

FISCAL EFFECT:

Projected costs to Medi-Cal of at least $4.6 million GF ($15.2 million total funds) to restore podiatric services as a benefit. Costs may be slightly higher based on the removal of podiatric-specific visit limitations and prior authorization requirements. To the extent this increases access to podiatric services among individuals with diabetes, it may prevent more costly complications in some cases.

COMMENTS:

1. Purpose. As a result of the fiscal crisis, the 2009-10 Budget Act eliminated a number of Medi-Cal optional benefits, including “podiatric services.” The elimination prohibited podiatrists from claiming reimbursement, but did not change Medi-Cal coverage of foot and ankle care. Physicians are currently reimbursed by Medi-Cal for such care. This bill seeks to allow podiatrists to be reimbursed for currently covered services, in order to expand the pool of qualified providers available to the Medi-Cal population. In addition, it seeks to remove restrictions on podiatric care that do not apply to physicians for the same type of care, and that are reimbursed at the same rate. It is sponsored by the California Podiatric Medical Association.
2. Prior Legislation. AB 1868 (Gomez), of the 2013-14 Legislative Session, also would have restored podiatric services coverage in Medi-Cal. It was held on the Suspense File of the Senate Appropriations Committee.

AB 5 X3 (Evans), Chapter 20, Statutes of 2009, eliminated specified optional benefits in Medi-Cal, including dental and podiatric services.

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

Date of Hearing: April 2, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 678

Author:(Flora) – As Introduced Ver:February 15, 2019

SUBJECT: Medi-Cal: podiatric services.

SUMMARY: Requires podiatric services to be covered under the Medi-Cal program. Prohibits a doctor of podiatric medicine (podiatrist) from being required to submit a request for prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician providing the same services would not be required to submit prior authorization to the Department of Health Care Services (DHCS). Subjects a podiatrist providing services to the same Medi-Cal billing and services policies as required for a physician. Specifically, this bill:

1. Requires podiatric services to be covered under the Medi-Cal program as of January 1, 2020, or the effective date of any necessary federal approvals, whichever is later.
   
2. Prohibits a podiatrist from being required to submit prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician providing the same services would not be required to submit prior authorization to DHCS.
   
3. Makes a podiatrist acting within their scope of practice and providing services subject to the same Medi-Cal billing and services policies as required for a physician.
4. Repeals the existing law prohibition on prior authorization for podiatric services provided on an outpatient or inpatient basis from being required when all of the following conditions are met:
   
   a) The services are provided by a podiatrist acting within their scope of practice;
5. The services are related to trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage;
6. The services are medically necessary;
7. An urgent or emergency need for services exists at the time the service is provided;
8. The patient was referred to a podiatrist by a physician; and,
9. Prior authorization is not required for a physician providing the same service.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS and under which qualified low-income persons receive health care benefits.
2. Establishes a schedule of benefits in the Medi-Cal program. Excludes specified optional benefits from coverage under the Medi-Cal program, including podiatry, except for beneficiaries under the Early and Periodic Screening Diagnosis and Treatment Program (EPSDT), which is the Medicaid benefit for individuals under age 21, and beneficiaries receiving long-term care in a nursing facility that is a skilled nursing facility or intermediate care facility that is licensed as a nursing facility.
   
3. Limits Medi-Cal coverage of specified services, including podiatry, acupuncture, occupational therapy, speech pathology, audiological services, and specified hospital outpatient clinic services involving these providers, to a maximum of two services from among those services in any one calendar month.
   
4. Prohibits prior authorization for podiatric services provided on an outpatient or inpatient basis from being required when all of the following conditions are met:
   1. The services are provided by a doctor of podiatric medicine acting within the scope of his or her practice;
   2. The services are related to trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage;
   3. The services are medically necessary;
   4. An urgent or emergency need for services exists at the time the service is provided;
   5. The patient was referred to the doctor of podiatric medicine by a physician; and,
   6. Prior authorization is not required for a physician providing the same service.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, eliminating podiatric services from Medi-Cal has made an access problem worse for low-income and disabled populations. This bill would ensure that Medi-Cal patients have access to essential services and would provide for better health outcomes for already vulnerable populations.
2. Medicaid optional and mandatory benefits. States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. States are required to cover certain "mandatory benefits," and can choose to provide other "optional benefits" through the Medicaid program, for which they can receive federal financial participation (federal “matching funds”). Children are entitled to all Medicaid benefit under the federal EPSDT benefit. The federal Centers for Medicare and Medicaid Services indicates the following are mandatory and optional benefits in Medicaid for adults:
   

*This includes services furnished in a religious non-medical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital.

1. Background on Medi-Cal optional benefit elimination. In 2009, the Legislature and Governor enacted AB 5 (Committee on Budget), Chapter 20, Statutes of 2009, which eliminated some optional benefits for adults that had been covered under Medi-Cal under a trigger mechanism. Medi-Cal optional benefits eliminated by AB 5 were acupuncture services, audiology and speech therapy services, chiropractic services, optometric and optician services, including services provided by a fabricating optical laboratory, podiatric services, psychology services, and incontinence creams and washes. Although the state eliminated optional benefits, services that were previously provided are covered if provided by a physician. DHCS indicates in its optional benefit exclusion policy that it also allows certain populations (pregnant women and beneficiaries under 21 years old) to continue to receive these optional services. DHCS also indicates all Medi-Cal eligible beneficiaries can access optional benefit services in certain settings, such as hospital outpatient departments/ emergency rooms, and some optional services (such as podiatry and chiropractic services) can be received in FQHCs and RHCs.
   
   Most of the General Fund (GF) savings from the optional benefit elimination in AB 5 resulted from the elimination of adult dental. Litigation brought by RHCs resulted in podiatry, chiropractic and adult dental and other services being reinstated at RHCs and FQHCs. Optometry services were reinstated (eye exams and procedures by optometrist) to adults 21 and over in July 2010, but all eye appliances (glasses, contact lenses, low vision devices) and dispensing optician services, including services provided by fabricating optical laboratories for adults 21 and over, are still excluded from coverage until 2020 (subject to a legislative appropriation).
   
   Psychology services were reinstated in January 1, 2014, and in 2013, the Legislature and Governor reinstated some adult dental services in AB 82 (Budget Committee), Chapter 23, Statutes of 2013, the 2013-14 budget health trailer bill. SB 97 (Committee on Budget and Fiscal Review), Chapter 52, Statutes of 2017, restored the optical lab and optician services (including glasses) no sooner than January 1, 2020 or January 1 of the subsequent calendar year following subject to a legislative appropriation. SB 97 also fully restored adult optional dental benefits that were not restored in May 2014. The Governor’s proposed 2019-20 budget does not include funding for restoring the Medi-Cal optical benefit.
   
   The Legislative Analyst’s Office estimates the annual cost of restoration of podiatry as a Medi-Cal benefit would have a total funds cost of $15.3 million ($4.6 million General Fund). This estimate does not include the change to the prior authorization and elimination of the two a month limit for podiatry services.
2. PRIOR AUTHORIZATION CHANGE. This bill prohibits a podiatrist from being required to submit a prior authorization for podiatric services rendered in either an outpatient or inpatient basis if a physician providing the same services would not be required to submit prior authorization to DHCS. This change replaces the narrower existing law language that prohibits prior authorization on an outpatient or inpatient service from being required when all of the specified conditions are met, including that
   
   1. The services are related to trauma, infection management, pain control, wound management, diabetic foot care, or limb salvage; and,
   2. An urgent or emergency need for services exists at the time the service is provided.
      

Prior authorization in Medi-Cal is done by requiring providers to fill out and submit a Treatment Authorization Requests (TARs). TARs are a form of utilization control, and require DHCS approval in order for a provider to receive payment for the service. According to the sponsor, an example of a procedure requiring a TAR involves removal of foreign body (such as a piece of glass) from a patient’s foot. The sponsor indicates this is a very common procedure that is typically done in the outpatient office or clinic, and is a simple, inexpensive procedure. A physician would not be required to obtain a TAR to remove the glass and put on a bandage, but a podiatrist must seek prior authorization through a TAR, which results in either a delay in care (until the TAR is approved), the patient being in pain because of the glass in their foot, or the podiatrist performing the service without being assured of Medi-Cal payment. 

1. SUPPORT. This bill is sponsored by the California Podiatric Medical Association (CPMA) to reinstate full foot and ankle care by podiatrists in Medi-Cal. CPMA states this elimination removed Medi-Cal coverage by podiatrists, but not the services themselves as the same services provided by a physician are covered in Medi-Cal. CPMA argues eliminating coverage of services provided by podiatrists has resulted in much more expensive complications down the road as podiatrists perform physician services and have full medical staff admitting and surgical privileges in hospitals and surgery centers. However, CPMA indicates hospital podiatrists are prohibited from providing on-call services to emergency patients in the Medi-Cal system. This has led to a delay in care in cases of diabetic foot care, traumatic foot, and ankle injuries as patients attempt to find a provider. It has also placed an increased burden on emergency room providers who are now tasked with providing essential foot and ankle services for these Medi-Cal patients.
   
   CPMA states recent studies show access to podiatrists can prevent complications for patients and actually provide savings for delivery systems, as diabetic ulcerations are the primary factor leading to lower extremity amputations. CPMA cites a study conducted by Thomson Reuters Healthcare that found, for Medicare eligible patients, a savings of $4,271 per patient with diabetes can be realized over a three-year period if there is at least one visit to a podiatrist in the year preceding ulceration, and each $1 invested in care by a podiatrist results in $9 to $13 of savings. Overall, patients with diabetes were less likely to experience a lower extremity amputation if a podiatrist was a member of the patient care team according to Thomson Reuters Healthcare. CPMA concludes that eliminating podiatric services from Medi-Cal has exacerbated an already acute access problem for the low income and disabled population, and this bill would provide better access to foot and ankle care for this vulnerable patient population.
2. PREVIOUS LEGISLATION. AB 1868 (Gomez) of 2014 would have restored Medi-Cal coverage of medical and surgical services provided by a podiatrist within his or her scope of practice that, if provided by a physician, would be considered physician services, for services which can be provided by either a physician or a podiatrist. AB 1868 was held on the Senate Appropriations Committee suspense file.
3. POLICY QUESTION. Several optional benefits eliminated by AB 5 have since been restored, but other benefits, including incontinence creams and washes, speech therapy, chiropractic, audiological services, have not been. Which Medi-Cal optional benefits should be restored?
4. DRAFTING CLARIFICATION. Medi-Cal limits certain services from a group of services rendered by particular providers to no more than two a month under what is known as the Medi-Service Reservation limitation. This bill seeks to remove this limit for podiatrists by making a podiatrist acting within their scope of practice and providing services subject to the same Medi-Cal billing and services policies as required for a physician. The author may wish to consider making the intent of this language of exempting podiatrists from the Medi-Service Reservation limitation more explicit in the bill language.

REGISTERED SUPPORT / OPPOSITION:

Support

California Podiatric Medical Association (sponsor)
Association of California Healthcare Districts
Association of Regional Center Agencies

California Podiatric Medical Association

CaliforniaHealth+ Advocates

Western Center on Law & Poverty, Inc.

Opposition

None on file.

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