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

Under existing law, in-person, face-to-face contact is not required under the Medi-Cal program when covered health care services are provided by video synchronous interaction, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet certain criteria.

This bill would require the department to to, by October 1, 2025, produce a public report on telehealth in the Medi-Cal program that includes analyses of, among other things, (1) telehealth access and utilization, (2) the effect of telehealth on timeliness of, access to, and quality of care, and (3) the effect of telehealth on clinical outcomes, as specified. The bill would authorize the department, in collaboration with the California Health and Human Services Agency, to issue policy recommendations based on the reports findings.

Existing law establishes the California Health and Human Services Agency, which includes departments charged with the administration of health, social, and other human services. Existing law establishes the Center for Data Insights and Innovation within the California Health and Human Services Agency to ensure the enforcement of state law mandating the confidentiality of medical information. Existing law requires the center to develop tools and education related to improvement of consumer access to care, quality of care, and addressing the disparities in quality of care related to socioeconomic status. Existing law also establishes the State Department of Health Care Services and requires the department, among other things, to administer the Medi-Cal program.

This bill would require the department, in collaboration with the agency, to collect appropriate data and identify indicators for tracking telehealth outcomes associated with impacting individual patient outcomes and overall population health. The bill would require the department to use the data collected to measure health outcomes of populations, as specified.

The bill would make a related intent statement.

SENATE COMMITTEE ON

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

AB 1943 (Weber) - Medi-Cal: telehealth

Bill Summary:

AB 1943 would require the Department of Health Care Services (DHCS) to use Medi-Cal data and other data sources available to DHCS to produce a public report on telehealth in the Medi-Cal program.

Fiscal Impact:

Unknown one-time costs, likely hundreds of thousands, for DHCS to produce the public report (General Fund and federal funds).

Background:

Current law 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. This includes asynchronous store-and-forward transfers (transmitting a patient’s medical information from an originating site to a health care provider at a distant site) and synchronous interaction (a real-time interaction between patient and provider located at different sites).

The Medi-Cal program provides medical coverage to eligible low-income individuals. In April 2024, DHCS published a Telehealth Utilization Data Dashboard and a companion narrative Telehealth Utilization Report. The dashboard includes telehealth utilization data for medical services, which can be stratified by categories such as age, sex, race/ethnicity, aid code groupings, primary language spoken, and more. Both the dashboard and the report are expected to be updated at regular intervals with the most currently available data. DHCS is aiming to publish an update to the dashboard in September 2024, which will expand the dataset to also include Drug Medi-Cal and dental services. DHCS’s dashboard and report primarily focus on claims and encounter data elements specific to telehealth access and utilization.

Proposed Law:

AB 1943 would require DHCS, by no later than October 1, 2025, to use Medi-Cal data and other data sources available to the department to produce a public report on telehealth in the Medi-Cal program that includes analyses of:

• Telehealth access and utilization.
• The effect of telehealth on timeliness of, access to, and quality of care, as specified.
• The effect of telehealth on clinical outcomes, as specified.
• The effect of telehealth on preventive care quality measures reported by Medi-Cal managed care plans, as specified.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: AB 1943

SUBJECT: Medi-Cal: telehealth.

SUMMARY:

1. Requires the Department of Health Care Services (DHCS) to use Medi-Cal data and other data sources available to DHCS to produce a public report on telehealth in the Medi-Cal program covering issues of access, utilization, quality of care, clinical outcomes, and preventive care.

Existing law:

1. 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. Includes asynchronous store-and-forward transfers (transmitting a patient’s medical information from an originating site to a health care provider at a distant site) and synchronous interaction (a real-time interaction between patient and provider located at different sites). [BPC §2290.5]
2. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
3. Specifies that in-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by DHCS, using telehealth as defined in 1) above or through audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed. Provides payment parity for telehealth and in-person services. [WIC §14132.725]
4. Requires providers to inform Medi-Cal recipients receiving telehealth services of their right to in-person services and that choosing in-person services will not affect their ability to access Medi-Cal services in the future, as well as of their right to transportation services when other available resources have been reasonably exhausted. Requires DHCS to develop informational materials about the availability of telehealth services and the right to in-person services. [WIC §14132.725]
5. Requires DHCS to develop a telehealth research and evaluation plan that proposes strategies to analyze the relationship between telehealth and access to care, quality of care, and Medi-Cal program costs, utilization, and program integrity; examines issues using an equity framework that includes stratification by geographic and demographic factors; and prioritizes research questions that directly inform Medi-Cal policy. [WIC §14132.725]

This bill:

1. Requires DHCS to use Medi-Cal data and other data sources available to DHCS to produce a public report on telehealth in the Medi-Cal program that includes analyses of the following:
2. Telehealth access and utilization;
3. The effect of telehealth on timeliness of, access to, and quality of care, including specialty care, for Medi-Cal enrollees, including among target populations of Medi-Cal enrollees identified within the DHCS’s Comprehensive Quality Strategy;
4. The effect of telehealth on clinical outcomes at an individual and population level; and,
5. The effect of telehealth on preventive care Healthcare Effectiveness Data and Information Set (HEDIS) quality measures reported by Medi-Cal managed care plans.
6. Requires the analyses, wherever possible based on the availability of data, to be stratified by geographic, demographic, and social determinants of health categories to identify disparities. Allows social determinants of health categories to be approximated using existing data sources, including the Healthy Places Index or similar indices.
7. Allows DHCS, in collaboration with the California Health and Human Services Agency, to issue policy recommendations based on the report’s findings.
8. States the intent of the Legislature to advance the use of telehealth and increase access to health care by establishing state policy that optimizes the use of telehealth to augment and enhance health and medical care for all California residents, especially those residents who are medically underserved, in order to improve individual patient outcomes and overall population health.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill would have one-time costs of an unknown amount, likely less than $150,000, to DHCS to prepare the report and make policy recommendations using existing data (General Fund, federal funds).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, the goal of this bill is to harness the power of telehealth technology to increase access to quality healthcare and specialized medical expertise for low-income and medically disadvantaged Californians. It would require DHCS to collect data and identify indicators for tracking telehealth outcomes associated with individual patient outcomes and overall population health to augment and enhance health and medical care for all California residents. It is the next essential step beyond reimbursement parity to drive access to health and medical care through the collection of essential data to ensure “Telehealth For All.” 
2. Telehealth in Medi-Cal. Medi-Cal’s telehealth policy was established pursuant to the Telemedicine Development Act of 1996 (Thompson, Chapter 864, Statutes of 1996) and updated in compliance with Assembly Bill 415 (Logue, Chapter 547, Statutes of 2011), known as the Telehealth Advancement Act of 2011. In 2019, DHCS undertook a policy review process, following extensive stakeholder engagement and public comment, to inform policy refinement. The revised 2019 policy afforded flexibility for providers to make clinically appropriate decisions regarding the use of synchronous and asynchronous telehealth modalities. The finalized policy was published in the Medi-Cal provider manual and disseminated to Medi-Cal managed care plans via an All Plan Letter. In 2020, due to the COVID-19 public health emergency, DHCS implemented additional broad flexibilities relative to telehealth modalities via blanket waivers and Disaster Relief state plan amendments. This enabled Medi-Cal’s health care delivery systems to meet the health care needs of Medi-Cal beneficiaries where in-person encounters were not recommended or available. Such expansions included expanding which providers could use telehealth, allowing telehealth to be used for new patients, allowing many services to be provided audio-only, expanding payment parity for telehealth services, waiving site limitations for federally qualified health centers (FQHCs) and rural health centers (RHCs), and expanding access through non-public technology platforms.

In 2021, several of these COVID-19 flexibilities were extended until December 31, 2022 via budget trailer bill AB 133 (Committee on Budget, Chapter 143, Statutes of 2021), along with a requirement for DHCS to convene a Telehealth Advisory Workgroup to inform the development of telehealth policies beyond the public health emergency. The workgroup met four times throughout 2021 and 2022 and as a result, DHCS published a report covering a number of policy areas, many of which were subsequently incorporated as existing telehealth policy into SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022). SB 184 also required a research and evaluation plan to propose strategies to analyze the effect of telehealth on the Medi-Cal program’s access to care, quality of care, program costs, and equity.

DHCS published the research and evaluation plan required by SB 184 in December 2022. For that report, DHCS conducted an internal assessment of its current telehealth data, reporting, and analytics capabilities to better understand the capabilities that form the foundation of the plan, and inform the types of research and evaluation objectives that could be achieved in the near- versus long-term. The plan identified some shortcomings in data that required new coding modifiers to be implemented, and in some cases outlined the timing that in which these changes would occur. The plan also identified existing data that could be leveraged to better understand impact of telehealth on the access, quality, cost, and equity questions. For the long-term questions in particular, the ability of DHCS to address these questions is dependent on the availability of resources.

In April 2024, DHCS published a Telehealth Utilization Data Dashboard and a companion narrative Telehealth Utilization Report. The dashboard includes telehealth utilization data for medical services, which can be stratified by categories such as age, sex, race/ethnicity, aid code groupings, primary language spoken, and more. Both the dashboard and the report are expected to be updated at regular intervals with the most currently available data. DHCS is aiming to publish an update to the dashboard in September 2024, which will expand the dataset to also include Drug Medi-Cal and dental services. DHCS’s dashboard and report, primarily focus on claims and encounter data elements specific to telehealth access and utilization. Some elements of this bill are not planned for inclusion such as the effects of telehealth on clinical outcomes, preventive care (including HEDIS quality measures), timeliness of care, and quality of care at both the individual and population level.

1. Related legislation. AB 2339 (Aguiar-Curry) allows providers to be reimbursed for a telehealth visit that establishes a new patient relationship through asynchronous store-and-forward when the visit is related to sensitive services, or when the new patient requests such a modality, as specified. AB 2339 is pending in this Committee.
2. Prior legislation. AB 1241 (Weber, Chapter 172, Statutes of 2023) clarifies that Medi-Cal providers of telehealth services are not required to schedule an appointment with a different provider in order to meet the requirement in existing law that they facilitate in-person care.

SB 184 (Committee on Budget and Fiscal Review, Chapter 47, Statutes of 2022) among other provisions, required DHCS to produce a research and evaluation plan to propose strategies to analyze the effect of telehealth on the Medi-Cal program’s access to care, quality of care, program costs, and equity.

AB 32 (Aguiar-Curry, Chapter 515, Statutes of 2022) permits DHCS to allow new patients to be established with health care providers in the Medi-Cal program using audio-only synchronous and other telehealth modalities.

AB 133 (Committee on Budget, Chapter 143, Statutes of 2021) among other provisions, extended, until December 31, 2022, flexibilities in reimbursement for care provided to Medi-Cal beneficiaries via telehealth, including through audio-only modalities, implemented during the COVID-19 public health emergency, and required DHCS to convene a Telehealth Advisory Workgroup.

1. Support. Sponsors the California Emerging Technologies Fund write that public research findings indicate higher morbidity and mortality rates for all leading causes of death in low-income households and communities of color. Key factors that contribute to these higher mortality and morbidity rates include less access to health care and medical expertise. Therefore, the challenge remains to measure to what extent access to telehealth—including specialty care through remote patient visits and expert consultations—can reduce adverse health outcomes for residents who are both economically disadvantaged and medically disadvantaged. While the COVID-19 pandemic was the impetus for the exponential growth of telehealth, it also served to illuminate another level of inequities in health care access regarding differentials in the ability for low-income households to use telehealth. This bill would establish the principle of equality in healthcare access by creating accountability for improved patient outcomes and population health.
2. Amendments. The author and committee have agreed on amendments to include a deadline for the report:

Sec. 2 14132.726. (a) No later than October 1, 2025, The department shall use Medi-Cal data and other data sources available to the department to produce a public report on telehealth in the Medi-Cal program that includes analyses of all of the following:

SUPPORT AND OPPOSITION:

Support: California Emerging Technology Fund (sponsor)

AARP California

American GI Forum Education Foundation of Santa Maria, California

Asynchealth

Beehive Technology Solutions

Calexico Wellness Center

California Association of Health Facilities

California Human Development

California Pan-Ethnic Health Network

California Primary Care Association Advocates

California State Association of Psychiatrists

Central Valley Opportunity Center

Cleanearth4kids.org

Community Tech Network

Corporation for Education Network Initiatives in California

First Day Foundation

Inland Coalition for Immigrant Justice

LA Cooperativa Campesina de California

LeadingAge California

Los Angeles Jewish Health

Partners in Care Foundation

Proteus, Inc.

Oppose: None received.

-- END --

Date of Hearing: May 1, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 1943

Author:(Weber) – As Amended Ver:April 4, 2024

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

SUMMARY:

This bill requires the Department of Health Care Services (DHCS) to use Medi-Cal data and other data to produce a report on telehealth in the Medi-Cal program, as specified, and authorizes DHCS, in collaboration with the California Health and Human Services Agency, to issue policy recommendations based on the report.

FISCAL EFFECT:

One-time costs of an unknown amount, likely less than $150,000, to DHCS to prepare the report and make policy recommendations using existing data (General Fund, federal funds).

COMMENTS:

1. Purpose. The California Emerging Technology Fund is the sponsor of this bill. According to the author:

California faces a significant challenge in understanding the usage and effectiveness of Telehealth, especially among those enrolled in the Medi-Cal Program, which serves low-income individuals. This shortfall in data hampers the ability of policymakers to refine and expand Telehealth services to ensure equitable access for all…

AB 1943 requires the California Department of Health Care Services to gather data and track Telehealth's impact on healthcare delivery and outcomes. By moving beyond reimbursement models to a data-driven approach, AB 1943 seeks to ensure equitable access to healthcare services for all Californians, making "Telehealth for All" a reality. This streamlined strategy aims to break down barriers to access and foster a more inclusive healthcare system statewide.

1. Medi-Cal Telehealth Data. DHCS has produced telehealth data reports by analyzing a subset of claims and encounters that include a telehealth “modifier,” which is a two-letter code appended to a service code to indicate the service was delivered via telehealth. DHCS’ telehealth data have been housed within an internal dashboard that includes data from the DHCS Medi-Cal Data Warehouse. The data include outpatient medical and non-specialty mental health services, but not dental, specialty mental health or substance use disorder services; however, DHCS plans to incorporate these data in the future.
   
   DHCS has produced public reports on telehealth visits per 100,000 beneficiaries by age group, sex, race/ethnicity, aid code (indicating category of Medi-Cal eligibility), delivery system (fee for service (FFS) or managed care), and managed care plan. Additionally, DHCS analyses examined claims volume and percent of telehealth office visits for new and established patients, including, for example, for behavioral health and treatment of speech, language, and hearing disorders. DHCS analyses have also examined utilization of services by modality of care, e.g., use of telehealth along with in-person office visits.
2. Medi-Cal Quality Data. DHCS requires managed care plans report a large number of quality measures to assess their overall success in delivering recommended care. DHCS has published a Comprehensive Quality Strategy which outlines priority areas, including behavioral health integration, improved maternal outcomes, and children’s preventive care. Many of these priority areas are tracked through a set of metrics called Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is a measurement system used nationwide to measure and improve performance in health care. These data can be analyzed with telehealth data to examine the impact of telehealth on HEDIS measures and other quality metrics.
3. Medi-Cal Telehealth Research and Evaluation Plan (R&E Plan). Pursuant to a requirement included in SB 184, DHCS issued the R&E plan in December 2022. The R&E Plan described DHCS’ state of telehealth data collection processes and capabilities, as well as opportunities to support more comprehensive data collection and analyses in the future. DHCS describes the R&E Plan as a path to assess the impact of telehealth on utilization, access, quality, outcomes, equity, and provider and enrollee experience, which could then inform future telehealth policy development. The plan presented telehealth R&E Plan questions that have been proposed by DHCS and stakeholders across key domains, and proposed both near-term and longer-term R&E Plan questions.
   
   According to the R&E Plan, the most pressing need in the near term is to better understand the impact of all telehealth modalities on access and utilization of care among Medi-Cal enrollees, and will be addressed by collecting data, analyzing and reporting findings on baseline telehealth utilization and access to care among Medi-Cal enrollees. Longer-term, DHCS intends to use data to understand the effects of Medi-Cal telehealth policy on experience, quality, outcomes (including HEDIS measures), and costs. This longer-term research has a three-to-five-year time frame. DHCS notes research for longer-term questions relies on different data sources, metrics, and data collection, and the analysis may require the support of external research partners or other entities.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 2, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 1943

Author:((Weber) – As Introduced Ver:January 29, 2024

SUBJECT: Health information.

SUMMARY: Requires the Department of Health Care Services (DHCS), in collaboration with the California Health and Human Services Agency (CHHSA), to collect specified data on telehealth access and individual and population health outcomes, and use the data to measure the health outcomes of populations using a specified list of determinants. Specifically, this bill:

1. Requires DHCS, in collaboration with the CHHSA, to collect appropriate data and identify indicators for tracking telehealth outcomes associated with impacting individual patient outcomes and overall population health, including the following data:
   1. Medi-Cal program data that tracks individual and overall population health outcomes;
   2. Medi-Cal program data on who has access to telehealth, the effectiveness of telehealth, and access to special care; and,
   3. Medi-Cal program morbidity and mortality data, including environmental factors.
      
2. Requires DHCS to use the data collected to measure the health outcomes of populations by using all of the following determinants:
   1. Medical care;
   2. Public health interventions;
   3. Social determinants, including income, employment, social support, and culture;
   4. Physical environment, including urban design, air quality, and access to clean water;
   5. Genetics; and,
   6. Individual behavior.

EXISTING LAW:

1. Establishes the Medi-Cal Program, administered by DHCS, to provide comprehensive health benefits to low-income individuals who meet specified eligibility criteria. [Welfare and Institutions Code (WIC) §14000 et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program. [WIC §14132]
3. Establishes Medi-Cal coverage for health care services provided through telehealth, including specifying that in-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by DHCS, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed. [WIC §14132.725 and §14132.100]
4. Defines “telehealth” to:
   1. Mean 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; and, [Business and Professions Code (BPC)§ 2290.5]
   2. Include synchronous interactions as well as asynchronous store and forward transfers, which are defined as the transmission of a patient’s medical information from an originating site to the health care provider at a distant site. [BPC § 2290.5 (a)]
5. Requires DHCS to develop a telehealth research and evaluation plan by January 1, 2023. [WIC §14132.725]

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California faces a significant challenge in understanding the usage and effectiveness of telehealth, especially among those enrolled in Medi-Cal, which serves low-income individuals. The author indicates this shortfall in data hampers the ability of policymakers to refine and expand telehealth services to ensure equitable access for all. This bill introduces a statewide policy to collect and analyze multiple Medi-Cal datasets to inform telehealth policy with a comprehensive view of how various social, economic, biological, and environmental factors impact health across populations. This bill is sponsored by the California Emerging Technology Fund (CETF), a non-profit corporation focused on closing the digital divide that was established pursuant to orders from the California Public Utilities Commission as a condition of approving a telecommunications merger.
2. BACKGROUND.
   1. Asynchronous Store and Forward. Current law defines “asynchronous store and forward” as the transmission of a patient's medical information from an originating site to the health care provider at a distant site without the presence of the patient. This may include, for example, electronic transmission of medical information, such as digital images, documents, and pre-recorded videos to a practitioner, often a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction. According to the Center for Connected Health Policy, store-and-forward technologies are most commonly used in radiology, pathology, dermatology, and ophthalmology. For example:
      1. In radiology, a physician at a small rural hospital can forward an X-ray or magnetic resonance imaging to a specialist at a major medical center for review.
      2. In dermatology, a primary care provider can take digital photos of their patients’ skin conditions and forward the images to a dermatologist for review and determination of treatment if needed.
   2. Telehealth in Medi-Cal. Telehealth is a mode of delivering health care services remotely using information technology. The three primary modalities are video, audio (including telephone), and asynchronous store and forward, which can be used when a real-time interaction is not needed.
      
      Telehealth utilization increased rapidly in response to the COVID-19 pandemic. According to data published by DHCS, prior to the onset of the COVID-19 pandemic, telehealth represented around 300 claims per 100,000 Medi-Cal member months. By April 2020, telehealth claims increased dramatically to over 12,000 claims per 100,000 member months and remained relatively stable through March 2021. Following March 2021, telehealth claims per 100,000 member months remained significantly higher than pre-COVID-19 pandemic levels but declined from the peak to around 7,700 claims per 100,000 member months.
   3. Recent History of Medi-Cal Telehealth Policy. Prior to the COVID-19 pandemic, DHCS had expanded the availability of telehealth in Medi-Cal by allowing most clinically appropriate services to be provided through telehealth. During the COVID-19 pandemic, DHCS implemented additional telehealth flexibilities to allow Medi-Cal providers to meet the health care needs of enrollees. After significant stakeholder engagement and legislative agreement on final trailer bill language, post-pandemic Medi-Cal telehealth policies were codified through the 2022-23 health trailer bill, SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, with minor and clarifying changes made through subsequent legislation.
   4. Medi-Cal Telehealth Policy. According to DHCS, California has been a leading state in the expansiveness of its coverage and reimbursement for services delivered via telehealth. DHCS has committed to continuing to enable broad telehealth coverage for all Medi-Cal covered benefits and services, as long as the provider is able to meet the standard of care, subject to billing, reimbursement and utilization management policies developed by DHCS. In addition, DHCS notes Medi-Cal is unique among other state Medicaid programs in regard to payment parity, in that the state reimburses a broad array of services at parity when delivered via audio-only visits. Medi-Cal telehealth policies are described below:
      1. Provider Requirements: A health care provider rendering Medi-Cal covered benefits and services via telehealth must be:
         1. Licensed in California or otherwise authorized by law; and,
         2. Enrolled as a Medi-Cal rendering provider or be a non-physician medical practitioner affiliated with an enrolled Medi-Cal provider group.
            

Unlicensed providers designated by DHCS, such as doulas, may provide services within their scope through telehealth, as specified in the Medi-Cal Provider Manual.

• • 1. Telehealth Covered Services: Telehealth services are reimbursable if the health care provider believes that the service being provided is clinically appropriate. The telehealth service must meet the procedural definition of the Current Procedural Terminology or Healthcare Common Procedure Coding System code associated with the service, as well as follow any additional guidance provided by DHCS (e.g., through the Medi-Cal Provider Manual).
    2. Telehealth Covered Modalities: Medi-Cal reimburses for telehealth visits conducted via audio-only telehealth (i.e., telephone), video telehealth, or through asynchronous telehealth (i.e., store and forward and e-consults).
    3. Telehealth Payment Parity: The amount paid by Medi-Cal, through both fee-for-service (FFS) and Medi-Cal managed care plans, for a service rendered via any telehealth modality is the same as the amount paid for the applicable service when rendered in-person.
    4. Telehealth Modifiers: Providers must designate telehealth modality with an appropriate modifier when billing for telehealth services.
    5. Establishment of New Patients via Telehealth: According to DHCS policy, a health care provider may bill Medi-Cal for a visit with a new patient that is conducted via video. AB 32 (Aguilar-Curry), Chapter 515, Statutes of 2022, Medi-Cal also allows a provider to bill for a visit with a new patient that is conducted via audio-only telehealth (e.g., phone or other audio device), but only under certain circumstances. These circumstances include when the visit is related to “sensitive services,” including behavioral health and reproductive health services, or when the patient requests an audio-only modality or attests they do not have access to video. Additional exceptions may be made by DHCS in consultation with stakeholders.
    6. Patient Consent: A health care provider must inform the patient once prior to the initial delivery of telehealth services about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services. Statute specifies information that must be shared with a patient.

Statute also establishes two policies that are not currently implemented, which will be implemented no sooner than January 1, 2024.

• • 1. Patient Choice of Telehealth Modality: No sooner than January 1, 2024, DHCS will phase in an approach that requires a provider offer both video and audio-only telehealth to ensure patients have their choice of telehealth modality. DHCS is developing guidance on exceptions to this requirement, to include exceptions based on a Medi-Cal provider’s lack of access to adequate broadband speeds to effectively stream video.
    2. Patient Right to In-Person Services: No sooner than January 1, 2024, DHCS will phase in an approach where providers who offer services via telehealth will be required to either offer those same services in-person or arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.
  1. Disparities in Utilization. In addition to Medi-Cal utilization data, the California Health Interview Survey (CHIS) has been a key data source for statewide telehealth data. According to an October 2023 analysis of CHIS data by the UCLA Center for Health Policy Research, “Telehealth and the Future of Health Care Access in California,” in 2021, about half (49%) of California adults reported using telehealth to seek care and telehealth use decreased to 46.7% in 2022. The report notes telehealth remained a popular way to access care even after declining from record-high utilization levels seen during the pandemic. However, the use of telehealth varied widely. The report concluded:
     1. Twice as large a proportion of adults who had health insurance used telehealth compared to adults without health insurance.
     2. Compared to adults with employer-sponsored insurance, smaller proportions of adults with Medicaid or private insurance, and larger proportions of adults with either Medicare and Medicaid or Medicaid and other public insurance, used telehealth.
     3. Adults above the age of 26 were more likely to use telehealth than young adults between the ages of 18 and 26, with adults over 65 being the most likely to use telehealth.
     4. Smaller proportions of adults with incomes below 300% of the federal poverty level (FPL) used telehealth compared to adults with incomes at or above 300% FPL.
     5. Latinx and Asian adults were less likely to use telehealth compared with white adults. White, Black, and American Indians and Alaska Native adults were more likely to use telehealth compared with the general California adult population.

According to a 2023 Issue Brief released by the California Health Care Foundation, “Telehealth Use and Experiences Among California Adults,” in general, the patterns of telehealth use track with broader patterns of having seen a doctor in any setting. People on Medicare (both those dually covered by Medicaid and those only on Medicare) and people in poor health report more doctor visits in general and are more likely to use telehealth. Similarly, the uninsured, younger people, people with lower incomes, and those in better health report fewer doctor visits overall and less telehealth use. Black Californians were slightly more likely to use telehealth than other racial groups and reported a higher level of satisfaction with video visits than the population overall. The brief found no evidence that telehealth exacerbated overall health care access disparities, but neither did it eliminate access to care disparities at the population level during the pandemic. According to the brief, this is likely due to the persistence of structural barriers, such as limited provider availability, even as telehealth use has grown.

• 1. Currently Available Medi-Cal Data.
     1. Administrative Data. DHCS has access to claims data that DHCS pays directly through the FFS Medi-Cal program, as well as encounter data provided to DHCS by managed care plans that pay providers for Medi-Cal services. Claims and encounter data include a large number of data elements about each medical service provided, for instance, type of service (often called a service or billing code), procedures, diagnoses, rendering provider, and dates of service. FFS claims data also includes provider charges and payment data. Although there are some concerns about the accuracy of claims data for certain types of analyses, they provide a detailed picture of health status and service utilization at an individual level. DHCS also has other administrative data, such as on age and race/ethnicity, which it links with claims data to provide a fuller picture of the health status and service utilization of different Medi-Cal populations.
     2. Telehealth Data. DHCS has produced telehealth data reports by analyzing a subset of claims and encounters that include a telehealth “modifier,” which is a two-letter code appended to a service code to designate the service was delivered via telehealth. DHCS’ telehealth data have been housed within an internal dashboard that includes FFS and managed care data from the DHCS Medi-Cal Data Warehouse. These include outpatient medical and non-specialty mental health services and do not currently include dental, specialty mental health or substance use disorder services; however, DHCS plans to incorporate these data in the future. DHCS has used the internal dashboard to conduct analyses of outpatient claims over time, starting before the pandemic, and also to produce point-in-time measures. DHCS has committed to creating a public telehealth dashboard to display these data.
        
        DHCS has produced public reports on telehealth visits per 100,000 beneficiaries by age group, sex, race/ethnicity, aid code (which designates a beneficiary’s category of Medi-Cal eligibility), delivery system (FFS or managed care), and managed care plan. Additionally, DHCS analyses examined the claims volume and percent of telehealth office visits for new and established patients, including, for example, for behavioral health and treatment of speech, language, and hearing disorders. DHCS analyses have also examined utilization of services by modality of care, e.g., use of telehealth along with in-person office visits.
     3. Quality Data. DHCS requires reporting of a large number of quality measures to measure the overall success of managed care plans in delivering recommended care. DHCS has published a Comprehensive Quality Strategy which outlines priority areas, including behavioral health integration, improved maternal outcomes, and children’s preventive care. Many of these priority areas are tracked through a set of metrics called Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS a measurement system used nationwide to measure and improve performance in health care. These data can be analyzed with telehealth data to examine the impact of telehealth on HEDIS measures and other quality metrics.
  2. 2022 Medi-Cal Telehealth Research and Evaluation Plan (R&E Plan). Pursuant to a statutory requirement included in SB 184, DHCS issued the R&E plan in December 2022. The R&E Plan described DHCS’ state of telehealth data collection processes and capabilities, as well as opportunities to support more comprehensive data collection and analyses in the future. DHCS describes the R&E Plan as a path to assess the impact of telehealth on utilization, access, quality, outcomes, equity, and provider and enrollee experience, which could then inform future telehealth policy development. The plan presented telehealth R&E Plan questions that have been proposed by DHCS and stakeholders across key domains, and proposed both near-term and longer-term R&E Plan questions.
     
     According to the R&E Plan, the most pressing need in the near term is to better understand the impact of all telehealth modalities on access and utilization of care among Medi-Cal enrollees. This is done by collecting data, analyzing and reporting findings on baseline telehealth utilization and access to care among Medi-Cal enrollees. Longer-term, DHCS indicates a desire to use data to understand the impact of Medi-Cal telehealth policy on experience, quality, outcomes, and cost, including the impact of telehealth on HEDIS measures, as mentioned above. This longer-term research has a three to five year time frame. DHCS notes longer-term questions are different from the set of near-term research questions in that the research relies on different data sources, metrics, and data collection, and that the analysis may require the support of external research partners or other entities. Given some of the longer-term questions require careful research designs and significant data analysis, the ability of DHCS to address these longer-term research questions is dependent on the availability of resources.

With respect to the goals of this bill, a “deep dive” to examine the nuanced reasons for disparities in telehealth use and quality of care delivered through telehealth could potentially improve health equity by illuminating barriers to more and better telehealth use to in the delivery of timely, quality specialty care. As DHCS notes in the R&E Plan, this level of analysis may require the support of external research partners.

1. SUPPORT. According to CETF, the bill’s sponsor, this is the next step to drive access to health and medical care through the collection of essential data to ensure “Telehealth for All” to achieve health equity. CETF notes that despite the work of the state on telehealth policy and research, the challenge remains to measure to what extent access to telehealth—including specialty care through remote patient visits and expert consultations—can reduce adverse health outcomes for residents who are both economically and medically disadvantaged. Asynchealth, a start-up asynchronous telepsychiatry company that uses Artificial Intelligence to improve care, similarly lauds this bill’s impact on health equity.
   
2. DOUBLE REFERRAL. This bill is double referred, upon passage of this Committee, this bill will be re-referred to the Assembly Privacy and Consumer Protection Committee.
   
3. RELATED LEGISLATION. AB 2339 (Aguiar-Curry) allows providers to be reimbursed for a telehealth visit that establishes a new patient relationship through asynchronous store-and-forward when the visit is related to sensitive services, or when the new patient requests such a modality, as specified. AB 2339 is pending in this Committee.
4. PREVIOUS LEGISLATION.
   1. AB 1241 (Weber), Chapter 172, Statutes of 2023, clarifies two provisions of current law requiring a provider furnishing services through video or audio telehealth to offer services in-person or facilitate in-person care.
   2. AB 32 establishes Medi-Cal coverage for establishment of new patients through audio telehealth under specified circumstances, including for reproductive health and behavioral health services, and clarified DHCS shall consider a Medi-Cal provider’s access to broadband at specified speeds, in establishing exceptions to the requirement that providers offering audio-only telehealth also offer video telehealth.
   3. SB 184 establishes Medi-Cal telehealth policy, including coverage, reimbursement patient consent standards, informational notices, DHCS authority to designate providers who may provide services through telehealth, treatment of telehealth for network adequacy purposes and a research and evaluation plan.
   4. AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, extended until December 31, 2022, flexibilities in reimbursement for care provided to Medi-Cal beneficiaries via telehealth, implemented during the COVID-19 public health emergency and required DHCS to convene a telehealth advisory workgroup, as specified.
   5. AB 457 (Santiago), Chapter 439, Statutes of 2021, established requirements on health plans and health insurers intended to ensure care offered through third-party telehealth providers remain coordinated with a patient’s primary care providers.
   6. AB 1022 (Mathis) of 2022 would have expanded the ability of an approved Program of All-Inclusive Care for the Elderly organization, which provides Medi-Cal and Medicare services, authority to use video telehealth to conduct all assessments, as specified. AB 1022 was referred to the Assembly Health Committee and not heard.
5. AMENDMENTS. To more clearly define the bill’s focus on how telehealth impacts access to specialty care, reduce the administrative potential burden of producing novel data sources, and better align with DHCS’s planned telehealth research agenda, the author and Committee have agreed to strike Section 2 of the bill and insert the following language:

(a) Using Medi-Cal data and other data sources available to the department, the department shall produce a public report on telehealth in the Medi-Cal program that includes analyses of the following:

1. Telehealth access and utilization.
2. Effect of telehealth on timeliness of, access to, and quality of care, including specialty care, for Medi-Cal enrollees, including among target populations of Medi-Cal enrollees identified within the Comprehensive Quality Strategy.
3. Effect of telehealth on clinical outcomes at an individual and population level.
4. Effect of telehealth on preventive care HEDIS quality measures reported by Medi-Cal managed care plans.

(b) (i) Wherever possible based on the availability of such data, these analyses shall be stratified by geographic, demographic and social determinants of health categories to identify disparities.

(ii) Social determinants of health categories may be approximated using existing data sources such as Healthy Places Index or similar indices.

(c) The department, in collaboration with the California Health and Human Services Agency, may issue policy recommendations based on the report’s findings, as determined by the department.

REGISTERED SUPPORT / OPPOSITION:

Support

California Emerging Technology Fund (sponsor)
AARP
American GI Forum Education Foundation of Santa Maria, CA
AsyncHealth
Beehive Technology Solutions
Calexico Wellness Center
California Human Development
California Pan - Ethnic Health Network
California Telehealth Policy Coalition
Central Valley Opportunity Center
Community Tech Network
Contra Costa Health Services
Corporation for Education Network Initiatives in California
First Day Foundation
Inland Coalition for Immigrant Justice
LA Cooperativa Campesina de California
LeadingAge California
Los Angeles Jewish Health
Partners in Care Foundation
Proteus, Inc.

Opposition

None on file.

Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097