Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including comprehensive perinatal services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, a pregnant individual or targeted low-income child who is eligible for, and is receiving, health care coverage under any of specified Medi-Cal programs is eligible for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individuals pregnancy.

This bill, during the one-year postpregnancy eligibility period, and as part of comprehensive perinatal services under Medi-Cal, would require the department to cover additional comprehensive perinatal assessments and individualized care plans and to provide additional visits and units of services in an amount, duration, and scope that are at least proportional to those available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period in effect on that date. The bill would require the department, in coordination with the State Department of Public Health, to consider input from certain stakeholders, as specified, in determining the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered.

The bill would require the department to cover comprehensive perinatal services that are rendered by a nonlicensed perinatal health worker in a beneficiarys home or other community setting away from a medical site, as specified. The bill would also require the department to allow a nonlicensed perinatal health worker rendering those services to be supervised by a community-based organization (CBO) or a local health jurisdiction (LHJ). For these purposes, the bill would require a CBO or LHJ supervising a nonlicensed perinatal health worker to provide those services under contract with a Comprehensive Perinatal Services Program provider.

The bill would condition implementation of the provisions above on receipt of any necessary federal approvals and the availability of federal financial participation. The bill would authorize the department to implement these provisions by all-county letters or similar instructions until regulations are adopted.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including comprehensive perinatal services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, a pregnant individual or targeted low-income child who is eligible for, and is receiving, health care coverage under any of specified Medi-Cal programs is eligible for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individuals pregnancy.

This bill, during the one-year postpregnancy eligibility period, and as part of comprehensive perinatal services under Medi-Cal, would require the department to cover additional comprehensive perinatal assessments and individualized care plans and to provide additional visits and units of services in an amount, duration, and scope that are at least proportional to those available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period in effect on that date. The bill would require the department to consider input from the State Department of Public Health and department, in coordination with the State Department of Public Health, to consider input from certain stakeholders, as specified, in determining the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered.

The bill would require the department to cover comprehensive perinatal services that are rendered by a nonlicensed perinatal health worker in a beneficiarys home or other community setting away from a medical site, as specified. The bill would also require the department to allow a nonlicensed perinatal health worker rendering those services to be supervised by a community-based organization (CBO) or a local health jurisdiction (LHJ). For these purposes, the bill would require a CBO or LHJ supervising a nonlicensed perinatal health worker to provide those services under contract with a Comprehensive Perinatal Services Program provider.

The bill would condition implementation of the provisions above on receipt of any necessary federal approvals and the availability of federal financial participation. The bill would authorize the department to implement these provisions by all-county letters or similar instructions until regulations are adopted.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including comprehensive perinatal services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, a pregnant individual or targeted low-income child who is eligible for, and is receiving, health care coverage under any of specified Medi-Cal programs is eligible for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individuals pregnancy.

This bill, during the one-year postpregnancy eligibility period, and as part of comprehensive perinatal services under Medi-Cal, would require the department to cover additional comprehensive perinatal assessments and individualized care plans and to provide additional visits and units of services in an amount, duration, and scope that are at least proportional to those available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period in effect on that date. The bill would require the department to collaborate with the State Department of Public Health and a broad stakeholder group to determine consider input from the State Department of Public Health and certain stakeholders, as specified, in determining the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered.

The bill would condition implementation of the provisions above on an appropriation by the Legislature and on receipt of any necessary federal approvals and the availability of federal financial participation. The bill would authorize the department to implement these provisions by all-county letters or similar instructions until regulations are adopted.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including comprehensive perinatal services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, a pregnant individual or targeted low-income child who is eligible for, and is receiving, health care coverage under any of specified Medi-Cal programs is eligible for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individuals pregnancy.

This bill, during the one-year postpregnancy eligibility period, and as part of comprehensive perinatal services under Medi-Cal, would require the department to cover additional comprehensive perinatal assessments and individualized care plans and to provide additional visits and units of services in an amount, duration, and scope that are at least proportional to those available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period in effect on that date. The bill would require the department to collaborate with the State Department of Public Health and a broad stakeholder group to determine the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered.

The bill would require the department to seek any necessary federal approvals to cover preventive services that are recommended by a physician or other licensed practitioner and that are rendered by a nonlicensed perinatal health worker in a beneficiarys home or other community setting away from a medical site, as specified. The bill would also require the department to seek any necessary federal approvals to allow a nonlicensed perinatal health worker rendering those preventive services to be supervised by (1) an enrolled Medi-Cal provider that is a clinic, hospital, community-based organization (CBO), or licensed practitioner, or (2) a CBO that is not an enrolled Medi-Cal provider, so long as an enrolled Medi-Cal provider is available for Medi-Cal billing purposes.

The bill would condition implementation of the provisions above on an appropriation by the Legislature and on receipt of any necessary federal approvals and the availability of federal financial participation.

GOVERNOR'S VETO

GV Bill Id:AB 608

Author:(Schiavo)

As Enrolled Ver:September 11, 2023

2/3 vote

SUMMARY

Extends the length of time postpartum services are available under the Comprehensive Perinatal Services Program (CPSP) benefit in Medi-Cal, and expands the settings and supervisors for non-licensed Comprehensive Perinatal Health Workers (CPHWs) to provide CPSP services.

Senate Amendments

Strengthen requirements for the Department of Health Care Services (DHCS) to work in coordination with the California Department of Public Health (DPH) in determining coverage policy for additional units of service under CPSP.

Governor’s Veto Message

This bill would require the Department of Health Care Services (DHCS) to cover additional services as part of Medi-Cal's Comprehensive Perinatal Services Program (CPSP) and allow non-licensed perinatal health workers to provide services in a beneficiary's home or community setting, upon federal approval.

I support the author's goal to improve maternal health outcomes and reduce disparities. However, Medi-Cal already provides full-scope coverage for one year after pregnancy, and DHCS is actively working on a "Birthing Care Pathway" proposal to improve services provided during the perinatal period, reduce maternal mortality, and address disparities in maternal health outcomes. Given the significant ongoing General Fund costs of over $20 million annually to implement this bill, it should be evaluated as part of the annual budget process.

In partnership with the Legislature, we enacted a budget that closed a shortfall of more than $30 billion through balanced solutions that avoided deep program cuts and protected education, health care, climate, public safety, and social service programs that are relied on by millions of Californians. This year, however, the Legislature sent me bills outside of this budget process that, if all enacted, would add over $7.4 billion in one-time-and over $11.3 billion in ongoing costs unaccounted for in our budget.

With our state facing continuing economic risk and revenue uncertainty, it is important to remain disciplined and reject bills with significant fiscal implications, such as this measure.

COMMENTS

1. CPSP. CPSP was established in the early 1980's, based on the results of a pilot conducted in July 1979 through June 1982. The pilot demonstrated that obstetrical care, supplemented by psychosocial, health education and nutrition services and prenatal vitamins and minerals, could significantly reduce the incidence of low birth weight in infants. The Maternal, Child and Adolescent Health Program in DPH oversees CPSP and the statewide system of perinatal care established in statute. The goals of CPSP are to: a) decrease the incidence of low birthweight in infants; b) improve the outcome of every pregnancy; c) give every baby a healthy start in life; and, d) lower health care costs by preventing catastrophic and chronic illness in infants and children.

CPSP has a unique program design. It integrates Medi-Cal billing and coverage with quality and monitoring activities at local health jurisdictions (LHJs, or county public health departments), as overseen by DPH. Most LHJs employ a Perinatal Services Coordinator, who certifies providers who meet CPSP program standards and provides technical assistance to CPSP providers in their communities. To bill fee-for-service Medi-Cal or a contracting Medi-Cal managed care plan for CPSP services, a provider must enroll in and be CPSP-certified through their local LHJ, in addition to being enrolled in Medi-Cal.

1. CPSP as a Medi-Cal Benefit. Statute and regulation establish a set of services that comprise the CPSP Medi-Cal benefit. These services include a program orientation; initial and follow-up nutrition, psychosocial and health education assessments, and corresponding interventions; comprehensive individual and group health education, and prenatal vitamins. A CPSP practitioner develops an Individualized Care Plan to address needs identified in the assessments, conducts case coordination, and ensures that the Medi-Cal enrollee receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. CPSP services can be provided to Medi-Cal eligible enrollees, throughout pregnancy through the end of the second month after delivery. DHCS establishes maximum units of service for each CPSP service. Additional services can be provided as medically necessary with an approved Treatment Authorization Request.

The CPSP benefit is a set of outpatient services that supplement, and do not replace, services that are part of standard prenatal, delivery, and postpartum care. Because of benefit expansions and managed care requirements that have been implemented since the creation of CPSP, pregnant and postpartum people in Medi-Cal also have coverage for other services, outside of CPSP, that supplement standard obstetrical care. These include, among other services, a comprehensive set of behavioral health services as well as health education, community health worker, and doula services, as further discussed in "Related Medi-Cal Efforts," below.

1. Medi-Cal Coverage of Pregnancy and Recent Postpartum Eligibility Expansion. Because of the critical importance of prenatal care for maternal and infant health, Medi-Cal coverage for pregnant persons is more generous than that for non-pregnant individuals. Specifically, eligibility for pregnant persons extends to 322% of federal poverty level (FPL), while Medi-Cal coverage for other individuals generally extends to 138% of the FPL. Correspondingly, Medi-Cal paid for approximately 40% of California's 420,754 births in 2021.

The health budget trailer bill, AB 133 (Budget Committee), Chapter 143, Statutes of 2021, implemented a federal option to expand coverage to 12 months postpartum and provide full-scope benefits for these pregnant and postpartum individuals. Under this bill, the allowable timeline for provision of CPSP would also be extended to cover additional comprehensive perinatal assessments and individualized care plans, and provide additional visits and units of services during the one-year post-pregnancy eligibility period.

1. Related Medi-Cal Efforts. DHCS is currently implementing numerous Medi-Cal program improvement and transformation efforts, most notably through a number of federal demonstrations and waivers dubbed CalAIM (California Advancing and Innovating Medi-Cal). Several recent program efforts are targeted at improving maternal health or intersect with the provision of CPSP services. Specifically, several design elements of CPSP align with or overlap with the department's transformation and improvement efforts, particularly in relation to case coordination and care management functions that address the social determinants of health during the perinatal period.

On July 20, 2023, DHCS presented to the department's Stakeholder Advisory Committee a new DHCS project called the Birthing Care Pathway Project. DHCS explained the department is developing a comprehensive Birthing Care Pathway that is envisioned as a care model to cover conception through 12 months postpartum, with related benefit and payment strategies in Medi-Cal, to reduce maternal morbidity and mortality and address significant racial and ethnic disparities in maternal health outcomes among Black, American Indian/Alaska Native, and Pacific Islander individuals.

1. Additional Medi-Cal Managed Care Requirements. Recently updated managed care plan contracts require plans to "utilize the most current standards or guidelines of American College of Obstetricians and Gynecologists (ACOG) and CPSP to ensure Members receive quality perinatal and postpartum services." Plans must also implement a comprehensive risk assessment tool for all pregnant members that is comparable to the ACOG standards and CPSP standards in existing state regulation, follow up on all identified risks consistent with those standards, and document the assessment and interventions in the individual's medical record. DHCS imposes other general requirements on contracted managed care plans that are similar to the CPSP benefit.
2. CPHWs. Existing state regulation for CPSP defines a CPHW as being at least 18 years of age, is a high school graduate or equivalent, and has at least one year of full-time paid practical experience in providing perinatal care; and provides services in a clinic under the direct supervision of a comprehensive perinatal practitioner. In their guidance on CPSP, DPH states CPSP services delivered are consistent with approved protocols signed off by nutrition, health education and psychosocial consultants. DPH also requires CPSP services to be provided by or under the personal supervision of a physician, and CPHWs to work under the direct supervision of a physician.

This bill would instead allow CPHWs to be supervised by community-based organizations or local health jurisdictions. This bill would expand the location where CPHWs can provide services to include a beneficiary's home or other community setting away from a medical site.

According to the Author

This bill addresses two interrelated problems that limit the ability of CPSP to fully serve Medi-Cal beneficiaries in the pregnancy and postpartum periods. First, the bill expands Medi-Cal's CPSP benefit throughout a 12-month postpartum period instead of solely the initial 60-day period. According to the author, the 60-day time period limits the ability of CPSP providers to identify and address postpartum depression, connect parents to programs that address food and housing insecurity, and provide a host of other services that may be needed beyond the initial 60-day postpartum period. It also adopts the federal option to allow CPHWs – a subset of community health workers with expertise in perinatal health – to provide supportive services in the mother's home or elsewhere in the community, not just at a clinic or doctor's office.

Arguments in Support

This bill is sponsored by Maternal and Child Health Access (MCHA) and supported by consumers', children's, and women's health groups to improve access to critical social and other supports for low-income mothers and infants during Medi-Cal's 12-month postpartum eligibility period.

MCHA writes that the CPSP benefit connects mothers to necessary medical care and social supports during pregnancy, and this bill would address the need for these supports during Medi-Cal's extended 12-month postpartum eligibility period as well. Without this bill, MCHA is extremely concerned that birth experiences and necessary follow-up for conditions uncovered during pregnancy will not be given the proper attention. MCHA states new mothers need a structure for health and social support long beyond the initial 60 days following a pregnancy.

Arguments in Opposition

The Department of Finance (DOF) is opposed to this bill because it results in ongoing General Fund costs and future cost pressure in the Medi-Cal program not included in the 2023 Budget Act. Additionally, DOF notes this bill should be considered alongside other policy changes as part of the annual budget development process, and that a similar proposal was heard and ultimately not included in the 2023 Budget Act.

DOF explains the expansion of full-scope Medi-Cal coverage for one year after pregnancy has already been operationalized, pursuant to Chapter 143, Statutes of 2021 (AB 133), and there is likely overlap between CPSP services available after 60 days postpartum and existing services already provided under this one-year postpartum care extension.

DOF notes the bill would result in significant overlap with planned expansions to provide pregnant and postpartum individuals access to behavioral health services, midwives, alternative birthing centers, doulas, community health workers, and dyadic services, as well as potentially duplicating DHCS' Enhanced Care Management Birth Equity population of focus, which will launch in January 2024. Finance notes that this bill is substantially similar to AB 1930 (Arambula, 2022), which was vetoed by the Governor citing that DHCS already provides full-scope coverage for all individuals for one year after pregnancy, which offers a range of services above and beyond the services provided by CPSP, and that the bill would result in millions of dollars in ongoing General Fund costs.

FISCAL COMMENTS

According to the Senate Appropriations Committee, unknown, ongoing costs (General Fund and federal funds) for the Medi-Cal program for extending the CPSP benefit.

VOTES

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

ASSEMBLY FLOOR: 80-0-0

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ASSEMBLY FLOOR: 79-0-1

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Luz Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Essayli

UPDATED

VERSION: September 11, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0002539

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 608

Author:(Schiavo)

As Amended Ver:July 12, 2023

Majority vote

SUMMARY

Extends the length of time postpartum services are available under the Comprehensive Perinatal Services Program (CPSP) benefit in Medi-Cal, and expands the settings and supervisors for non-licensed Comprehensive Perinatal Health Workers (CPHWs) to provide CPSP services.

Senate Amendments

Strengthen requirements for the Department of Health Care Services (DHCS) to work in coordination with the California Department of Public Health (DPH) in determining coverage policy for additional units of service under CPSP.

COMMENTS

1. CPSP. CPSP was established in the early 1980's, based on the results of a pilot conducted in July 1979 through June 1982. The pilot demonstrated that obstetrical care, supplemented by psychosocial, health education and nutrition services and prenatal vitamins and minerals, could significantly reduce the incidence of low birth weight in infants. The Maternal, Child and Adolescent Health Program in DPH oversees CPSP and the statewide system of perinatal care established in statute. The goals of CPSP are to: a) decrease the incidence of low birthweight in infants; b) improve the outcome of every pregnancy; c) give every baby a healthy start in life; and, d) lower health care costs by preventing catastrophic and chronic illness in infants and children.

CPSP has a unique program design. It integrates Medi-Cal billing and coverage with quality and monitoring activities at local health jurisdictions (LHJs, or county public health departments), as overseen by DPH. Most LHJs employ a Perinatal Services Coordinator, who certifies providers who meet CPSP program standards and provides technical assistance to CPSP providers in their communities. To bill fee-for-service Medi-Cal or a contracting Medi-Cal managed care plan for CPSP services, a provider must enroll in and be CPSP-certified through their local LHJ, in addition to being enrolled in Medi-Cal.

1. CPSP as a Medi-Cal Benefit. Statute and regulation establish a set of services that comprise the CPSP Medi-Cal benefit. These services include a program orientation; initial and follow-up nutrition, psychosocial and health education assessments, and corresponding interventions; comprehensive individual and group health education, and prenatal vitamins. A CPSP practitioner develops an Individualized Care Plan to address needs identified in the assessments, conducts case coordination, and ensures that the Medi-Cal enrollee receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. CPSP services can be provided to Medi-Cal eligible enrollees, throughout pregnancy through the end of the second month after delivery. DHCS establishes maximum units of service for each CPSP service. Additional services can be provided as medically necessary with an approved Treatment Authorization Request.

The CPSP benefit is a set of outpatient services that supplement, and do not replace, services that are part of standard prenatal, delivery, and postpartum care. Because of benefit expansions and managed care requirements that have been implemented since the creation of CPSP, pregnant and postpartum people in Medi-Cal also have coverage for other services, outside of CPSP, that supplement standard obstetrical care. These include, among other services, a comprehensive set of behavioral health services as well as health education, community health worker, and doula services, as further discussed in "Related Medi-Cal Efforts," below.

1. Medi-Cal Coverage of Pregnancy and Recent Postpartum Eligibility Expansion. Because of the critical importance of prenatal care for maternal and infant health, Medi-Cal coverage for pregnant persons is more generous than that for non-pregnant individuals. Specifically, eligibility for pregnant persons extends to 322% of federal poverty level (FPL), while Medi-Cal coverage for other individuals generally extends to 138% of the FPL. Correspondingly, Medi-Cal paid for approximately 40% of California's 420,754 births in 2021.

The health budget trailer bill, AB 133 (Budget Committee), Chapter 143, Statutes of 2021, implemented a federal option to expand coverage to 12 months postpartum and provide full-scope benefits for these pregnant and postpartum individuals. Under this bill, the allowable timeline for provision of CPSP would also be extended to cover additional comprehensive perinatal assessments and individualized care plans, and provide additional visits and units of services during the one-year post-pregnancy eligibility period.

1. Related Medi-Cal Efforts. DHCS is currently implementing numerous Medi-Cal program improvement and transformation efforts, most notably through a number of federal demonstrations and waivers dubbed CalAIM (California Advancing and Innovating Medi-Cal). Several recent program efforts are targeted at improving maternal health or intersect with the provision of CPSP services. Specifically, several design elements of CPSP align with or overlap with the department's transformation and improvement efforts, particularly in relation to case coordination and care management functions that address the social determinants of health during the perinatal period.

On July 20, 2023, DHCS presented to the department's Stakeholder Advisory Committee a new DHCS project called the Birthing Care Pathway Project. DHCS explained the department is developing a comprehensive Birthing Care Pathway that is envisioned as a care model to cover conception through 12 months postpartum, with related benefit and payment strategies in Medi-Cal, to reduce maternal morbidity and mortality and address significant racial and ethnic disparities in maternal health outcomes among Black, American Indian/Alaska Native, and Pacific Islander individuals.

1. Additional Medi-Cal Managed Care Requirements. Recently updated managed care plan contracts require plans to "utilize the most current standards or guidelines of American College of Obstetricians and Gynecologists (ACOG) and CPSP to ensure Members receive quality perinatal and postpartum services." Plans must also implement a comprehensive risk assessment tool for all pregnant members that is comparable to the ACOG standards and CPSP standards in existing state regulation, follow up on all identified risks consistent with those standards, and document the assessment and interventions in the individual's medical record. DHCS imposes other general requirements on contracted managed care plans that are similar to the CPSP benefit.
2. CPHWs. Existing state regulation for CPSP defines a CPHW as being at least 18 years of age, is a high school graduate or equivalent, and has at least one year of full-time paid practical experience in providing perinatal care; and provides services in a clinic under the direct supervision of a comprehensive perinatal practitioner. In their guidance on CPSP, DPH states CPSP services delivered are consistent with approved protocols signed off by nutrition, health education and psychosocial consultants. DPH also requires CPSP services to be provided by or under the personal supervision of a physician, and CPHWs to work under the direct supervision of a physician.

This bill would instead allow CPHWs to be supervised by community-based organizations or local health jurisdictions. This bill would expand the location where CPHWs can provide services to include a beneficiary's home or other community setting away from a medical site.

According to the Author

This bill addresses two interrelated problems that limit the ability of CPSP to fully serve Medi-Cal beneficiaries in the pregnancy and postpartum periods. First, the bill expands Medi-Cal's CPSP benefit throughout a 12-month postpartum period instead of solely the initial 60-day period. According to the author, the 60-day time period limits the ability of CPSP providers to identify and address postpartum depression, connect parents to programs that address food and housing insecurity, and provide a host of other services that may be needed beyond the initial 60-day postpartum period. It also adopts the federal option to allow CPHWs – a subset of community health workers with expertise in perinatal health – to provide supportive services in the mother's home or elsewhere in the community, not just at a clinic or doctor's office.

Arguments in Support

This bill is sponsored by Maternal and Child Health Access (MCHA) and supported by consumers', children's, and women's health groups to improve access to critical social and other supports for low-income mothers and infants during Medi-Cal's 12-month postpartum eligibility period.

MCHA writes that the CPSP benefit connects mothers to necessary medical care and social supports during pregnancy, and this bill would address the need for these supports during Medi-Cal's extended 12-month postpartum eligibility period as well. Without this bill, MCHA is extremely concerned that birth experiences and necessary follow-up for conditions uncovered during pregnancy will not be given the proper attention. MCHA states new mothers need a structure for health and social support long beyond the initial 60 days following a pregnancy.

Arguments in Opposition

The Department of Finance (DOF) is opposed to this bill because it results in ongoing General Fund costs and future cost pressure in the Medi-Cal program not included in the 2023 Budget Act. Additionally, DOF notes this bill should be considered alongside other policy changes as part of the annual budget development process, and that a similar proposal was heard and ultimately not included in the 2023 Budget Act.

DOF explains the expansion of full-scope Medi-Cal coverage for one year after pregnancy has already been operationalized, pursuant to Chapter 143, Statutes of 2021 (AB 133), and there is likely overlap between CPSP services available after 60 days postpartum and existing services already provided under this one-year postpartum care extension.

DOF notes the bill would result in significant overlap with planned expansions to provide pregnant and postpartum individuals access to behavioral health services, midwives, alternative birthing centers, doulas, community health workers, and dyadic services, as well as potentially duplicating DHCS' Enhanced Care Management Birth Equity population of focus, which will launch in January 2024. Finance notes that this bill is substantially similar to AB 1930 (Arambula, 2022), which was vetoed by the Governor citing that DHCS already provides full-scope coverage for all individuals for one year after pregnancy, which offers a range of services above and beyond the services provided by CPSP, and that the bill would result in millions of dollars in ongoing General Fund costs.

FISCAL COMMENTS

According to the Senate Appropriations Committee, unknown, ongoing costs (General Fund and federal funds) for the Medi-Cal program for extending the CPSP benefit.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

ASSEMBLY FLOOR: 80-0-0

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones‑Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

UPDATED

VERSION: July 12, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0001683

 THIRD READING  

Bill No: AB 608

Author: Schiavo (D), et al.

Amended: 7/12/23 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 12-0, 7/5/23

AYES: Eggman, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

SENATE GOVERNMENTAL ORG. COMMITTEE: 14-0, 7/11/23

AYES: Dodd, Wilk, Alvarado-Gil, Archuleta, Ashby, Bradford, Glazer, Jones, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: 7-0, 9/1/23

AYES: Portantino, Jones, Ashby, Bradford, Seyarto, Wahab, Wiener

ASSEMBLY FLOOR: 80-0, 5/31/23 - See last page for vote

SUBJECT: Medi-Cal: comprehensive perinatal services

SOURCE: March of Dimes

Maternal and Child Health Access

The Children’s Partnership

DIGEST:

This bill requires the Department of Health Care Services (DHCS) to extend the Comprehensive Perinatal Services Program benefit for up to one year after the end of a Medi-Cal beneficiary’s pregnancy. Requires DHCS to allow an unlicensed perinatal provider to render preventive services recommended by a licensed provider and to provide those services in a beneficiary’s home or other community setting away from a medical site.

ANALYSIS: Existing federal law authorizes federal financial participation in the Medicaid program for diagnostic, screening, preventive, and rehabilitative services, including any clinical preventive services that are assigned a grade A or B by the United States Preventive Services Task Force and any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law. [42 U.S.C. §1396d]

Existing state law:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
2. Requires the Medi-Cal program to cover a pregnant individual who is eligible for and is receiving health care coverage under a Medi-Cal program for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individual’s pregnancy. [WIC §14005.185]
3. Establishes the Comprehensive Perinatal Services Program (CPSP) within the California Department of Public Health (CDPH) as a community-based system of comprehensive perinatal care for low-income women. States that prenatal care, delivery service, postpartum care, and neonatal and infant care are necessary services that have been demonstrated effective in preventing or reducing maternal, perinatal, and infant mortality and morbidity, including prematurity and low birth weight. Includes initial and ongoing physical assessment, psychosocial, nutrition, and health education assessments, interventions, counseling and referral, food supplement programs, vitamins, and breast-feeding and other services as appropriate. Requires all contracted providers to make these services available directly or by subcontract, and to use an appropriate multidisciplinary team. [HSC §123475, et seq.]
4. Establishes the CPSP program services as a Medi-Cal benefit. [WIC §14132]
5. Defines CPSP providers to include any general practice physician, family practice physician, obstetrician-gynecologist, pediatrician, certified nurse midwife, a group, any of whose members is one of the above-named physicians, or any preferred provider organization or clinic enrolled in the Medi-Cal program and certified pursuant to the standards of this section. Allows providers to contract with medical and other practitioners for the purpose of delivering CPSP services. [WIC §14134.5]
6. States that perinatal means the period from the establishment of pregnancy to one month following delivery. Requires the CPSP provider to schedule visits with appropriate providers and track the patient to make sure services have been received. Requires that the patient receive psychosocial assessment and referrals; nutrition assessment, appropriate referrals to counseling for food supplement programs, vitamins, and breastfeeding, health, childbirth, and parenting education. [WIC §14134.5]

This bill:

1. Requires DHCS to include, as part of the CPSP Medi-Cal benefit, additional comprehensive perinatal assessments, individualized care plans, visits and services in an amount, duration, and scope that are at least proportional to those that were available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period, for a period of up to one year after the end of a Medi-Cal beneficiary’s pregnancy.
2. Requires DHCS, in coordination with the Maternal, Child, and Adolescent Health Division of the State Department of Public Health, to consider input from CDPH and a stakeholder group, including perinatal health workers and community-based organizations providing perinatal services, to determine the specific number of additional services to be covered pursuant to 1) above.
3. Requires DHCS to cover comprehensive perinatal services that are rendered by a nonlicensed perinatal health worker in a beneficiary’s home or other community setting that is not medical site.
4. Allows nonlicensed perinatal health workers rendering such services to be supervised by a community-based organization or local health jurisdiction in addition to the entities otherwise authorized by law or regulation to supervise nonlicensed perinatal health workers. Requires community-based organization or local health jurisdiction supervising nonlicensed perinatal health workers to provide those comprehensive perinatal services under contract with a CPSP provider.
5. Conditions the implementation of this bill on the receipt of federal approval and federal financial participation. Allows DHCS to implement this bill via guidance until regulations are adopted.

Comments

1. Author’s statement. According to the author, this bill ensures every Californian has a healthy start in life by extending coverage of services provided by CPSP to one year postpartum. Childbirth and parenting is unique to each family. However, without postpartum support, some challenges many parents face can lead to disruptions with the mental and physical wellbeing of parent or child. For example, it is estimated that postpartum depression affects one in seven parents after delivery. If unaddressed, this can lead to long-term behavioral health issues in children, and, in severe cases, suicide. More than four of every five people who die by suicide after the end of their pregnancy, died in the late postpartum period 43 to 365 days after birth. If extending CPSP into that first year after pregnancy can help treat postpartum depression and reduce the number of suicides, we should be doing everything we can to make these services easily accessible to more people.
2. Medi-Cal’s postpartum expansion. There have been several recent efforts to expand postpartum coverage in the Medi-Cal program in order to improve maternal and child health outcomes, reduce maternal death, and create access for mental health services for new mothers. As part of the 2019-2020 Budget Act, the Provisional Postpartum Care Expansion was passed, a state-funded program that extended the postpartum care period from 60 days to 12 months after the last day of pregnancy to an eligible individual who is receiving pregnancy-related services and is diagnosed with a mental health condition. Given the lack of federal funding available at the time, maternal mental health conditions were prioritized. Although this Provisional Postpartum Care Expansion was implemented in 2020, this occurred after the federal public health emergency due to COVID-19 went into effect, and the federal government required states to maintain Medicaid and Children’s Health Insurance Program (CHIP) coverage for all enrollees for the duration of the emergency in order to receive a higher federal matching rate for Medicaid and CHIP services. Thus, in theory, no individual who gave birth while on Medi-Cal lost their coverage from March 2020 until the requirement ended in 2023.

As part of the American Rescue Act Plan (ARPA), effective April 1, 2022, the federal government gave states the option of expanding postpartum Medicaid coverage for an additional ten months with federal matching funds. California quickly adopted this option and included it in the 2021-2022 health trailer bill, AB 133 (Committee on Budget, Chapter 143, Statutes of 2021). Now an individual eligible for pregnancy and postpartum care services under Medi-Cal is entitled to an additional ten months of postpartum coverage at the end of their 60-day postpartum period for a total 12 months of postpartum coverage. According to DHCS, this coverage includes the full breadth of medically necessary services through the pregnancy and postpartum period.

DHCS stated the importance of extending postpartum services in its state plan amendment adopting this federal option: All pregnant individuals should receive comprehensive care during the postpartum period to assess their physical recovery from pregnancy and childbirth, address chronic conditions (such as diabetes or hypertension), address mental health issues (including postpartum depression), discuss reproductive health (including contraception and birth spacing), and ensure continuity of care. In spite of having a higher prevalence of medical conditions such as diabetes and hypertension, pregnant Medicaid and CHIP individuals have lower postpartum care visit rates than do individuals with private insurance. The Pregnancy Mortality Surveillance System (PMSS) defines a pregnancy-related death as the death of a woman while pregnant or within one year of the end of pregnancy from any cause related to or aggravated by the pregnancy. Over one half of maternal deaths occur between the first day of the postpartum period up through the 365th day during postpartum period. Causes can include cardiovascular issues, hypertension, or infection. Identifying the causes of maternal mortality and morbidity is complex and coverage is only one factor. Research strongly indicates that access to healthcare throughout a woman’s reproductive years is essential for prevention, early detection, and treatment of some of the conditions that place women at higher risk for pregnancy-related complications, including cardiovascular disease, diabetes, and chronic hypertension.

1. CPSP. CPSP is administered by the CDPH’s Maternal, Child and Adolescent Health division. CPSP provides a model of enhanced perinatal services for Medi-Cal eligible pregnant and postpartum individuals from entry to care through postpartum. These enhanced services are delivered by qualified Medi-Cal providers. CPSP services must be provided in conformance with current American College of Obstetrics and Gynecologists recommendations and California regulation. CPSP providers are reimbursed by fee-for-service Medi-Cal or according to their contract with a Medi-Cal managed care plan. CPSP clients receive a program orientation, initial nutrition, psychosocial and health education assessments, second and third trimester reassessments and postpartum assessments. The practitioner develops an individualized care plan to address needs identified in the assessments, conducts case coordination, and ensures that the client receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. The plan is developed for each CPSP client at the time of the initial assessment and updated at least every trimester and postpartum visit, and more often if needed. CPSP providers are also required to make referrals to programs and services such as the Women, Infant and Children nutrition program, genetic screening, dental care, and family planning, as well as provide case coordination to assure that health care members work together with the client to assure that the care plan is completed, and the client receives the necessary services.
2. Federal preventive services rule change. The Affordable Care Act changed federal Medicaid law to encourage the provision of preventive care in several respects. One of those changes allows preventive services to be provided by non-licensed individuals under the supervision of a licensed health care provider. Previously, Medicaid regulations limited coverage of preventive services to services that were directly provided by physician or other licensed practitioner. As of January 2014, Medicaid may reimburse for preventive services delivered by a non-licensed health care professional, such as a community health worker, when the service is recommended by a physician or other licensed provider within their scope of practice under state law. Under this rule, states have the authority to define practitioner qualifications; ensure appropriate services are provided by qualified practitioners; define preventive services to be provided, subject to federal requirements; and, describe the reimbursement methodology.

The rule change did not make changes to what services may be provided. The services must still be medical or remedial in nature; involve direct patient care; and, be for the express purpose of diagnosing, treating, or preventing illness, injury, or other impairments to an individual’s physical or mental health. Existing regulation for the CPSP program includes a list of comprehensive perinatal practitioners, including a perinatal health worker (PHW). PHWs must be at least 18 years of age, a high school graduate or equivalent, and have at least one year of full-time paid practical experience in providing perinatal care, and are required to provide services in a clinic that is either licensed or exempt from licensure under the direct supervision of a comprehensive perinatal practitioner. This bill would expand the location where PHWs can provide services to include a beneficiary’s home or other community setting away from a medical site. It would also expand who could supervise PHWs to include a community-based organization so long as the organization has an enrolled Medi-Cal provider available for billing. These expansions in location and supervision are authorized under the federal preventive services rule.

1. Additional efforts to serve postpartum individuals via Medi-Cal. DHCS has recently implemented various initiatives to serve pregnant and postpartum individuals via the Medi-Cal program, including the addition of doula services and by including pregnant and postpartum individuals as populations of focus for the Enhanced Care Management (ECM) services that are provided by Medi-Cal managed care (MCMC) plans as part of the CalAIM initiative. As of January 1, 2023, doula services are a covered Medi-Cal benefit. Doulas may provide services for up to 12 months from the end of pregnancy, including prenatal visits, support during labor and delivery, abortion, or miscarriage, and postpartum visits. As this is a brand new benefit, it is not known at this time how many Medi-Cal beneficiaries who want these services are able to access these services.

The ECM program is an interdisciplinary approach to care that addresses the clinical and non-clinical needs of Medi-Cal managed care members with the most complex medical and social needs. According to DHCS’s ECM policy guide, examples of services for pregnant or postpartum individuals include:

• 1. Facilitating access to Community Supports that will help the pregnant or postpartum individual as they prepare for or recover from labor and delivery, including housing and food related Community Supports;
  2. Coordinating the transition from hospital to home after labor and delivery and with various health and social services providers, including sharing data (as appropriate), to facilitate better-coordinated whole-person care;
  3. Supporting treatment adherence, including scheduling prenatal and postpartum appointments and well-child visits, appointment reminders, coordinating transportation, ensuring connection to public benefits, identifying barriers to adherence and accompanying beneficiaries to appointments, as needed;
  4. Connecting the pregnant or postpartum individual, their partner, and/or their family with resources regarding the beneficiary’s conditions to assist them with providing support for the beneficiary’s health and newborn or infant’s health; or,
  5. Coordinating care across all applicable delivery systems and care coordinators

Pregnant and postpartum individuals subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality (currently Black, American Indian and Alaska Natives, and Pacific Islanders) or who qualify for ECM on another basis (e.g. experiencing homelessness, transitioning from incarceration, or with serious mental health and/or substance use disorder issues) enrolled in MCMC plans are eligible for these services.

1. CHBRP analysis. For a summary of the California Health Benefit Review Program analysis on a similar bill from last session, see the full Senate Health Committee analysis.

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

According to the Senate Appropriations Committee, this bill would have unknown, ongoing costs (General Fund and federal funds) for the Medi-Cal program for extending the CPSP benefit.

SUPPORT: (Verified 8/22/23)

March of Dimes (co-source)

Maternal and Child Health Access (co-source)

The Children’s Partnership (co-source)

Access Reproductive Justice

American Academy of Pediatrics California

American College of Obstetricians and Gynecologists District IX

American Nurses Association California

Asian Americans Advancing Justice Southern California

Black Women for Wellness Action Project

Buen Vecino

California Academy of Family Physicians

California Alliance of Child and Family Services

California Black Health Network

California Breastfeeding Coalition

California Catholic Conference

California Children’s Hospital Association

California Children’s Trust

California Health+ Advocates,

California Immigrant Policy Center

California Latinas for Reproductive Justice

California Nurse Midwives Association

California Nurses Association

California Pan-Ethnic Health Network

California Rural Legal Assistance Foundation

California State Council of Service Employees International Union

California WIC Association

Centro Binacional Para El Desarrollo Indígena Oaxaqueño

Children Now

Children’s Bureau of Southern California

Children’s Law Center of California

Children's Bureau of Southern California

Children's Specialty Care Coalition

Chula Vista Partners in Courage

City and County of San Francisco

Community Clinic Association of Los Angeles County

Desert AIDS Project (DAP) Health

Emanate Health

Employee Rights Center

Empowering Pacific Islander Communities

Everychild Foundation

First 5 Association of California

Friends Committee on Legislation of California

Health Access California

Health Officers Association of California

InnerCity Struggle

LA Best Babies Network

NARAL Pro-choice California

National Association of Social Workers, California Chapter

National Health Law Program

National Service Office of the Nurse-Family Partnership and Child First

Northeast Valley Health Corporation

Nurse – Family Partnership

Orange County United Way

Public Law Center

Rising Communities (formerly Community Health Councils)

Sacramento Breastfeeding Coalition

San Francisco Department of Public Health

Senior and Disability Action

Sonoma County Department of Health Services

South Bay People Power

The California Children’s Trust

The Leukemia & Lymphoma Society

Universidad Popular

Vision y Compromiso

Western Center on Law & Poverty

Worksite Wellness LA

OPPOSITION: (Verified 8/22/23)

Department of Finance

ARGUMENTS IN SUPPORT: Co-sponsors Maternal Child Health Access, March of Dimes, and The Children’s Partnership write that CPSP was designed, and adopted by the Legislature, as part of Medi-Cal’s schedule of benefits, precisely as a preventive care measure. CalAIM’s ECM and Community Supports benefits, in contrast, target a very different population, i.e., those with severe mental illness, substance use disorders, the justice-involved, and/or chronically homeless individuals with severe impairments. While DHCS recently took the helpful step of adding certain racial groups to the list during pregnancy given their population risk profile, individuals not in those populations are still left out. Moreover, as noted, the goal of CPSP is provide early interventions so that pregnant people of any racial group may avoid the need for CalAIM’s high level of care. They also note that among the assessments included in the CPSP services are mental health assessments which are important considering that many maternal suicides occur late in the postpartum period, 43 to 365 days after the end of the pregnancy. Finally, they note that approval to render CPSP services in the community, and not just at a medical facility, would be an invaluable resource for expanding the services of organizations that provide these services in the community, including the Black community.

ARGUMENTS IN OPPOSITION: The Department of Finance is opposed to this bill because it results in ongoing General Fund costs and future cost pressure in the Medi-Cal program not included in the 2023 Budget Act. The expansion of full-scope Medi-Cal coverage for one year after pregnancy has already been operationalized, and there is likely overlap between CPSP services available after 60 days postpartum and existing services already provided under this one-year postpartum care extension. This bill would result in significant overlap with planned expansions to provide pregnant and postpartum individuals access to behavioral health services, midwives, alternative birthing centers, doulas, community health workers, and dyadic services. This bill also poses possible duplication with DHCS’ Enhanced Care Management Birth Equity population of focus, which will launch in January 2024.

ASSEMBLY FLOOR: 80-0, 5/31/23

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting,

Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

Prepared by: Jen Flory / HEALTH / (916) 651-4111

9/2/23 9:57:23

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 608 (Schiavo) - Medi-Cal: comprehensive perinatal services

Bill Summary:

AB 608 would require the Department of Health Care Services (DHCS) to extend the Comprehensive Perinatal Services Program (CPSP) Medi-Cal benefit for up to one year after the end of a Medi-Cal beneficiary’s pregnancy.

Fiscal Impact:

Unknown, ongoing costs (General Fund and federal funds) for the Medi-Cal program for extending the CPSP benefit.

Background:

CPSP is administered by the California Department of Public Health’s (CDPH) Maternal, Child and Adolescent Health division. CPSP provides a model of enhanced perinatal services for Medi-Cal eligible pregnant and postpartum individuals from entry to care through postpartum. These enhanced services are delivered by qualified Medi-Cal providers. CPSP services must be provided in conformance with current American College of Obstetrics and Gynecologists (ACOG) recommendations and California regulation. CPSP providers are reimbursed by fee-for-service Medi-Cal. Medi-Cal managed care providers offering CPSP services are reimbursed according to their contract with the managed care plan. CPSP clients receive a program orientation, initial nutrition, psychosocial and health education assessments, second and third trimester reassessments and postpartum assessments. Services are available up to 60 days following the end of the pregnancy.

The federal Affordable Care Act (ACA) changed federal Medicaid law to encourage the provision of preventive care in several respects. One of those changes allows preventive services to be provided by non-licensed individuals under the supervision of a licensed health care provider. Previously, Medicaid regulations limited coverage of preventive services to services that were directly provided by physician or other licensed practitioner. As of January 2014, Medicaid may reimburse for preventive services delivered by a non-licensed health care professional, such as a community health worker, when the service is recommended by a physician or other licensed provider within their scope of practice under state law.

Proposed Law:

Specific provisions of the bill would:

• Require DHCS to include as part of the CPSP Medi-Cal benefit, additional comprehensive perinatal assessments, individualized care plans, visits and services in an amount, duration, and scope that are at least proportional to those that were available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period, for a period of one year after the end of a Medi-Cal beneficiary’s pregnancy.
• Require DHCS to utilize the federal option to cover preventive services that are recommended by a physician or other licensed practitioner and that are rendered by a nonlicensed perinatal health worker in a beneficiary’s home or other community setting away from a medical site.

Related Legislation:

AB 1930 (Arambula, 2022) was similar to this bill. The bill was vetoed by the Governor. The veto message included, “This bill would result in millions of dollars in ongoing General Fund costs that are not accounted for in the budget.”

The California Health Benefits Review Program (CHBRP) analysis of AB 1930 estimated an increase of $75,000 in annual expenditures for Medi-Cal managed care plans that are licensed by the Department of Managed Health Care, an increase of approximately $16,000 for Medi-Cal County Organized Health Systems managed care plans, and an unknown increase for Medi-Cal fee-for-service programs.

-- END --

SENATE COMMITTEE ON GOVERNMENTAL ORGANIZATION

Senator Bill Dodd

Chair

2023 - 2024 Regular

Bill No: 608 Hearing Date: 7/11/2023

SUBJECT: Medi-Cal: comprehensive perinatal services

DIGEST: Requires the Department of Health Care Services (DHCS) to extend the Comprehensive Perinatal Services Program (CPSP) benefit for up to one year after the end of a Medi-Cal beneficiary’s pregnancy, as specified. Additionally, this bill exempts DHCS from the Administrative Procedures Act (APA), as specified, in implementing this bill until the time regulations are adopted.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the State DHCS and under which qualified low-income individuals receive health care services, including comprehensive perinatal services.
2. Provides that a pregnant individual or targeted low-income child who is eligible for, and is receiving, health care coverage under any of specified Medi-Cal programs is also eligible for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individual’s pregnancy.
3. Establishes the Administrative Procedures Act (APA) with rulemaking procedures and standards for state agencies in California designed to provide the public with a meaningful opportunity to participate in the adoption of state regulations and to ensure that regulations are clear, necessary, and legally valid.

This bill:

1. Requires that during the one-year postpregnancy eligibility period described above, as part of comprehensive perinatal services under the Medi-Cal program, DHCS cover additional comprehensive perinatal assessments and individualized care plans and must provide additional visits and units of services in an amount, duration, and scope that are at least proportional to those available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period in effect on that date.
2. Requires DHCS, in determining the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered, and in coordination with the Maternal, Child, and Adolescent Health Division of the State Department of Public Health (DPH), to consider input from stakeholders, including, but not limited to, perinatal health workers and community-based organizations providing perinatal services.
3. Requires DHCS, as part of the comprehensive perinatal services under the Medi-Cal program, to do both of the following:
   1. Cover comprehensive perinatal services that are rendered by a nonlicensed perinatal health worker in a beneficiary’s home or other community setting away from a medical site, as specified.
   2. Allow a nonlicensed perinatal health worker rendering comprehensive perinatal services to be supervised by a community-based organization or a local health jurisdiction, in addition to those entities otherwise authorized by law or regulation to supervise a nonlicensed perinatal health worker.
4. Provides that this bill shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.
5. Authorizes DHCS, without taking further regulatory action, to implement, interpret, or make specific this bill by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, until the time regulations are adopted.

Background

Author Statement. According to the author’s office, “AB 608 ensures every Californian has a healthy start in life by extending coverage of services provided by the Comprehensive Perinatal Services Program (CPSP) to one year postpartum. Childbirth and parenting is unique to each family. However, without postpartum support, some challenges many parents face can lead to disruptions with the mental and physical wellbeing of parent or child. For example, it’s estimated that postpartum depression affects one in seven parents after delivery. If unaddressed, this can lead to long-term behavioral health issues in children, and, in severe cases, suicide. More than four of every five people who die by suicide after the end of their pregnancy, died in the late postpartum period 43-365 days after birth. If extending CPSP into that first year after pregnancy can help treat postpartum depression and reduce the number of suicides, we should be doing everything we can to make these services easily accessible to more people.”

CPSP as a Medi-Cal Benefit. Statute and regulation establish a set of services that comprise the CPSP Medi-Cal benefit. These services include a program orientation; initial and follow-up nutrition, psychosocial and health education assessments, and corresponding interventions; comprehensive individual and group health education, and prenatal vitamins. CPSP also reimburses about $57 as a bonus for early prenatal care if an initial comprehensive prenatal visit is conducted prior to 16 weeks. A CPSP practitioner develops an Individualized Care Plan to address needs identified in the assessments, conducts case coordination, and ensures that the Medi-Cal enrollee receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. CPSP services can be provided to Medi-Cal eligible enrollees, throughout pregnancy through the end of the second month after delivery. DHCS establishes maximum units of service for each CPSP service. Additional services can be provided as medically necessary with an approved Treatment Authorization Request.

The CPSP benefit is a set of outpatient services that supplement, and do not replace, services that are part of standard prenatal, delivery, and postpartum care. Because of benefit expansions and managed care requirements that have been implemented since the creation of CPSP, pregnant and postpartum people in Medi-Cal also have coverage for other services, outside of CPSP, that supplement standard obstetrical care. These include, among other services, a comprehensive set of behavioral health services as well as health education, community health worker, and doula services.

Under this bill, the allowable timeline for provision of CPSP would also be extended to cover additional comprehensive perinatal assessments and individualized care plans, and provide additional visits and units of services during the one-year post-pregnancy eligibility period. This bill would also require DHCS to collaborate with DPH and a broad stakeholder group to determine the specific number of additional services.

The California Administrative Procedures Act. The APA, originally established by SB 705 (DeLap, Chapter 867, Statutes of 1945), predates the federal version and is a set of laws and regulations that governs how state agencies in California must conduct administrative rulemaking and adjudicative proceedings. The APA was established in response to concerns that the number of administrative regulations had grown significantly, and that many regulations were written in an unclear and unnecessarily complex manner. The APA aims to ensure that regulations are written in a comprehensible manner, are authorized by statute, and are consistent with other law.

To achieve these goals, the APA established the Office of Administrative Law (OAL) as a central office within state government charged with the orderly review of adopted regulations. The OAL is responsible for reviewing regulations to ensure that they are written in a comprehensible manner, are authorized by statute, and are consistent with other law. The OAL is also tasked with reducing the number of administrative regulations and improving the quality of those regulations that are adopted.

State agencies must actively seek to reduce the unnecessary regulatory burden on private individuals and entities by substituting performance standards for prescriptive standards wherever performance standards can be reasonably expected to be as effective and less burdensome, and that this substitution shall be considered during the course of the agency rulemaking process.

The APA requires that state agencies must give the OAL ready access to their records and full information and reasonable assistance in any matter of research requiring recourse to them or to data within their knowledge or control.

Furthermore, any interested person may petition a state agency requesting the adoption, amendment, or repeal of a regulation as provided in Article 5 of the APA. The state agency must notify the petitioner in writing of the receipt and must within 30 days deny the petition indicating why the agency has reached its decision on the merits of the petition in writing or schedule the matter for public hearing in accordance with the notice and hearing requirements of that article.

The APA was designed to promote transparency, fairness, and public participation in the administrative process. Its main objectives are to ensure that regulations are written in a comprehensible manner, are authorized by statute, and are consistent with other law. The APA established the OAL to review and improve the quality of adopted regulations, and state agencies must actively seek to reduce the unnecessary regulatory burden on private individuals and entities.

This bill authorizes DHCS, without taking any further regulatory action, to implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, until the time regulations are adopted.

As Proposed to be Amended. This analysis reflects the bill, as proposed to be amended, to reflect an agreement between the author and the Senate Health Committee. Due to timing constraints, the agreed technical amendment in the Senate Health Committee will be adopted in the Senate Governmental Organization Committee, clarifying that DHCS must consider input from stakeholders, including, but not limited to, perinatal health workers and community-based organizations providing perinatal services.

14005.185(a)(2)(B) In determining the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered pursuant to subparagraph (A), the department, in coordination with the Maternal, Child, and Adolescent Health Division of the State Department of Public Health, shall consider input from the Maternal, Child, and Adolescent Health Division of the State Department of Public Health and from stakeholders, including, but not limited to, perinatal health workers and community-based organizations providing perinatal services.

Prior/Related Legislation

AB 274 (Bryan, 2023) exempts educational grants, awards, scholarships, loans, or fellowship benefits from consideration as income for purposes of determining eligibility for the California Work Opportunity and Responsibility to Kids (CalWORKs) and the Supplemental Nutrition Assistance Program (SNAP) – known as CalFresh – program and aid amount, as specified. Additionally, this bill requires the State Department of Social Services (DSS) to implement these changes through an all-county letter or similar instruction until regulations are adopted. (Pending in the Senate Appropriations Committee)

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

SUPPORT:

Access Reproductive Justice
American College of Obstetricians and Gynecologists District IX
American Nurses Association
California Academy of Family Physicians
California Alliance of Child and Family Services
California Black Health Network
California Catholic Conference
California Children's Hospital Assn
CaliforniaHealth+ Advocates
California Nurse Midwives Association
California Nurses Association
California Pan-Ethnic Health Network
California State Council of Service Employees International Union
California WIC Association
Children Now
Children's Bureau of Southern California
Children's Partnership
Children's Specialty Care Coalition
Community Clinic Association of Los Angeles County
Community Health Councils
Desert Aids Project
Everychild Foundation
First 5 Association of California
Friends Committee on Legislation of California
Health Access California
Health Officers Association of California
InnerCity Struggle
LA Best Babies Network
March of Dimes
Maternal and Child Health Access
NARAL Pro-choice California
National Association of Social Workers, California Chapter
National Health Law Program
Nurse-Family Partnership
Orange County United Way
Sacramento Breastfeeding Coalition
Senior and Disability Action
The California Children's Trust
Vision Y Compromiso
Western Center on Law & Poverty
Worksite Wellness LA

OPPOSITION:

None received

ARGUMENTS IN SUPPORT: The coalition of supporters state that, “CSP begins with assessments targeted to perinatal issues in each trimester and postpartum. Based on the assessments, an Individualized Care Plan is prepared, and crucially, needed follow services are arranged for health education, nutritional counseling, and psychosocial services. Even before the pandemic, pregnant Medi-Cal beneficiaries were at very high risk for a range of social conditions that negatively impact health with pronounced racial disparities, according to the state’s latest Maternal and Infant Health Assessment.”

DUAL REFERRAL: Senate Committee on Health (12-0) & Senate Committee on Governmental Organization

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: AB 608

SUBJECT: Medi-Cal: comprehensive perinatal services

SUMMARY:

Requires the Department of Health Care Services (DHCS) to extend the Comprehensive Perinatal Services Program benefit for up to one year after the end of a Medi-Cal beneficiary’s pregnancy. Requires DHCS to allow an unlicensed perinatal provider to render preventive services recommended by a licensed provider and to provide those services in a beneficiary’s home or other community setting away from a medical site.

Existing federal law: Authorizes federal financial participation in the Medicaid program for diagnostic, screening, preventive, and rehabilitative services, including any clinical preventive services that are assigned a grade A or B by the United States Preventive Services Task Force and any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law. [42 U.S.C. §1396d]

Existing state law:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [WIC §14000, et seq.]
2. Requires the Medi-Cal program to cover a pregnant individual who is eligible for and is receiving health care coverage under a Medi-Cal program for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individual’s pregnancy. [WIC §14005.185]
3. Establishes the Comprehensive Perinatal Services Program (CPSP) within the California Department of Public Health (CDPH) as a community-based system of comprehensive perinatal care for low-income women. States that prenatal care, delivery service, postpartum care, and neonatal and infant care are necessary services that have been demonstrated effective in preventing or reducing maternal, perinatal, and infant mortality and morbidity, including prematurity and low birth weight. Includes initial and ongoing physical assessment, psychosocial, nutrition, and health education assessments, interventions, counseling and referral, food supplement programs, vitamins, and breast-feeding and other services as appropriate. Requires all contracted providers to make these services available directly or by subcontract, and to use an appropriate multidisciplinary team. [HSC §123475, et seq.]
4. Establishes the CPSP program services as a Medi-Cal benefit. [WIC §14132]
5. Defines CPSP providers to include any general practice physician, family practice physician, obstetrician-gynecologist, pediatrician, certified nurse midwife, a group, any of whose members is one of the above-named physicians, or any preferred provider organization or clinic enrolled in the Medi-Cal program and certified pursuant to the standards of this section. Allows providers to contract with medical and other practitioners for the purpose of delivering CPSP services. [WIC §14134.5]
6. States that perinatal means the period from the establishment of pregnancy to one month following delivery. Requires the CPSP provider to schedule visits with appropriate providers and track the patient to make sure services have been received. Requires that the patient receive psychosocial assessment and referrals; nutrition assessment, appropriate referrals to counseling for food supplement programs, vitamins, and breastfeeding, health, childbirth, and parenting education. [WIC §14134.5]

This bill:

1. Requires DHCS to include, as part of the CPSP Medi-Cal benefit, additional comprehensive perinatal assessments, individualized care plans, visits and services in an amount, duration, and scope that are at least proportional to those that were available on July 27, 2021, during pregnancy and the initial 60-day postpregnancy period, for a period of up to one year after the end of a Medi-Cal beneficiary’s pregnancy.
2. Requires DHCS to consider input from CDPH and a stakeholder group, including perinatal health workers and community-based organizations providing perinatal services, to determine the specific number of additional services to be covered pursuant to 1) above.
3. Requires DHCS to cover comprehensive perinatal services that are rendered by a nonlicensed perinatal health worker in a beneficiary’s home or other community setting that is not medical site.
4. Allows nonlicensed perinatal health workers rendering such services to be supervised by a community-based organization or local health jurisdiction in addition to the entities otherwise authorized by law or regulation to supervise nonlicensed perinatal health workers. Requires community-based organization or local health jurisdiction supervising nonlicensed perinatal health workers to provide those comprehensive perinatal services under contract with a CPSP provider.
5. Conditions the implementation of this bill on the receipt of federal approval and federal financial participation. Allows DHCS to implement this bill via guidance until regulations are adopted.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

Costs of an unknown, but potentially significant amount to DHCS to extend the CPSP program to one year after a pregnancy. If one-half of the approximately 70,000 women who use CPSP services in a given year continue to access the extended benefit provided by this bill, at an average cost per beneficiary of $215, the annual cost would be $7.5 million ($2.4 million General Fund (GF), $5.1 million federal funds (FF)). Actual costs would depend on the available services and their costs, the accessibility of services, how many women choose to use the services, how many of the available services beneficiaries utilize, and other factors. (The California Health Benefits Review Program (CHBRP) estimated much lower costs for a similar bill, AB 1930 (Arambula), of the 2021-22 Legislative Session. CHBRP projected that only 349 women would choose to use the extended benefit, for a total cost of $75,000 (GF, FF). The governor’s veto message for AB 1930 cited “millions of dollars in ongoing General Fund costs.”)

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, this bill ensures every Californian has a healthy start in life by extending coverage of services provided by CPSP to one year postpartum. Childbirth and parenting is unique to each family. However, without postpartum support, some challenges many parents face can lead to disruptions with the mental and physical wellbeing of parent or child. For example, it is estimated that postpartum depression affects one in seven parents after delivery. If unaddressed, this can lead to long-term behavioral health issues in children, and, in severe cases, suicide. More than four of every five people who die by suicide after the end of their pregnancy, died in the late postpartum period 43 to 365 days after birth. If extending CPSP into that first year after pregnancy can help treat postpartum depression and reduce the number of suicides, we should be doing everything we can to make these services easily accessible to more people.
2. Medi-Cal’s postpartum expansion. There have been several recent efforts to expand postpartum coverage in the Medi-Cal program in order to improve maternal and child health outcomes, reduce maternal death, and create access for mental health services for new mothers. As part of the 2019-2020 Budget Act, the Provisional Postpartum Care Expansion was passed, a state-funded program that extended the postpartum care period from 60 days to 12 months after the last day of pregnancy to an eligible individual who is receiving pregnancy-related services and is diagnosed with a mental health condition. Given the lack of federal funding available at the time, maternal mental health conditions were prioritized. Although this Provisional Postpartum Care Expansion was implemented in 2020, this occurred after the federal public health emergency due to COVID-19 went into effect, and the federal government required states to maintain Medicaid and Children’s Health Insurance Program (CHIP) coverage for all enrollees for the duration of the emergency in order to receive a higher federal matching rate for Medicaid and CHIP services. Thus, in theory, no individual who has given birth while on Medi-Cal has lost their coverage since 2020. However, this maintenance of effort requirement has since ended and county eligibility workers are currently processing Medi-Cal redeterminations with the first terminations scheduled to take effect in July 2023.

As part of the American Rescue Act Plan (ARPA), effective April 1, 2022, the federal government gave states the option of expanding postpartum Medicaid coverage for an additional ten months with federal matching funds. California quickly adopted this option and included it in the 2021-2022 health trailer bill, AB 133 (Committee on Budget, Chapter 143, Statutes of 2021). Now an individual eligible for pregnancy and postpartum care services under Medi-Cal is entitled to an additional ten months of postpartum coverage at the end of their 60-day postpartum period for a total 12 months of postpartum coverage. According to DHCS, this coverage includes the full breadth of medically necessary services through the pregnancy and postpartum period.

DHCS stated the importance of extending postpartum services in its state plan amendment adopting this federal option: All pregnant individuals should receive comprehensive care during the postpartum period to assess their physical recovery from pregnancy and childbirth, address chronic conditions (such as diabetes or hypertension), address mental health issues (including postpartum depression), discuss reproductive health (including contraception and birth spacing), and ensure continuity of care. In spite of having a higher prevalence of medical conditions such as diabetes and hypertension, pregnant Medicaid and CHIP individuals have lower postpartum care visit rates than do individuals with private insurance. The Pregnancy Mortality Surveillance System (PMSS) defines a pregnancy-related death as the death of a woman while pregnant or within one year of the end of pregnancy from any cause related to or aggravated by the pregnancy. Over one half of maternal deaths occur between the first day of the postpartum period up through the 365th day during postpartum period. Causes can include cardiovascular issues, hypertension, or infection. Identifying the causes of maternal mortality and morbidity is complex and coverage is only one factor. Research strongly indicates that access to healthcare throughout a woman’s reproductive years is essential for prevention, early detection, and treatment of some of the conditions that place women at higher risk for pregnancy-related complications, including cardiovascular disease, diabetes, and chronic hypertension.

1. CPSP. CPSP is administered by the CDPH’s Maternal, Child and Adolescent Health division. CPSP provides a model of enhanced perinatal services for Medi-Cal eligible pregnant and postpartum individuals from entry to care through postpartum. These enhanced services are delivered by qualified Medi-Cal providers. CPSP services must be provided in conformance with current American College of Obstetrics and Gynecologists recommendations and California regulation. CPSP providers are reimbursed by fee-for-service Medi-Cal or according to their contract with a Medi-Cal managed care plan. CPSP clients receive a program orientation, initial nutrition, psychosocial and health education assessments, second and third trimester reassessments and postpartum assessments. The practitioner develops an individualized care plan to address needs identified in the assessments, conducts case coordination, and ensures that the client receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. The plan is developed for each CPSP client at the time of the initial assessment and updated at least every trimester and postpartum visit, and more often if needed. CPSP providers are also required to make referrals to programs and services such as the Women, Infant and Children nutrition program, genetic screening, dental care, and family planning, as well as provide case coordination to assure that health care members work together with the client to assure that the care plan is completed, and the client receives the necessary services.
2. Federal preventive services rule change. The Affordable Care Act changed federal Medicaid law to encourage the provision of preventive care in several respects. One of those changes allows preventive services to be provided by non-licensed individuals under the supervision of a licensed health care provider. Previously, Medicaid regulations limited coverage of preventive services to services that were directly provided by physician or other licensed practitioner. As of January 2014, Medicaid may reimburse for preventive services delivered by a non-licensed health care professional, such as a community health worker, when the service is recommended by a physician or other licensed provider within their scope of practice under state law. Under this rule, states have the authority to define practitioner qualifications; ensure appropriate services are provided by qualified practitioners; define preventive services to be provided, subject to federal requirements; and, describe the reimbursement methodology.

The rule change did not make changes to what services may be provided. The services must still be medical or remedial in nature; involve direct patient care; and, be for the express purpose of diagnosing, treating, or preventing illness, injury, or other impairments to an individual’s physical or mental health. Existing regulation for the CPSP program includes a list of comprehensive perinatal practitioners, including a perinatal health worker (PHW). PHWs must be at least 18 years of age, a high school graduate or equivalent, and have at least one year of full-time paid practical experience in providing perinatal care, and are required to provide services in a clinic that is either licensed or exempt from licensure under the direct supervision of a comprehensive perinatal practitioner. This bill would expand the location where PHWs can provide services to include a beneficiary’s home or other community setting away from a medical site. It would also expand who could supervise PHWs to include a community-based organization so long as the organization has an enrolled Medi-Cal provider available for billing. These expansions in location and supervision are authorized under the federal preventive services rule.

1. Additional efforts to serve postpartum individuals via Medi-Cal. DHCS has recently implemented various initiatives to serve pregnant and postpartum individuals via the Medi-Cal program, including the addition of doula services and by including pregnant and postpartum individuals as populations of focus for the Enhanced Care Management (ECM) services that are provided by Medi-Cal managed care (MCMC) plans as part of the CalAIM initiative. As of January 1, 2023, doula services are a covered Medi-Cal benefit. Doulas may provide services for up to 12 months from the end of pregnancy, including prenatal visits, support during labor and delivery, abortion, or miscarriage, and postpartum visits. As this is a brand new benefit, it is not known at this time how many Medi-Cal beneficiaries who want these services are able to access these services.

The ECM program is an interdisciplinary approach to care that addresses the clinical and non-clinical needs of Medi-Cal managed care members with the most complex medical and social needs. According to DHCS’s ECM policy guide, examples of services for pregnant or postpartum individuals include:

• 1. Facilitating access to Community Supports that will help the pregnant or postpartum individual as they prepare for or recover from labor and delivery, including housing and food related Community Supports;
  2. Coordinating the transition from hospital to home after labor and delivery and with various health and social services providers, including sharing data (as appropriate), to facilitate better-coordinated whole-person care;
  3. Supporting treatment adherence, including scheduling prenatal and postpartum appointments and well-child visits, appointment reminders, coordinating transportation, ensuring connection to public benefits, identifying barriers to adherence and accompanying beneficiaries to appointments, as needed;
  4. Connecting the pregnant or postpartum individual, their partner, and/or their family with resources regarding the beneficiary’s conditions to assist them with providing support for the beneficiary’s health and newborn or infant’s health; or,
  5. Coordinating care across all applicable delivery systems and care coordinators.

Pregnant and postpartum individuals subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality (currently Black, American Indian and Alaska Natives, and Pacific Islanders) or who qualify for ECM on another basis (e.g. experiencing homelessness, transitioning from incarceration, or with serious mental health and/or substance use disorder issues) enrolled in MCMC plans are eligible for these services.

1. CHBRP analysis. AB 1996 (Thomson, Chapter 795, Statutes of 2002) requests the University of California to assess legislation proposing a mandated benefit or service and prepare a written analysis with relevant data on the medical, economic, and public health impacts of proposed health plan and health insurance benefit mandate legislation. CHBRP was created in response to AB 1996, and reviewed a substantively similar bill last year, AB 1930 (Arambula). Key findings include:
2. Benefit coverage. CHBRP estimates there are 69,861 users of CPSP services in Department of Managed Health Care (DMHC)-regulated MCMC plans. CHBRP estimates that an additional 349 Medi-Cal beneficiaries in DMHC-regulated managed care would use CPSP services as a result of this bill;
3. Utilization. CHBRP estimates that the current annual utilization of CPSP services rendered at a medical site is 82.5 per 1,000 covered Medi-Cal beneficiaries in DMHC-regulated managed care which will increase by approximately 0.27% to 82.7 per 1,000 beneficiaries in DMHC-regulated MCMC plans. Annual utilization of CPSP services rendered at a beneficiary’s home or other community setting away from a medical site will increase from zero per 1,000 covered beneficiaries in DMHC- regulated MCMC plans to 0.4 per 1,000;
4. Expenditures. This bill would raise total net annual expenditures by $75,000 (0.0001%) due to an increase in expenditures by MCMC plans. No expected offsets are projected due to an increase in CPSP visits. There are no measurable cost offsets due to CPSP services provided by unlicensed PHWs or in a setting away from a medical site. CHBRP believes it reasonable to assume that a population proportional increase of approximately $16,000 would occur in County Organized Health Systems (COHS) managed care. It seems likely that a similar impact would occur for beneficiaries with coverage through Medi-Cal’s fee-for-service program (though the exact amount is unknown);
5. Medical Effectiveness. CHBRP did not identify any studies that compared interventions that were provided for 60 days or less postpartum to interventions that were provided over a longer period of time. There are no CPSP-specific studies comparing these time periods because CPSP does not provide services past 60 days postpartum. Given the general lack of evidence on CPSP, CHBRP mostly included studies conducted in other states that covered comprehensive perinatal services similar to those that would be covered in California if this bill was enacted. These studies provided inconclusive evidence of the impact of programs in which services were delivered solely by unlicensed PHWs on breastfeeding and maternal depression and insufficient evidence of the impact of programs delivered by a combination of unlicensed PHWs and licensed health professionals. CHBRP did find that a preponderance of evidence shows that comprehensive perinatal services delivered by a combination of unlicensed PHWs and licensed professionals reduce risk of low birth weight; insufficient evidence that they reduce risk of being small for gestational age or infant mortality; and limited evidence that they reduce risk of preterm birth;
6. Public Health. CHBRP concludes that this bill would have no measurable short-term or long-term public health impact at the population-level, due to existing barriers to PHW supply and lack of evidence showing the effectiveness of comprehensive perinatal services when provided more than 60 days postpartum. It is important to note that the absence of evidence is not “evidence of no effect.” It is possible that an impact – desirable or undesirable – could result, but current evidence is insufficient to inform an estimate. At the individual level, evidence of effectiveness indicates that some Medi-Cal beneficiaries who would use CPSP services, particularly home visiting interventions when delivered by a combination of unlicensed PHWs plus licensed professionals, may see improved birth outcomes, including reduced risk of low birth weight and preterm birth, and increased breastfeeding duration. However, CHBRP is unable to estimate a specific number; and,
7. Long term impacts. Given the insufficient and inconclusive evidence on CPSP or CPSP-like services on maternal health outcomes, CHBRP is unable to determine the potential long-term utilization of CPSP services and long-term cost impacts.
8. Double referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Committee on Governmental Organization.
9. Related legislation. AB 492 (Pellerin) requires DHCS, on or before July 1, 2024, subject to an appropriation, to make grants, incentive payments, or other financial support available to Medi-Cal managed care plans to develop and implement reproductive and behavioral health integration pilot programs in partnership with specified qualified providers. AB 492 is pending in this Committee.

AB 583 (Wicks) establishes the Birthing Justice for California Families Pilot Project, administered by CDPH, to provide grants to community-based doula groups, local public health departments, and other organizations to provide full-spectrum doula care to pregnant and birthing people who not eligible for Medi-Cal and are from communities with high rates of negative birth outcomes and incarcerated people. AB 583 was held on the Assembly Appropriations Committee suspense file.

AB 904 (Calderon) requires health plans and insurers to develop a maternal and infant health equity program to address racial disparities through the use of doulas. Authorizes the Department of Managed Health Care and the Department of Insurance to jointly convene a workgroup to examine the implementation of the maternal and infant health equity program. AB 904 is set for hearing in the Senate Appropriations Committee on July 3, 2023.

AB 1478 (Cervantes) requires CDPH to develop and maintain on its internet website a referral network of community-based mental health providers and support services addressing, among other topics, postpartum depression and prenatal care, as specified. AB 1478 is set for hearing on July 12, 2023 in this Committee.

AB 1701 (Weber) expands the entities eligible to apply for funding through the California Perinatal Equity Initiative to include city health departments, in addition to county health departments. AB 1701 passed the Senate Health Committee by a vote of 12-0 on June 7, 2023.

1. Prior legislation. AB 1930 (Arambula of 2022) was substantially similar to this bill. AB 1930 was vetoed by Governor Newsom who stated in his veto message, “I support the author's efforts to improve maternal health outcomes and ensure Medi-Cal offers appropriate care for beneficiaries during and after their pregnancy. DHCS already provides full-scope coverage for all individuals for one year after pregnancy, which offers a range of services above and beyond the services provided by CPSP. However, this bill attempts to expand the services offered by comprehensive perinatal workers and make these services a Medi-Cal benefit apart from CPSP. This bill would result in millions of dollars in ongoing General Fund costs that are not accounted for in the budget.”

AB 133 (Committee on Budget, Chapter 143, Statutes of 2021) contained a provision to extend eligibility for full-scope Medi-Cal benefits for a pregnant individuals for a period of one year following the last day of the individual’s pregnancy, without conditioning the extended eligibility to a diagnosis of a maternal mental health condition.

SB 104 (Committee on Budget and Fiscal Review, Chapter 67, Statutes of 2019) contained the PPCE, a state-funded program that extends the postpartum care period from 60 days to 12 months after the last day of pregnancy to an eligible individual who is receiving pregnancy-related services and is diagnosed with a mental health condition.

1. Support. Co-sponsors Maternal Child Health Access, March of Dimes, and The Children’s Partnership write that CPSP was designed, and adopted by the Legislature, as part of Medi-Cal’s schedule of benefits, precisely as a preventive care measure. CalAIM’s ECM and Community Supports benefits, in contrast, target a very different population, i.e., those with severe mental illness, substance use disorders, the justice-involved, and/or chronically homeless individuals with severe impairments. While DHCS recently took the helpful step of adding certain racial groups to the list during pregnancy given their population risk profile, individuals not in those populations are still left out. Moreover, as noted, the goal of CPSP is provide early interventions so that pregnant people of any racial group may avoid the need for CalAIM’s high level of care. They also note that among the assessments included in the CPSP services are mental health assessments which are important considering that many maternal suicides occur late in the postpartum period, 43 to 365 days after the end of the pregnancy. Finally, they note that approval to render CPSP services in the community, and not just at a medical facility, would be an invaluable resource for expanding the services of organizations that provide these services in the community, including the Black community.
2. Amendments. To better reflect CDPH’s role in administering the CPSP benefit, the following change is recommended:

14005.185(a)(2)(B) In determining the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered pursuant to subparagraph (A), the department, in coordination with the Maternal, Child, and Adolescent Health Division of the State Department of Public Health, shall consider input from the Maternal, Child, and Adolescent Health Division of the State Department of Public Health and from stakeholders, including, but not limited to, perinatal health workers and community-based organizations providing perinatal services.

SUPPORT AND OPPOSITION:

Support: March of Dimes (co-sponsor)

Maternal and Child Health Access (co-sponsor)

The Children’s Partnership (co-sponsor)

Access Reproductive Justice

American Academy of Pediatrics California
American College of Obstetricians and Gynecologists District IX
American Nurses Association California
Asian Americans Advancing Justice Southern California

Black Women for Wellness Action Project

Buen Vecino

California Academy of Family Physicians

California Alliance of Child and Family Services

California Black Health Network

California Breastfeeding Coalition
California Catholic Conference

California Children’s Hospital Association

California Children’s Trust
California Health+ Advocates,

California Immigrant Policy Center

California Latinas for Reproductive Justice

California Nurse Midwives Association
California Pan-Ethnic Health Network
California Rural Legal Assistance Foundation

California State Council of Service Employees International Union

California WIC Association
Centro Binacional Para El Desarrollo Indígena Oaxaqueño

Children’s Law Center of California

Children Now

Children's Bureau of Southern California
Children's Specialty Care Coalition

Chula Vista Partners in Courage
City and County of San Francisco

Community Clinic Association of Los Angeles County
Desert AIDS Project (DAP) Health

Emanate Health

Employee Rights Center

Empowering Pacific Islander Communities

Everychild Foundation
First 5 Association of California
Friends Committee on Legislation of California
Health Access California
InnerCity Struggle
LA Best Babies Network
NARAL Pro-choice California
National Association of Social Workers, California Chapter
National Health Law Program

National Service Office of the Nurse-Family Partnership and Child First

Northeast Valley Health Corporation
Orange County United Way
Public Law Center

Rising Communities (formerly Community Health Councils)

Sacramento Breastfeeding Coalition

San Francisco Department of Public Health

Senior and Disability Action

Sonoma County Department of Health Services

South Bay People Power

The Leukemia & Lymphoma Society

Universidad Popular
Vision y Compromiso
Western Center on Law & Poverty
Worksite Wellness LA

Oppose: None received.

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 608

Author:(Schiavo)

As Amended Ver:April 17, 2023

Majority vote

SUMMARY

Extends the length of time postpartum services are available under the Comprehensive Perinatal Services Program (CPSP) benefit in Medi-Cal, and expands the settings and supervisors for non-licensed Comprehensive Perinatal Health Workers (CPHWs) to provide CPSP services.

Major Provisions

COMMENTS

This bill is sponsored by Maternal and Child Health Access, March of Dimes, and The Children's Partnership to improve maternal and infant health outcomes. According to the author, this bill addresses two interrelated problems that limit the ability of CPSP to fully serve Medi-Cal beneficiaries in the pregnancy and postpartum periods. First, the bill expands Medi-Cal's CPSP benefit throughout a 12-month postpartum period instead of solely the initial 60-day period. This bill also expands both the settings that a non-licensed CPHWs can work in, and the types of organizations who can supervise a CPHW. The author has a corresponding budget request for $2.4 million General Fund and matching federal funds in 2023-24 to fund additional CPSP service.

1. CPSP. CPSP was established in the early 1980's, based on the results of a pilot conducted in July 1979 through June 1982. The pilot demonstrated that obstetrical care, supplemented by psychosocial, health education and nutrition services and prenatal vitamins and minerals, could significantly reduce the incidence of low birth weight in infants. The Maternal, Child and Adolescent Health Program in DPH oversees CPSP and the statewide system of perinatal care established in statute. The goals of CPSP are to: a) decrease the incidence of low birthweight in infants; b) improve the outcome of every pregnancy; c) give every baby a healthy start in life; and, d) lower health care costs by preventing catastrophic and chronic illness in infants and children.

CPSP has a unique program design. It integrates Medi-Cal billing and coverage with quality and monitoring activities at local health jurisdictions (LHJs, or county public health departments), as overseen by DPH. Most LHJs employ a Perinatal Services Coordinator, who certifies providers who meet CPSP program standards and provides technical assistance to CPSP providers in their communities. To bill fee-for-service Medi-Cal or a contracting Medi-Cal managed care plan for CPSP services, a provider must enroll in and be CPSP-certified through their local LHJ, in addition to being enrolled in Medi-Cal.

1. CPSP as a Medi-Cal Benefit. Statute and regulation establish a set of services that comprise the CPSP Medi-Cal benefit. These services include a program orientation; initial and follow-up nutrition, psychosocial and health education assessments, and corresponding interventions; comprehensive individual and group health education, and prenatal vitamins. A CPSP practitioner develops an Individualized Care Plan to address needs identified in the assessments, conducts case coordination, and ensures that the Medi-Cal enrollee receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. CPSP services can be provided to Medi-Cal eligible enrollees, throughout pregnancy through the end of the second month after delivery. The Department of Health Care Services (DHCS) establishes maximum units of service for each CPSP service. Additional services can be provided as medically necessary with an approved Treatment Authorization Request.

The CPSP benefit is a set of outpatient services that supplement, and do not replace, services that are part of standard prenatal, delivery, and postpartum care. Because of benefit expansions and managed care requirements that have been implemented since the creation of CPSP, pregnant and postpartum people in Medi-Cal also have coverage for other services, outside of CPSP, that supplement standard obstetrical care. These include, among other services, a comprehensive set of behavioral health services as well as health education, community health worker, and doula services, as further discussed in "Related Medi-Cal Efforts," below.

1. Medi-Cal Coverage of Pregnancy and Recent Postpartum Eligibility Expansion. Because of the critical importance of prenatal care for maternal and infant health, Medi-Cal coverage for pregnant persons is more generous than that for non-pregnant individuals. Specifically, eligibility for pregnant persons extends to 322% of federal poverty level (FPL), while Medi-Cal coverage for other individuals generally extends to 138% of the FPL. Correspondingly, Medi-Cal paid for approximately 40% of California's 420,754 births in 2021.

The health budget trailer bill, AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, implemented a federal option to expand coverage to 12 months postpartum and provide full-scope benefits for these pregnant and postpartum individuals. Under this bill, the allowable timeline for provision of CPSP would also be extended to cover additional comprehensive perinatal assessments and individualized care plans, and provide additional visits and units of services during the one-year post-pregnancy eligibility period.

1. Related Medi-Cal Efforts. DHCS is currently implementing numerous Medi-Cal program improvement and transformation efforts, most notably through a number of federal demonstrations and waivers dubbed CalAIM (California Advancing and Innovating Medi-Cal). Several recent program efforts are targeted at improving maternal health or intersect with the provision of CPSP services. Specifically, several design elements of CPSP align with or overlap with the department's transformation and improvement efforts, particularly in relation to case coordination and care management functions that address the social determinants of health during the perinatal period.
2. Additional Medi-Cal Managed Care Requirements. Recently updated managed care plan contracts require plans to "utilize the most current standards or guidelines of American College of Obstetricians and Gynecologists (ACOG) and CPSP to ensure Members receive quality perinatal and postpartum services." Plans must also implement a comprehensive risk assessment tool for all pregnant members that is comparable to the ACOG standards and CPSP standards in existing state regulation, follow up on all identified risks consistent with those standards, and document the assessment and interventions in the individual's medical record. DHCS imposes other general requirements on contracted managed care plans that are similar to the CPSP benefit.
3. CPHWs. Existing state regulation for CPSP defines a CPHW as being at least 18 years of age, is a high school graduate or equivalent, and has at least one year of full-time paid practical experience in providing perinatal care; and provides services in a clinic under the direct supervision of a comprehensive perinatal practitioner. In their guidance on CPSP, DPH states CPSP services delivered are consistent with approved protocols signed off by nutrition, health education and psychosocial consultants. DPH also requires CPSP services to be provided by or under the personal supervision of a physician, and CPHWs to work under the direct supervision of a physician.

This bill would instead allow CPHWs to be supervised by community-based organizations or local health jurisdictions. This bill would expand the location where CPHWs can provide services to include a beneficiary's home or other community setting away from a medical site.

According to the Author

This bill addresses two interrelated problems that limit the ability of CPSP to fully serve Medi-Cal beneficiaries in the pregnancy and postpartum periods. First, the bill expands Medi-Cal's CPSP benefit throughout a 12-month postpartum period instead of solely the initial 60-day period. According to the author, the 60-day time period limits the ability of CPSP providers to identify and address postpartum depression, connect parents to programs that address food and housing insecurity, and provide a host of other services that may be needed beyond the initial 60-day postpartum period. Furthermore, the author explains, the postpartum Medi-Cal coverage period was recently updated from 60 days to 12 months, and this bill aligns postpartum CPSP services with the postpartum coverage period.

Arguments in Support

This bill is sponsored by Maternal and Child Health Access (MCHA) and supported by consumer's, children's, and women's health groups to improve access to critical social and other supports for low-income mothers and infants during Medi-Cal's 12-month postpartum eligibility period. MCHA states this bill would require DHCS to: 1) continue Medi-Cal's CPSP benefit beyond the initial 60-day postpartum period; and, 2) adopt the federal option to allow CPHWs—a subset of community health workers with expertise in perinatal health—to provide supportive services in the mother's home or elsewhere in the community, not just at a clinic or doctor's office.

MCHA writes that the CPSP benefit connects mothers to necessary medical care and social supports during pregnancy, and this bill would address the need for these supports during Medi-Cal's extended 12-month postpartum eligibility period as well. Without this bill, MCHA is extremely concerned that birth experiences and necessary follow-up for conditions uncovered during pregnancy will not be given the proper attention. MCHA states new mothers need a structure for health and social support long beyond the initial 60 days following a pregnancy.

Arguments in Opposition

There is no known opposition.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, costs of an unknown, but potentially significant amount to DHCS to extend the CPSP program to one year after a pregnancy. If one-half of the approximately 70,000 women who use CPSP services in a given year continue to access the extended benefit provided by this bill, at an average cost per beneficiary of $215, the annual cost would be $7.5 million ($2.4 million General Fund (GF), $5.1 million federal funds (FF)). Actual costs would depend on the available services and their costs, the accessibility of services, how many women choose to use the services, how many of the available services beneficiaries utilize, and other factors. (The California Health Benefits Review Program (CHBRP) estimated much lower costs for a similar bill, AB 1930 (Arambula), of the 2021-22 Legislative Session. CHBRP projected that only 349 women would choose to use the extended benefit, for a total cost of $75,000 (GF, FF). The governor's veto message for AB 1930 cited "millions of dollars in ongoing General Fund costs.")

VOTES

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner Horvath, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

UPDATED

VERSION: April 17, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0000726

Date of Hearing: May 3, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 608

Author:(Schiavo) – As Amended Ver:April 17, 2023

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

SUMMARY:

This bill extends the length of time postpartum services are available under the Comprehensive Perinatal Services Program (CPSP) benefit in Medi-Cal, and expands the settings and types of supervisors allowed for non-licensed Comprehensive Perinatal Health Workers (CPHWs) to provide CPSP services.

FISCAL EFFECT:

Costs of an unknown, but potentially significant amount to DHCS to extend the CPSP program to one year after a pregnancy. If one-half of the approximately 70,000 women who use CPSP services in a given year continue to access the extended benefit provided by this bill, at an average cost per beneficiary of $215, the annual cost would be $7.5 million ($2.4 million General Fund (GF), $5.1 million federal funds (FF)). Actual costs would depend on the available services and their costs, the accessibility of services, how many women choose to use the services, how many of the available services beneficiaries utilize, and other factors. (The California Health Benefits Review Program (CHBRP) estimated much lower costs for a similar bill, AB 1930 (Arambula), of the 2021-22 Legislative Session. CHBRP projected that only 349 women would choose to use the extended benefit, for a total cost of $75,000 (GF, FF). The governor’s veto message for AB 1930 cited “millions of dollars in ongoing General Fund costs.”)

COMMENTS:

1. Purpose. This bill is sponsored by Maternal and Child Health Access, March of Dimes, and The Children’s Partnership. According to the author:

AB 608 ensures every Californian has a healthy start in life by extending coverage of services provided by the Comprehensive Perinatal Services Program (CPSP) to one year postpartum. Childbirth and parenting is unique to each family. However, without postpartum support, some challenges many parents face can lead to disruptions with the mental and physical wellbeing of parent or child. For example, it’s estimated that postpartum depression affects 1 in 7 parents after delivery. If unaddressed, this can lead to long-term behavioral health issues in children, and, in severe cases, suicide. More than four of every five people who die by suicide after the end of their pregnancy, died in the late postpartum period 43-365 days after birth. If extending CPSP into that first year after pregnancy can help treat postpartum depression and reduce the number of suicides, we should be doing everything we can to make these services easily accessible to more people.

1. CPSP. CPSP was established in the early 1980’s, based on the results of a pilot that demonstrated that obstetrical care, supplemented by psychosocial, health education and nutrition services and prenatal vitamins and minerals, could significantly reduce the incidence of low birth weight in infants. The Maternal, Child and Adolescent Health Program in Department of Public Health (DPH) oversees CPSP and the statewide system of perinatal care established in statute.
   
   CPSP integrates Medi-Cal billing and coverage with quality and monitoring activities at local health jurisdictions, as overseen by DPH. Most LHJs employ a Perinatal Services Coordinator, who certifies providers and gives technical assistance to CPSP providers in their communities. To bill fee-for-service (FFS) Medi-Cal or a contracting Medi-Cal managed care plan for CPSP services, a provider must enroll in and be CPSP-certified through their local LHJ, in addition to being enrolled in Medi-Cal.
   
   The CPSP benefit supplements, and does not replace, services that are part of standard prenatal, delivery, and postpartum care. Because of benefit expansions and managed care requirements that have been implemented since the creation of CPSP, pregnant and postpartum people in Medi-Cal also have coverage for other services, outside of CPSP, that supplement standard obstetrical care. These include, among other services, a comprehensive set of behavioral health services, as well as health education, community health worker, and doula services.
2. CPHWs. CPSP services, unlike many other Medi-Cal services offered to individuals in the perinatal period, may be provided by non-licensed practitioners. In addition to licensed practitioners like physicians, certified nurse midwives, registered nurses, nurse practitioners, licensed vocational nurses, physician assistants, licensed midwives, and licensed behavioral health practitioners, CPSP providers may employ or contract with health educators, childbirth educators, registered dieticians, and CPHWs to provide CPSP services. This bill would expand the location where CPHWs can provide services to include a beneficiary’s home or other community setting away from a medical site.

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

Date of Hearing: April 11, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 608

Author:(Schiavo) – As Introduced Ver:February 9, 2023

SUBJECT: Medi-Cal: comprehensive perinatal services.

SUMMARY: Extends the length of time postpartum services are available under the Comprehensive Perinatal Services Program (CPSP) benefit in Medi-Cal, and expands the settings and supervisors for non-licensed Comprehensive Perinatal Health Workers (CPHWs) to provide CPSP services. Specifically, this bill:

1. Requires the Department of Health Care Services (DHCS) to cover additional comprehensive perinatal assessments and individualized care plans and provide additional visits and units of services in an amount, duration, and scope that are at least proportional to those available on July 27, 2021, during pregnancy and the initial 60-day post-pregnancy period in effect on that date during the one-year post-pregnancy eligibility in existing law, as part of the CPSP benefit.
   
2. Requires DHCS to collaborate with the California Department of Public Health (DPH) and a broad stakeholder group to determine the specific number of additional comprehensive perinatal assessments, individualized care plans, visits, and units of services to be covered pursuant to 1) above.
   
3. Requires DHCS, as part of the CPSP benefit, to seek any necessary federal approvals to do both of the following:
   
   1. Cover preventive services that are recommended by a physician or other licensed practitioner and that are rendered by a non-licensed perinatal health worker in a beneficiary’s home or other community setting away from a medical site, as described in federal Medicaid law and regulation; and,
   2. Allow a non-licensed perinatal health worker rendering preventive services in accordance with a) above to be supervised by either of the following:
      1. An enrolled Medi-Cal provider that is a clinic, a hospital, a community-based organization (CBO), or a licensed practitioner; or,
      2. A CBO that is not an enrolled Medi-Cal provider, so long as an enrolled Medi-Cal provider is available for Medi-Cal billing purposes.
         
4. Implements 3) above only to the extent that any necessary federal approvals are obtained and federal financial participation is available.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which low-income individuals are eligible for medical coverage. [Welfare and Institutions Code (WIC) §14000, et seq.]
   
2. Establishes a schedule of benefits under the Medi-Cal program, which includes benefits required under federal law and benefits which are provided at state option. [WIC §14132]
   
3. Authorizes, under federal Medicaid law, federal financial participation (matching funds) for other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law. [42 United States Code 1396d]
   
4. Defines, pursuant to federal Medicaid regulation, “preventive services” to mean services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice under state law to:
5. Prevent disease, disability, and other health conditions or their progression;
6. Prolong life; and,
   1. Promote physical and mental health and efficiency. [Title 42, Code of Federal Regulations § 440.130]
      
7. Requires the Medi-Cal program to cover a pregnant individual who is eligible for and is receiving health care coverage under a Medi-Cal program for full-scope Medi-Cal benefits for the duration of the pregnancy and for a period of one year following the last day of the individual’s pregnancy. [WIC §14005.185]
   
8. Establishes the CPSP within DPH as a community-based system of comprehensive perinatal care for low-income women. States that prenatal care, delivery service, postpartum care, and neonatal and infant care are necessary services that have been demonstrated effective in preventing or reducing maternal, perinatal, and infant mortality and morbidity, including prematurity and low birth weight. Includes initial and ongoing physical assessment, psychosocial, nutrition, and health education assessments, interventions, counseling and referral, food supplement programs, vitamins, and breast-feeding and other services as appropriate. Requires all contracted providers to make these services available directly or by subcontract, and to use an appropriate multidisciplinary team. [Health & Safety Code §123475, et seq.]
   
9. Establishes the CPSP program services as a Medi-Cal benefit. [WIC §14132]
   
10. Defines CPSP providers to include any one of the following, certified pursuant to specified CPSP standards:
    1. General practice physician;
    2. Family practice physician;
    3. Obstetrician-gynecologist;
    4. Pediatrician;
    5. Certified nurse midwife;
    6. A group, any of whose members is one of the above-named physicians; or,
    7. Any preferred provider organization or clinic enrolled in the Medi-Cal program.

Allows providers to contract with medical and other practitioners for the purpose of delivering CPSP services. [WIC §14134.5]

1. States that perinatal means the period from the establishment of pregnancy to one month following delivery. Requires the CPSP provider to schedule visits with appropriate providers and track the patient to make sure services have been received. Requires that, through CPSP, the patient receive psychosocial assessment and referrals; nutrition assessment, appropriate referrals to counseling for food supplement programs, vitamins, and breastfeeding, health, childbirth, and parenting education. [WIC §14134.5]
   

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

COMMENTS:

1. PURPOSE OF THIS BILL. This bill is sponsored by Maternal and Child Health Access, March of Dimes, and The Children’s Partnership to improve maternal and infant health outcomes. According to the author, this bill addresses two interrelated problems that limit the ability of CPSP to fully serve Medi-Cal beneficiaries in the pregnancy and postpartum periods. First, the bill expands Medi-Cal’s CPSP benefit throughout a 12-month postpartum period instead of solely the initial 60-day period. According to the author, the 60-day time period limits the ability of CPSP providers to identify and address postpartum depression, connect parents to programs that address food and housing insecurity, and provide a host of other services that may be needed beyond the initial 60-day postpartum period. Furthermore, the author explains, the postpartum Medi-Cal coverage period was recently updated from 60 days to 12 months, and this bill aligns postpartum CPSP services with the postpartum coverage period.
   
   This bill also expands both the settings that a non-licensed CPHWs can work in, and the types of organizations who can supervise a CPHW. Specifically, this bill would require Medi-Cal reimbursement for preventive services CPHWs provide to beneficiaries in their homes or in other community settings, in order to “meet patients where they are.” Furthermore, the author notes, this change would align with recent DHCS policy for non-licensed providers such as doulas and community health workers, who can provide services in community settings. The addition of organizations who can supervise CPHWs to include CBOs is also intended to expand allowable provider types to include non-clinical organizations who have direct community experience. The author indicates this is also meant to align with policies recently adopted by DHCS for community health workers.

The author has a corresponding budget request for $2.4 million General Fund and matching federal funds in 2023-24 to fund additional CPSP service.

1. BACKGROUND.
   1. CPSP. CPSP was established in the early 1980’s, based on the results of a pilot conducted in July 1979 through June 1982. The pilot demonstrated that obstetrical care, supplemented by psychosocial, health education and nutrition services and prenatal vitamins and minerals, could significantly reduce the incidence of low birth weight in infants. The Maternal, Child and Adolescent Health Program in DPH oversees CPSP and the statewide system of perinatal care established in statute. The goals of CPSP are to: i) decrease the incidence of low birthweight in infants; ii) improve the outcome of every pregnancy; iii) give every baby a healthy start in life; and, iv) lower health care costs by preventing catastrophic and chronic illness in infants and children.
      
      CPSP has a unique program design. It integrates Medi-Cal billing and coverage with quality and monitoring activities at local health jurisdictions (LHJs, or county public health departments), as overseen by DPH. Most LHJs employ a Perinatal Services Coordinator, who certifies providers who meet CPSP program standards and provides technical assistance to CPSP providers in their communities. To bill fee-for-service (FFS) Medi-Cal or a contracting Medi-Cal managed care plan for CPSP services, a provider must enroll in and be CPSP-certified through their local LHJ, in addition to being enrolled in Medi-Cal.
   2. CPSP as a Medi-Cal Benefit. Statute and regulation establish a set of services that comprise the CPSP Medi-Cal benefit. These services include a program orientation; initial and follow-up nutrition, psychosocial and health education assessments, and corresponding interventions; comprehensive individual and group health education, and prenatal vitamins. CPSP also reimburses about $57 as a bonus for early prenatal care if an initial comprehensive prenatal visit is conducted prior to 16 weeks. A CPSP practitioner develops an Individualized Care Plan to address needs identified in the assessments, conducts case coordination, and ensures that the Medi-Cal enrollee receives appropriate nutrition, health education and psychosocial interventions and referrals from a multidisciplinary team. CPSP services can be provided to Medi-Cal eligible enrollees, throughout pregnancy through the end of the second month after delivery. DHCS establishes maximum units of service for each CPSP service. Additional services can be provided as medically necessary with an approved Treatment Authorization Request.
      
      The CPSP benefit is a set of outpatient services that supplement, and do not replace, services that are part of standard prenatal, delivery, and postpartum care. Because of benefit expansions and managed care requirements that have been implemented since the creation of CPSP, pregnant and postpartum people in Medi-Cal also have coverage for other services, outside of CPSP, that supplement standard obstetrical care. These include, among other services, a comprehensive set of behavioral health services as well as health education, community health worker, and doula services, as further discussed in “Related Medi-Cal Efforts,” below.
   3. Medi-Cal Coverage of Pregnancy and Recent Postpartum Eligibility Expansion. Because of the critical importance of prenatal care for maternal and infant health, Medi-Cal coverage for pregnant persons is more generous than that for non-pregnant individuals. Specifcally, eligibility for pregnant persons extends to 322% of federal poverty level (FPL), while Medi-Cal coverage for other individuals generally extends to 138% of the FPL. Correspondingly, Medi-Cal paid for approximately 40% of California’s 420,754 births in 2021.
      
      H.R. 1319, the American Rescue Plan Act of the 117th Congress 2021-2022, (Pub. Law 117-2) allowed states to extend their Medicaid postpartum care period for pregnancy-related Medi-Cal eligibility from 60 days after birth to an additional 10 months (for a total of one year) and broadened the scope of coverage to full-scope benefits during both the pregnancy and postpartum periods, effective April 1, 2022. The health budget trailer bill, AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, implemented this federal option to expand coverage to 12 months and provide full-scope benefits for these pregnant and postpartum individuals. Although many individuals who gave birth while on Medi-Cal coverage retained Medi-Cal coverage following their pregnancy, even prior to this change, coverage for certain groups, such as undocumented residents without a mental health diagnosis whose Medi-Cal eligibility was specifically tied to pregnancy, ended after 60 days. In 2024, the state will expand Medi-Cal to all income-eligible residents, regardless of immigration status, which will further shrink the population that only becomes eligible for Medi-Cal only because of their pregnancy.
      
      A 2022 brief by the Center for Health Care Strategies on recent Medi-Cal maternity and reproductive health care efforts identified that stakeholders consider the interaction of the postpartum expansion and CPSP’s 60-day time limit for coverage of services as an outstanding question.
      
      Under this bill, the allowable timeline for provision of CPSP would also be extended to cover additional comprehensive perinatal assessments and individualized care plans, and provide additional visits and units of services during the one-year post-pregnancy eligibility period. This bill would also require DHCS to collaborate with DPH and a broad stakeholder group to determine the specific number of additional services.
   4. Related Medi-Cal Efforts. DHCS is currently implementing numerous Medi-Cal program improvement and transformation efforts, most notably through a number of federal demonstrations and waivers dubbed CalAIM (California Advancing and Innovating Medi-Cal). Several recent program efforts are targeted at improving maternal health or intersect with the provision of CPSP services. Specifically, several design elements of CPSP align with or overlap with the department’s transformation and improvement efforts, particularly in relation to case coordination and care management functions that address the social determinants of health during the perinatal period.
      
      For instance, as part of CalAIM, DHCS is seeking to advance “whole-person care” with appropriate assessments and interventions to address social drivers of health. These initiatives generally focus on high-risk groups, including those who are pregnant and birthing with elevated risk. DHCS has established two “populations of focus,” for the provision of a service known as Enhanced Care Management (ECM). ECM is targeted for individuals with high health care costs, risk, and/or care needs. Medi-Cal managed care plans are required to provide ECM for populations of focus, which includes care management activities relating to social and behavioral health needs. Similar to ECM, CPSP also focuses on comprehensive assessment, development of an individual care plan, case coordination, and the provision of appropriate referrals and interventions. The two pregnancy-related populations of focus for ECM include the following:
      1. Pregnant or postpartum individuals at higher risk (who qualify for ECM on another basis, including experiencing homelessness, transitioning from incarceration, or with serious mental health and/or substance use disorder needs). ECM is currently being provided for this population of focus.
      2. “Birth Equity Population of Focus.” Effective January 1, 2024, ECM will also be provided to individuals who are subject to racial and ethnic disparities, as defined by California public health data on maternal morbidity and mortality. According to DHCS, based on state public health data, the racial and ethnic groups experiencing disparities in care for maternal morbidity and mortality are Black, American Indian and Alaska Native, and Pacific Islander pregnant and postpartum individuals. Pregnant or postpartum individuals identifying in these racial/ethnic categories at risk for disparities would become eligible for ECM on that basis.

ECM is only provided through Medi-Cal managed care, not in FFS. Other Medi-Cal maternal health efforts include the following (not an exhaustive list):

• • 1. The 2022 Medi-Cal Comprehensive Quality Strategy includes “50 x 25 Bold Goals,” including closing maternity care disparities for Black and Native American people, and improving maternal depression screening, each by 50% by 2025. In the Population Health Management Strategy And Roadmap published in July 2022, DHCS indicates it plans to issue future guidance for Medi-Cal managed care plans regarding best practices to address maternal health outcomes.
    2. Effective July 1, 2022, community health worker (CHW) services are a Medi-Cal benefit. CHWs offer health education, health navigation, screening and assessment, and individual support or advocacy to assist a beneficiary in preventing a health condition, injury, or violence. Per the formal definition of the CHW benefit as listed in the California Medicaid State Plan, CHWs help address a number of health conditions, including perinatal health conditions.
    3. Effective January 1, 2023, doula services are a Medi-Cal benefit. Doula services are aimed at preventing perinatal complications and improving health outcomes for birthing parents and infants. Implementation of the doula benefit is also intended to lessen racial disparities in maternal health outcomes. DHCS defines doulas as birth workers who provide health education, advocacy, and physical, emotional and nonmedical support for pregnant and postpartum persons before, during and after childbirth, including support during miscarriage, stillbirth, and abortion. Doulas may provide services for up to 12 months from the end of pregnancy, including prenatal visits; support during labor and delivery, abortion, or miscarriage; and postpartum visits.
    4. Per the 2022-23 Budget Act, DHCS is allocating $700 million over a multiyear period for Equity and Practice Transformation Grants. One of four “workstreams” of this initiative is identifying and addressing disparities and clinical quality outcomes for pregnant persons and infants.
  1. Additional Medi-Cal Managed Care Requirements. Most individuals enrolled in Medi-Cal receive their services through Medi-Cal managed care plans, and DHCS projects that over 99% of enrollees will receive services through managed care by 2024. DHCS has recently undertaken a major effort to comprehensively update the standard Medi-Cal managed care plan contract and has awarded new contracts to managed care plans, which will be effective January 1, 2024, through a statewide Request For Proposal process. This updated managed care plan contract, under “Covered Services: Pregnant and Postpartum Members,” requires plans to “utilize the most current standards or guidelines of American College of Obstetricians and Gynecologists (ACOG) and CPSP to ensure Members receive quality perinatal and postpartum services.” Plans must also implement a comprehensive risk assessment tool for all pregnant members that is comparable to the ACOG standards and CPSP standards in existing state regulation, follow up on all identified risks consistent with those standards, and document the assessment and interventions in the individual’s medical record.

DHCS imposes other general requirements on contracted managed care plans that are similar to the CPSP benefit. These include a requirement to conduct health education and quality improvement strategies in accordance with the DHCS Comprehensive Quality Strategy (which includes perinatal quality goals related to maternal care disparities and maternal depression screening). It also requires plans, through a program called Basic Population Health Management, to proactively ensure all members have access to needed services including care coordination, navigation and referrals to services that address a variety of physical, behavioral, and other health needs.

• 1. CPHWs. A key difference between CPSP and many other Medi-Cal services offered to individuals in the perinatal period is the ability of non-licensed practitioners to provide CPSP services. In addition to licensed practitioners like physicians, certified nurse midwives, registered nurses, nurse practitioners, licensed vocational nurses, physician assistants, licensed midwives, and licensed behavioral health practitioners, CPSP providers can employ or contract with health educators, childbirth educators, registered dieticians, and CPHWs to provide CPSP services.
     
     Existing state regulation for CPSP defines a CPHW as meeting the following requirements:
     1. Is at least 18 years of age, is a high school graduate or equivalent, and has at least one year of full-time paid practical experience in providing perinatal care; and,
     2. Provides services in a clinic that is either licensed or exempt from licensure under the direct supervision of a comprehensive perinatal practitioner.

This bill would expand the location where CPHWs can provide services to include a beneficiary’s home or other community setting away from a medical site.

• 1. Preventive Services Option and Supervision of CPHWs. States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. Effective January 1, 2014, federal Medicaid regulations allow states to reimburse for preventive services delivered by a non-licensed health care professional when the service is recommended by a physician or other licensed provider within their scope of practice under state law. This federal “preventive services” authority opens opportunities for Medicaid programs to reimburse for services non-licensed providers work outside of the supervision of a licensed provider. California has used this authority to add new preventive health benefits to the Medi-Cal program, including the National Diabetes Prevention Plan services, community health worker services, and doula services.
     
     In their guidance on CPSP, DPH states CPSP services delivered are consistent with approved protocols signed off by nutrition, health education and psychosocial consultants. DPH also requires CPSP services to be provided by or under the personal supervision of a physician, and CPHWs to work under the direct supervision of a physician.
     
     This bill would instead allow CPHWs to be supervised by CBOs that are enrolled as Medi-Cal providers, or by CBOs that are not enrolled as Medi-Cal providers but work with a licensed provider for billing purposes. DHCS projects implementation of a Medi-Cal enrollment pathway for CBOs and local health jurisdictions in DHCS’s automated provider enrollment system, Provider Application and Validation for Enrollment (PAVE), in fall 2023.

1. SUPPORT. This bill is sponsored by Maternal and Child Health Access (MCHA) and supported by consumer’s, children’s, and women’s health groups to improve access to critical social and other supports for low-income mothers and infants during Medi-Cal’s 12-month postpartum eligibility period. MCHA states this bill would require DHCS to: a) continue Medi-Cal’s CPSP benefit beyond the initial 60-day postpartum period; and, b) adopt the federal option to allow CPHWs—a subset of community health workers with expertise in perinatal health—to provide supportive services in the mother’s home or elsewhere in the community, not just at a clinic or doctor’s office.
   
   MCHA writes that the CPSP benefit connects mothers to necessary medical care and social supports during pregnancy, and this bill would address the need for these supports during Medi-Cal’s extended 12-month postpartum eligibility period as well. Without this bill, MCHA is extremely concerned that birth experiences and necessary follow-up for conditions uncovered during pregnancy will not be given the proper attention. MCHA states new mothers need a structure for health and social support long beyond the initial 60 days following a pregnancy.
2. RELATED LEGISLATION.
   1. AB 1478 (Cervantes) requires DPH to develop and maintain on its internet website a referral network of community-based mental health providers and support services addressing, among other topics, postpartum depression and prenatal care, as specified. AB 1478 is pending in the Assembly Health Committee.
   2. AB 1701 (Weber) expands the California Perinatal Equity Initiative to include city health departments. AB 1701 is pending in the Assembly Health Committee.
   3. AB 583 (Wicks) establishes the Birthing Justice for California Families Pilot Project, administered by DPH, to provide grants to specified entities, including community-based doula groups, to provide full-spectrum doula care to pregnant and birthing people who are low income and do not qualify for Medi-Cal or who are from communities that experience high rates of negative birth outcomes, as specified. AB 583 is pending in the Assembly Health Committee.
   4. AB 492 (Pellerin) requires DHCS, on or before July 1, 2024, subject to an appropriation, to make grants, incentive payments, or other financial support available to Medi-Cal managed care plans to develop and implement reproductive and behavioral health integration pilot programs in partnership with identified qualified providers, as specified. AB 492 is pending in the Assembly Health Committee.
   5. AB 904 (Calderon) requires a health care service plan or health insurer, on or before January 1, 2025, to develop a maternal and infant health equity program that addresses racial health disparities in maternal and infant health outcomes through the use of doulas, authorizes the Department of Managed Health Care and the California Department of Insurance to convene a joint workgroup, and requires the departments to submit a report, as specified. AB 904 is pending in the Assembly Health Committee.
3. PREVIOUS LEGISLATION.
   1. AB 1930 (Arambula) of 2022 was substantially similar to this bill and was vetoed by Governor Newsom, who expressed support for efforts to improve maternal health outcomes and ensure Medi-Cal offers appropriate care. The veto message states DHCS already provides full-scope coverage for all individuals for one year after pregnancy, which offers a range of services above and beyond the services provided by CPSP. The veto message also notes concern that the bill attempts to expand the services offered by comprehensive perinatal workers and make these services a Medi-Cal benefit apart from CPSP, which would result in millions of dollars in ongoing General Fund costs that are not accounted for in the budget.
   2. AB 133 implements the federal option to expand Medi-Cal coverage to 12 months and provide full-scope benefits for these pregnant and postpartum individuals during pregnancy and the 12-month postpartum period.
   3. SB 104 (Committee on Budget and Fiscal Review), Chapter 67, Statutes of 2019 extended Medi-Cal eligibility for a pregnant individual who has been diagnosed with a maternal mental health condition, for a period of one year following the last day of the individual’s pregnancy. This eligibility expansion was later subsumed under a larger expansion to all postpartum individuals regardless of a maternal mental health diagnosis, per AB 133, as noted above.
4. POLICY COMMENTS/AMENDMENTS. The author and Committee staff have discussed a number of policy issues raised by this bill and the author has agreed to amendments addressing these issues, as described below:
   1. CPSP Services. Although providing postpartum services for 12 months has merit generally, the author may wish to consider more flexibility in what CPSP services are needed in the additional 10 months, given availability of other similar services. For instance, if a postpartum person is identified through CPSP as having behavioral health needs, given Medi-Cal now covers a broad range of behavioral health services, it may be appropriate to ensure referrals to a licensed behavioral health practitioner who could bill under other available billing codes for covered behavioral health services, instead of CPSP billing codes for psychosocial interventions. This could and should be happening currently in the Medi-Cal program, and it is unclear whether there is a need to provide, for instance, a CPSP psychosocial intervention during this 10-month period, versus a different behavioral health service.

This bill in its current form would require services offered in the additional 10 months be available in an amount, duration, and scope that are at least proportional to the number of services offered in the current CPSP period (pregnancy through two months postpartum). This may or may not be appropriate, given CPSP was designed based on a pilot which specifically addressed the pregnancy and immediate postpartum periods, as well as Medi-Cal coverage of other similar benefits. This bill also requires the convening of a broad stakeholder group to determine the specific scope, duration and amount of services. Although stakeholders can inform benefit design, determining specific units of service and utilization controls generally is appropriately, and should remain, within the scope of DHCS’s authority.

Amendments will preserve DHCS’s authority to define the scope of benefits and make DPH and stakeholder input advisory. Moving forward, the author may also wish to work with DHCS and stakeholders to ensure an appropriate scope for CPSP services that account for coverage of other, similar benefits.

• 1. Scope of Expansion for CPHW Services. This bill would also require Medi-Cal to cover “preventive services that are recommended by a physician or other licensed practitioner and that are rendered by a nonlicensed perinatal health worker” in community settings, under the 2014 federal preventive services authority. However, CPHWs are not currently defined or approved under this authority; as noted above, CPHWs are only defined through state regulation. The effect of this language is unclear but potentially could require DHCS to submit a new State Plan Amendment to define CPHW services more broadly under the Medicaid construct of federal preventive services, apart from the existing regulatory structure that establishes CPHWs.

Amendments will clarify this provision is simply intended to allow CPHWs to provide currently allowable services in additional settings, not to define a broader scope for CPHW services, by deleting references to “preventive services recommended by a physician” and the federal preventive services authority.

• 1. CPHW Supervision. As noted, current regulations define CPHWs as someone who provides services in a clinic, under the direct supervision of a comprehensive perinatal practitioner. In establishing a new supervision option by CBOs, the bill does not establish corresponding clinical oversight or protocols that would assure integration of CPHWs into a person’s prenatal medical care team. Adding non-clinical supervisors apart from this care team implies clinical oversight, and/or protocols that assure integration with a medical care team, may no longer be necessary. While the level of clinical oversight or integration is a reasonable issue to reconsider, such outside supervision is not contemplated under current regulations and guidance. The statutory addition of a CBO as supervisor in this context seems to be a stand-alone insertion into an existing regulatory construct.
     
     Amendments will also address the concern about integration by requiring a CBO or an LHJ supervising nonlicensed perinatal health workers to provide such services under contract with a CPSP provider. In accord with the author’s stated intent to align supervision for CPHWs with allowable supervisors for CHWs, amendments will add LHJs as allowable supervisors for CPHWs.
  2. Implementation. To ensure effective and timely implementation, amendments will add language allowing DHCS to issue guidance to implement the bill’s requirements and remove language making implementation contingent on an appropriation.

As this bill moves forward the author may also wish to consider a broader approach requiring DPH and/or DHCS to update regulations and policy to allow for expanded roles and flexibility for CPHWs, including supervision. This approach could offer flexibility to leverage these trained and experienced nonlicensed providers in additional settings, as well as integrating and aligning these workers from a policy perspective with other initiatives and Medi-Cal benefits. It is reasonable to consider a broader reexamination of the CPHW requirements in the context of the care delivery model DHCS is looking to encourage through its multiple initiatives to improve maternal care, given the CPSP construct was created at a different time where few supplemental and care coordination services were available.

REGISTERED SUPPORT / OPPOSITION:

Support

March of Dimes (cosponsor)
Maternal and Child Health Access (cosponsor)
Children's Partnership (cosponsor)
Access Reproductive Justice
American College of Obstetricians and Gynecologists District Ix
American Nurses Association/California
California Catholic Conference
California Children's Trust

California Nurse Midwives Association (CNMA)
California State Council of Service Employees International Union (SEIU California)
California Pan-Ethnic Health Network
California WIC Association
Children Now
Children's Specialty Care Coalition
Community Clinic Association of Los Angeles County (CCALAC)
Community Health Councils
Desert Aids Project (DAP Health)
Everychild Foundation
First 5 Association of California
Friends Committee on Legislation of California
Health Access California

Innercity Struggle
LA Best Babies Network
NARAL Pro-choice California

National Association of Social Workers, California Chapter
National Health Law Program

Nurse-Family Partnership
Orange County United Way
Senior and Disability Action
Vision Y Compromiso
Western Center on Law & Poverty
Worksite Wellness LA

Opposition

None listed.

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