Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for certain services and treatments, including medical transportation services. Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including emergency medical transport. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law, until January 1, 2031, authorizes a local emergency medical services (EMS) agency to develop a community paramedicine or triage to alternate destination program that, among other things, provides case management services to frequent EMS users or triage paramedic assessments, respectively.

This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025, to establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program, as defined.

The bill would require those contracts and policies to require an enrollee or insured who receives covered services from a noncontracting program to pay no more than the same cost-sharing amount that they would pay for the same covered services received from a contracting program. The bill would prohibit reimbursement rates adopted pursuant to this provision from exceeding the health care service plans or health insurers usual and customary charges for services rendered.

Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The bill would also make services provided by these programs covered benefits under the Medi-Cal program. The bill would condition this Medi-Cal coverage on an appropriation, receipt of any necessary federal approvals, and the availability of federal financial participation.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for certain services and treatments, including medical transportation services. Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including emergency medical transport. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law, until January 1, 2031, authorizes a local emergency medical services (EMS) agency to develop a community paramedicine or triage to alternate destination program that, among other things, provides case management services to frequent EMS users or triage paramedic assessments, respectively.

This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025, to establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program, as defined.

The bill would require those contracts and policies to require an enrollee or insured who receives covered services from a noncontracting program to pay no more than the same cost-sharing amount that they would pay for the same covered services received from a contracting program. The bill would prohibit reimbursement rates adopted pursuant to this provision from exceeding the health care service plans or health insurers usual and customary charges for services rendered.

Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The bill would also make services provided by these programs covered benefits under the Medi-Cal program. The bill would condition this Medi-Cal coverage on an appropriation, receipt of any necessary federal approvals, and the availability of federal financial participation.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for certain services and treatments, including medical transportation services. Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including emergency medical transport. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law, until January 1, 2031, authorizes a local emergency medical services (EMS) agency to develop a community paramedicine or triage to alternate destination program that, among other things, provides case management services to frequent EMS users or triage paramedic assessments, respectively.

This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January July 1, 2025, to establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program, as defined. The

The bill would require those contracts and policies to require an enrollee or insured who receives covered services from a noncontracting program to pay no more than the same cost-sharing amount that they would pay for the same covered services received from a contracting program. The bill would specify the reimbursement process and amount for a noncontracting program. Because prohibit reimbursement rates adopted pursuant to this provision from exceeding the health care service plans or health insurers usual and customary charges for services rendered.

Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The bill would also make services provided by these programs covered benefits under the Medi-Cal program. The bill would condition this Medi-Cal coverage on an appropriation, receipt of any necessary federal approvals, and the availability of federal financial participation.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for certain services and treatments, including medical transportation services. Existing law provides for establishes the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including emergency medical transport. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law, until January 1, 2031, authorizes a local emergency medical services (EMS) agency to develop a community paramedicine or triage to alternate destination program that, among other things, provides case management services to frequent EMS users and triage paramedic assessments. or triage paramedic assessments, respectively.

This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025, to establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program. program, as defined. The bill would require those plans contracts and policies to require an enrollee or insured who receives covered services from a noncontracting program to pay no more than the same cost-sharing amount that they would pay for the same covered services received from a contracting program. The bill would specify the reimbursement process and amount for a noncontracting program. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The

The bill would also make services provided by these programs covered benefits under the Medi-Cal program. The bill would condition this Medi-Cal coverage on an appropriation, receipt of any necessary federal approvals, and the availability of federal financial participation.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for certain services and treatments, including medical transportation services. Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including emergency medical transport. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law, until January 1, 2031, authorizes a local emergency medical services (EMS) agency to develop a community paramedicine or triage to alternate destination program that, among other things, provides case management services to frequent EMS users and triage paramedic assessments.

This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025, to include coverage establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program. The bill would require those plans and policies to require an enrollee or insured who receives covered services from a noncontracting program to pay no more than the same cost-sharing amount they would pay for the same covered services received from a contracting program. The bill would specify the reimbursement process and amount for a noncontracting program. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The bill would also make services provided by these programs covered benefits under the Medi-Cal program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for certain services and treatments, including medical transportation services. Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including emergency medical transport. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law, until January 1, 2031, authorizes a local emergency medical services (EMS) agency to develop a community paramedicine or triage to alternate destination program that, among other things, provides case management services to frequent EMS users and triage paramedic assessments.

This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025, to include coverage for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program. The bill would require those plans and policies to require an enrollee or insured who receives covered services from a noncontracting program to pay no more than the same cost-sharing amount they would pay for the same covered services received from a contracting program. The bill would specify the reimbursement process and amount for a noncontracting program. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The bill would also make services provided by these programs covered benefits under the Medi-Cal program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

 UNFINISHED BUSINESS  

Bill No: SB 1180

Author: Ashby (D), et al.

Amended: 6/24/24

Vote: 21

SENATE HEALTH COMMITTEE: 10-0, 4/24/24

AYES: Roth, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

NO VOTE RECORDED: Nguyen

SENATE APPROPRIATIONS COMMITTEE: 5-0, 5/16/24

AYES: Caballero, Ashby, Becker, Bradford, Wahab

NO VOTE RECORDED: Jones, Seyarto

SENATE FLOOR: 35-0, 5/21/24

AYES: 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, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

NO VOTE RECORDED: Allen, Nguyen, Niello, Ochoa Bogh, Seyarto

ASSEMBLY FLOOR: 76-0, 8/28/24 - See last page for vote

SUBJECT: Health care coverage: emergency medical services

SOURCE: California Professional Firefighters

DIGEST:

This bill

requires a health plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025 to establish a process to reimburse services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program. Makes these services a covered Medi-Cal benefit and requires the Department of Health Care Services to establish Medi-Cal rates for these services. Requires the Medi-Cal provisions to be implemented only to the extent federal financial participation is available and the Legislature appropriates funding.

Assembly Amendments

delay the bill requirements by six months from January to July 1, 2025; and, limit reimbursement rates pursuant to the bill to the plan’s or insurer’s usual and customary charges for services rendered.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [HSC §1340, et seq., INS §106, et seq., and WIC §14000, et seq.]
2. Defines “community paramedicine program,” as a program developed by a Local Emergency Medical Services Agency (LEMSA) and approved by Emergency Medical Services Agency (EMSA) to provide community paramedicine services consisting of one or more of the program specialties as described under the direction of medical protocols developed by the LEMSA that are consistent with the minimum medical protocols established by EMSA. Authorizes community paramedicine to consist of the following program specialties:
   • 1. Providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency to ensure effective treatment of the tuberculosis and to prevent spread of the disease;
     2. Providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources; and,
     3. Providing short-term, post discharge follow-up for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. [HSC §1815]
        
3. Defines “triage to alternate destination program,” as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments operating under triage and assessment protocols developed by the LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA. Permits triage paramedic assessments to consist of the following program specialties:
   • 1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient;
     2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility (authorized mental health facility or authorized sobering center); and,
     3. Providing transport services for patients who identify as veterans and desire transport to a local Veteran’s Administration emergency department for treatment, when appropriate. [HSC §1819]
        

This bill:

1. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025 to establish a process to reimburse services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program.
2. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025 to require an enrollee or insured who receives covered services from a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting community paramedicine program, triage to alternative destination program, or mobile integrated program.
3. Limits reimbursement for a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to no more than the health plan’s or insurer’s usual and customary charges for services rendered.
4. Requires DHCS to develop rates of reimbursement for services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program and makes these services a covered benefit under Medi-Cal. Requires this to be implemented only to the extent federal waivers or approvals are obtained and federal financial participation is available, and subject to an appropriation by the Legislature.
5. Defines “mobile integrated health program” as a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the Emergency Medical System (EMS) system.

Comments

According to the author, programs like community paramedicine, alternate destination triage, and mobile integrated health are critical for fire departments to deliver proper healthcare. However, with the lack of health insurance reimbursements, there is no clear path for these programs – leading to more reliance on emergency rooms for patients requiring mental health intervention or a sobering center. Sobering centers and mental health facilities offer a cost-effective solution and provide a monitored environment for individuals to receive treatment. These locations offer specialized alternatives to hospitalization while providing resources to treat substance use disorders and mental health crises. The implementation of these programs has already resulted in decreases in hospital readmissions, follow-up transports, and emergency room overcrowding – a proven method for also decreasing healthcare costs and improving treatment outcomes. Despite the willingness of fire departments to develop these programs, many are limited by the lack of financial resources available to support them. This bill will ensure that fire departments are able to recover necessary costs for services provided outside of the traditional EMS system, particularly for our homeless population and individuals with the most acute needs.

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

According to the Assembly Appropriations Committee, one-time and ongoing costs of unknown amounts, but likely hundreds of thousands to low millions of dollars to DHCS to add new provider types, including systems changes and staff positions to handle applications from EMS providers. Additional costs of an indeterminate amount to pay for new benefits in the Medi-Cal program (General Fund, federal funds).

DMHC estimates the costs of this bill as follows: $637,000 in fiscal year (FY) 2025-26; $432,000 in FY 2026-27; $434,000 in FY 2027-28; $436,000 in FY 2028-29; and, $438,000 in FY 2029-30 and annually thereafter Managed Care Fund (MCF). DMHC states it would need additional staff and consulting services to conduct legal research and provide guidance; review plan contracts, policies, and procedures, evidence of coverage and disclosure forms; and develop survey methodology and provide clinical review of paramedical services files. DMHC also anticipates costs for platform and software licensing support for additional staff. DMHC notes that generally, a $1 million increase to the MCF could result in a two-cent increase per enrollee on assessments to full-service health plans and a one-cent increase per enrollee to specialized health plans. To the extent this bill and others result in an additional assessment on health plans, consumers could face increased premiums.

CDI estimates costs of $21,000 in FY 2024-25 (Insurance Fund).

SUPPORT: (Verified 8/27/24)

California Professional Firefighters (source)

California Agents & Health Insurance Professionals

California Chiropractic Association

California Life Sciences

California State Association of Psychiatrists

City and County of San Francisco

City of Beverly Hills

City of Hayward

County of Sacramento, Board of Supervisors

County of San Diego

Elderly Care Everywhere

Emergency Medical Services Administrators Association of California

Sacramento County Board of Supervisors

Sacramento County Supervisor, Pat Hume

Sacramento Metropolitan Fire District

San Francisco Fire Department

OPPOSITION: (Verified 8/27/24)

None received

ARGUMENTS IN SUPPORT: The California Professional Firefighters (CPF), state council of the International Association of Fire Fighters is the sponsor of this bill and writes the healthcare needs of Californians have changed dramatically in recent years, compounded by the COVID-19 pandemic as well as the behavioral health and homelessness crises. Many people now rely on both emergency medical care and the emergency department of the hospital for their primary medical care, resulting in overcrowding and long delays that lead to impacts across the emergency system. In order to manage these needs new paradigms of medical care have developed in order to divert cases from the emergency department that can be effectively treated elsewhere, as well as connecting patients with needed services to reduce hospital readmissions and future 911 calls. Fire departments throughout California have been at the forefront of these efforts, piloting and implementing community paramedicine and triage to alternate destination programs as well as developing mobile integrated health units to meet their community members where they are needed. However, despite the willingness of departments to develop programs that are well suited to the needs of their communities, many are limited by the lack of resources available to support them. As public agencies, fire departments often work with strictly defined budgets leaving little room for programs that are not sustainable. In order to ensure that current programs are continued and departments that have not yet established programs are able to do so, departments must be able to seek cost-sharing reimbursement for the services that are provided by community paramedicine, triage to alternate destination, or mobile integrated healthcare programs. Under current law, departments may not seek reimbursement for the cost of community paramedicine services or triage to alternate destination transports, as they are not considered emergency services. As a result, such programs must either operate at a loss or rely on limited-term grant funding that is not guaranteed to continue.

ASSEMBLY FLOOR: 76-0, 8/28/24

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Chen, Connolly, Megan Dahle, Davies, Essayli, Flora, Mike 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, 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

NO VOTE RECORDED: Cervantes, Dixon, Ortega

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/29/24 11:26:08

**** END ****

 UNFINISHED BUSINESS  

Bill No: SB 1180

Author: Ashby (D), et al.

Amended: 6/24/24

Vote: 21

SENATE HEALTH COMMITTEE: 10-0, 4/24/24

AYES: Roth, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

NO VOTE RECORDED: Nguyen

SENATE APPROPRIATIONS COMMITTEE: 5-0, 5/16/24

AYES: Caballero, Ashby, Becker, Bradford, Wahab

NO VOTE RECORDED: Jones, Seyarto

SENATE FLOOR: 35-0, 5/21/24

AYES: 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, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

NO VOTE RECORDED: Allen, Nguyen, Niello, Ochoa Bogh, Seyarto

ASSEMBLY FLOOR: 76-0, 8/28/24

(Roll call vote not available)

SUBJECT: Health care coverage: emergency medical services

SOURCE: California Professional Firefighters

DIGEST:

This bill

requires a health plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025 to establish a process to reimburse services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program. Makes these services a covered Medi-Cal benefit and requires the Department of Health Care Services to establish Medi-Cal rates for these services. Requires the Medi-Cal provisions to be implemented only to the extent federal financial participation is available and the Legislature appropriates funding.

Assembly Amendments

delay the bill requirements by six months from January to July 1, 2025; and, limit reimbursement rates pursuant to the bill to the plan’s or insurer’s usual and customary charges for services rendered.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [HSC §1340, et seq., INS §106, et seq., and WIC §14000, et seq.]
2. Defines “community paramedicine program,” as a program developed by a Local Emergency Medical Services Agency (LEMSA) and approved by Emergency Medical Services Agency (EMSA) to provide community paramedicine services consisting of one or more of the program specialties as described under the direction of medical protocols developed by the LEMSA that are consistent with the minimum medical protocols established by EMSA. Authorizes community paramedicine to consist of the following program specialties:
   • 1. Providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency to ensure effective treatment of the tuberculosis and to prevent spread of the disease;
     2. Providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources; and,
     3. Providing short-term, post discharge follow-up for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. [HSC §1815]
        
3. Defines “triage to alternate destination program,” as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments operating under triage and assessment protocols developed by the LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA. Permits triage paramedic assessments to consist of the following program specialties:
   • 1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient;
     2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility (authorized mental health facility or authorized sobering center); and,
     3. Providing transport services for patients who identify as veterans and desire transport to a local Veteran’s Administration emergency department for treatment, when appropriate. [HSC §1819]
        

This bill:

1. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025 to establish a process to reimburse services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program.
2. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after July 1, 2025 to require an enrollee or insured who receives covered services from a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting community paramedicine program, triage to alternative destination program, or mobile integrated program.
3. Limits reimbursement for a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to no more than the health plan’s or insurer’s usual and customary charges for services rendered.
4. Requires DHCS to develop rates of reimbursement for services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program and makes these services a covered benefit under Medi-Cal. Requires this to be implemented only to the extent federal waivers or approvals are obtained and federal financial participation is available, and subject to an appropriation by the Legislature.
5. Defines “mobile integrated health program” as a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the Emergency Medical System (EMS) system.

Comments

According to the author, programs like community paramedicine, alternate destination triage, and mobile integrated health are critical for fire departments to deliver proper healthcare. However, with the lack of health insurance reimbursements, there is no clear path for these programs – leading to more reliance on emergency rooms for patients requiring mental health intervention or a sobering center. Sobering centers and mental health facilities offer a cost-effective solution and provide a monitored environment for individuals to receive treatment. These locations offer specialized alternatives to hospitalization while providing resources to treat substance use disorders and mental health crises. The implementation of these programs has already resulted in decreases in hospital readmissions, follow-up transports, and emergency room overcrowding – a proven method for also decreasing healthcare costs and improving treatment outcomes. Despite the willingness of fire departments to develop these programs, many are limited by the lack of financial resources available to support them. This bill will ensure that fire departments are able to recover necessary costs for services provided outside of the traditional EMS system, particularly for our homeless population and individuals with the most acute needs.

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

According to the Assembly Appropriations Committee, one-time and ongoing costs of unknown amounts, but likely hundreds of thousands to low millions of dollars to DHCS to add new provider types, including systems changes and staff positions to handle applications from EMS providers. Additional costs of an indeterminate amount to pay for new benefits in the Medi-Cal program (General Fund, federal funds).

DMHC estimates the costs of this bill as follows: $637,000 in fiscal year (FY) 2025-26; $432,000 in FY 2026-27; $434,000 in FY 2027-28; $436,000 in FY 2028-29; and, $438,000 in FY 2029-30 and annually thereafter Managed Care Fund (MCF). DMHC states it would need additional staff and consulting services to conduct legal research and provide guidance; review plan contracts, policies, and procedures, evidence of coverage and disclosure forms; and develop survey methodology and provide clinical review of paramedical services files. DMHC also anticipates costs for platform and software licensing support for additional staff. DMHC notes that generally, a $1 million increase to the MCF could result in a two-cent increase per enrollee on assessments to full-service health plans and a one-cent increase per enrollee to specialized health plans. To the extent this bill and others result in an additional assessment on health plans, consumers could face increased premiums.

CDI estimates costs of $21,000 in FY 2024-25 (Insurance Fund).

SUPPORT: (Verified 8/27/24)

California Professional Firefighters (source)

California Agents & Health Insurance Professionals

California Chiropractic Association

California Life Sciences

California State Association of Psychiatrists

City and County of San Francisco

City of Beverly Hills

City of Hayward

County of Sacramento, Board of Supervisors

County of San Diego

Elderly Care Everywhere

Emergency Medical Services Administrators Association of California

Sacramento County Board of Supervisors

Sacramento County Supervisor, Pat Hume

Sacramento Metropolitan Fire District

San Francisco Fire Department

OPPOSITION: (Verified 8/27/24)

None received

ARGUMENTS IN SUPPORT: The California Professional Firefighters (CPF), state council of the International Association of Fire Fighters is the sponsor of this bill and writes the healthcare needs of Californians have changed dramatically in recent years, compounded by the COVID-19 pandemic as well as the behavioral health and homelessness crises. Many people now rely on both emergency medical care and the emergency department of the hospital for their primary medical care, resulting in overcrowding and long delays that lead to impacts across the emergency system. In order to manage these needs new paradigms of medical care have developed in order to divert cases from the emergency department that can be effectively treated elsewhere, as well as connecting patients with needed services to reduce hospital readmissions and future 911 calls. Fire departments throughout California have been at the forefront of these efforts, piloting and implementing community paramedicine and triage to alternate destination programs as well as developing mobile integrated health units to meet their community members where they are needed. However, despite the willingness of departments to develop programs that are well suited to the needs of their communities, many are limited by the lack of resources available to support them. As public agencies, fire departments often work with strictly defined budgets leaving little room for programs that are not sustainable. In order to ensure that current programs are continued and departments that have not yet established programs are able to do so, departments must be able to seek cost-sharing reimbursement for the services that are provided by community paramedicine, triage to alternate destination, or mobile integrated healthcare programs. Under current law, departments may not seek reimbursement for the cost of community paramedicine services or triage to alternate destination transports, as they are not considered emergency services. As a result, such programs must either operate at a loss or rely on limited-term grant funding that is not guaranteed to continue.

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/28/24 22:39:42

**** END ****

SENATE THIRD READING

STR Bill Id:SB 1180

Author:(Ashby)

As Amended Ver:June 24, 2024

Majority vote

SUMMARY

Requires a health plan contract or health insurance policy to establish a process to reimburse for services provided by a community paramedicine program (CPP), a triage to alternate destination program (TADP), and a mobile integrated health program (MIHP), as defined. Prohibits reimbursement rates adopted in this bill from exceeding the health plan or insurer's usual and customary charges for services rendered. Requires coverage of these programs under Medi-Cal, upon appropriation, receipt of any necessary federal approvals, and the availability of federal financial participation.

Major Provisions

COMMENTS

1. Emergency Medical Services (EMS) in California. The Emergency Medical Services Agency (EMSA) is responsible for statewide coordination and leadership for planning, developing, and implementing local EMS systems and local trauma care systems in California. It also sets training standards and scope of practice for emergency services workers (e.g., paramedics, emergency medical technicians, mobile intensive care nurses, firefighters) among other duties. There are 34 local EMSA agencies (LEMSAs) that serve California's 58 counties. The state oversees the actions and compliance of these local agencies. The LEMSAs coordinate and contract with EMS transport entities.
2. CPP and TADP pilots. According to the California Health Benefits Review Program (CHBRP), an emerging area within the EMS field involves alternative models of care delivery that expand EMS professionals' scope of practice beyond responding to 911 calls and transporting patients to emergency departments (EDs). This may involve providing additional services such as nonemergency care and transporting patients to non-ED destinations. The specific programs may be developed and led by EMSAs, fire departments, hospitals or health systems, insurers, or independent companies, and the services may be targeted to vulnerable populations such as seniors, individuals with chronic conditions, underserved communities, or those who frequently use emergency services. In 2014, California sponsored a six year pilot project that implemented 10 CPP and 10 TADPs across the state. According to CHBRP, many programs have since ended. These are funded by grants, public EMS or city/county government agencies, or private EMS agencies (and health care partner organizations). These pilot projects intended to improve the efficiency and effectiveness of emergency medical and health care services by expanding the role of specially trained paramedics in the field. Of the 20 pilot projects launched in California between 2015 and 2020, five remain operational, one CPP and four TADPs. In addition, CHBRP is aware of two MIHPs in California. EMSA requires that LEMSAs apply for approval of CPP and TADPs. MIHPs are not subject to this process since they include staff who are licensed medical professionals. In California, CPP, TADP, and MIHPs have been and are currently funded by grants, public EMS or city/county government agencies, or private EMSAs (and health care partner organizations), not through payments from health plans or policies, or the Medi-Cal program. CHBRP is not aware of any California health plans or policies that currently pay for services provided by existing CPP, TADP, or MIHPs, as defined in this bill. Some state Medicaid programs cover community paramedicine services, as do some commercial insurers in other states. However, there is no standardized approach by insurers on how the services are delivered and covered, and coding for the covered services is not standardized between state Medicaid programs or insurers.
3. California laws. AB 1544 (Gipson), Chapter 138, Statutes of 2020, codified the Community Paramedicine or Triage to Alternate Destination Act of 2019, permitting LEMSAs, with approval by EMSA, to develop programs to provide CPP or TADP services in one of the following specialties: a) providing directly observed tuberculosis therapy; b) providing case management services to frequent EMS users; c) providing hospice services to treat patients in their homes; and, d) providing patients with TADP, which can either be an authorized mental health facility, or an authorized sobering center. AB 767 (Gipson), Chapter 270, Statues of 2023, extended the sunset in AB 1544 to 2031.

In 2023, the Department of Health Care Services (DHCS) received its approval of the State Plan Amendment to add community-based mobile crisis intervention services (mobile crisis services) as a Medi-Cal benefit. Mobile crisis services are a community-based intervention designed to provide de-escalation and relief to individuals experiencing a behavioral health or substance use-related crisis wherever they are, including at home, work, school, or in the community. As part of its California Advancing and Innovating Medi-Cal program's Mobile Crisis Services Initiative, mobile crisis services are provided by a multidisciplinary team of trained behavioral health professionals. Mobile crisis services provide rapid response, individual assessment and community-based stabilization to Medi-Cal beneficiaries who are experiencing a behavioral health crisis. Mobile crisis services are designed to provide relief to beneficiaries experiencing a behavioral health crisis, including through de-escalation and stabilization techniques; reduce the immediate risk of danger and subsequent harm; and, avoid unnecessary ED care, psychiatric inpatient hospitalizations, and law enforcement involvement.

According to the Author

Substance abuse centers and mental health facilities, both mandated in this bill, offer a cost-effective solution to ED overcrowding and help to better address patients with acute needs, particularly for our vulnerable communities. Drug addiction and mental illnesses are consistent risk factors associated with entering into homelessness, a population with little access to healthcare, which is a significant barrier to finding stable employment or securing permanent housing. The author writes that substance abuse centers and mental health facilities offer specialized alternatives to EDs while providing the extensive resources needed to address intensive care. It is vital that we deliver the resources needed to protect our most vulnerable populations by allowing our emergency medical response teams to connect patients with appropriate services. The author concludes that this bill will ensure that California can provide proper medical transportation to the best health resource for each patients individualized needs.

Arguments in Support

The California Professional Firefighters, sponsor, writes under current law, fire departments may not seek reimbursement for the cost of CPP services or TADP transports as they are not considered emergency services. As a result, such programs must either operate at a loss or rely on limited-term grant funding that is not guaranteed to continue. This also has the unintended consequence of limited CPP, TADP, and MIHP to larger, more well-funded departments that are able to either absorb the costs of the programs or dedicate personnel to pursuing funding. The sponsor states that this bill will ensure that departments are able to recover the necessary costs for the services that they provide outside of the traditional EMS system. The implementation of these programs has already resulted in decreases in hospital readmissions, follow-up transport, and emergency room overcrowding, and their further expansion throughout California to departments that would otherwise not have been able to operate them will provide continued benefits. The sponsor concludes that California's firefighters are dedicated to serving their communities and seeking innovative solutions to the issues impacting the state, and this bill will ensure that they have the supportive framework that is needed to do so.

Arguments in Opposition

The Department of Finance is opposed to this bill as it creates significant General Fund cost pressures to Medi-Cal and results in costs not accounted for in the state's spending plan. This bill may also lead to increased utilization of services and potential additional cost pressures for health plans and insurers. These costs could be passed on to consumers through higher premiums. Existing law established the Office of Health Care Affordability to slow healthcare spending and address prevailing cost drivers. While this bill in and of itself would not likely have a material impact on this state policy objective, increasing health care costs through legislation may conflict with the policy objective of limiting the growth in the costs of care.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, one-time and ongoing costs of unknown amounts, but likely hundreds of thousands to low millions of dollars to DHCS to add new provider types, including systems changes and staff positions to handle applications from EMS providers. Additional costs of an indeterminate amount to pay for new benefits in the Medi-Cal program (General Fund, federal funds).

The Department of Managed Health Care (DMHC) estimates the costs of this bill as follows: $637,000 in fiscal year (FY) 2025-26; $432,000 in FY 2026-27; $434,000 in FY 2027-28; $436,000 in FY 2028-29; and, $438,000 in FY 2029-30 and annually thereafter (Managed Care Fund). DMHC states it would need additional staff and consulting services to conduct legal research and provide guidance; review plan contracts, policies, and procedures, evidence of coverage and disclosure forms; and develop survey methodology and provide clinical review of paramedical services files. DMHC also anticipates costs for platform and software licensing support for additional staff. DMHC notes that generally, a $1 million increase to the MCF could result in a two-cent increase per enrollee on assessments to full-service health plans and a one-cent increase per enrollee to specialized health plans. To the extent this bill and others result in an additional assessment on health plans, consumers could face increased premiums.

The Department of Insurance estimates costs of $21,000 in FY 2024-25 (Insurance Fund).

According to the Legislative Analyst's Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years.

VOTES

SENATE FLOOR: 35-0-5

YES: 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, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood‑Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ABS, ABST OR NV: Allen, Nguyen, Niello, Ochoa Bogh, Seyarto

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Jackson, Flora, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Sanchez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 13-0-2

YES: Wicks, Sanchez, Arambula, Bryan, Calderon, Wendy Carrillo, Mike Fong, Grayson, Haney, Hart, Pellerin, Ta, Villapudua

ABS, ABST OR NV: Dixon, Jim Patterson

UPDATED

VERSION: June 24, 2024

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0004045

Date of Hearing: August 7, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

SBPCA Bill Id:SB 1180

Author:(Ashby) – As Amended Ver:June 24, 2024

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

SUMMARY:

This bill requires a health plan or insurance policy to establish a process to reimburse for services provided by a community paramedicine program (CPP), triage to alternate destination program (TADP), or mobile integrated health program (MIHP). The bill also requires the Medi-Cal program to cover CPP, TADP, and MIHP.

Specifically, this bill:

1. Requires a health plan contract or insurance policy issued, amended, or renewed on or after July 1, 2025, to establish a process to reimburse for services provided by a CPP, TADP, or MIHP.
   
2. Prohibits a health plan contract or insurance policy issued, amended, or renewed on or after July 1, 2025, from requiring an enrollee or insured who receives covered services from a noncontracting CPP, TADP, or MIHP from paying more than the same cost-sharing amount the enrollee or insured would pay for the same covered services from a contracting program.
   
3. Specifies the reimbursement for a noncontracting CPP, TADP, or MIHP may not exceed the health plan or insurer’s usual and customary charges.
4. Specifies that services provided by a CPP, TADP, or MIHP are a covered benefit under the Medi-Cal program. Requires the Department of Health Care Services (DHCS), in consultation with CPPs, TADPs, and MIHPs, to develop reimbursement rates for these providers’ services, to the extent DHCS obtains any necessary federal waivers or other federal approvals and that federal financial participation is available and not otherwise jeopardized, and subject to an appropriation by the Legislature for this purpose.
5. Defines a CPP as a program developed by a local emergency medical services agency (LEMSA) and approved by the Emergency Medical Services Authority (EMSA) to provide community paramedicine services consisting of one or more of the following program specialties under the direction of medical protocols developed by the LEMSA that are consistent with the minimum protocols established by EMSA.
   
   1. Directly observed therapy to persons with tuberculosis in collaboration with a public health agency.
   2. Case management services to frequent EMS (emergency medical services) users in collaboration with, and by providing referral to, existing appropriate community resources.
      
6. Defines a TADP as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments consisting of one or more of the following specialties operating under protocols developed by the LEMSA, as specified:
   1. Care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient.
   2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility.
   3. Providing transport services for patients who identify as veterans and desire transport to a local Veterans Administration emergency department (ED) when appropriate.
7. Defines an MIHP as a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the EMS System.

FISCAL EFFECT:

1. One-time and ongoing costs of unknown amounts, but likely hundreds of thousands to low millions of dollars to DHCS to add new provider types, including systems changes and staff positions to handle applications from EMS providers. Additional costs of an indeterminate amount to pay for new benefits in the Medi-Cal program (General Fund, federal funds).
2. The Department of Managed Health Care (DMHC) estimates the costs of this bill as follows:

• $637,000 in fiscal year (FY) 2025-26.
• $432,000 in FY 2026-27.
• $434,000 in FY 2027-28.
• $436,000 in FY 2028-29.
• $438,000 in FY 2029-30 and annually thereafter (Managed Care Fund).
  

DMHC states it would need additional staff and consulting services to conduct legal research and provide guidance; review plan contracts, policies, and procedures, evidence of coverage and disclosure forms; and develop survey methodology and provide clinical review of paramedical services files. DMHC also anticipates costs for platform and software licensing support for additional staff.

DMHC notes that generally, a $1 million increase to the MCF could result in a two-cent increase per enrollee on assessments to full-service health plans and a one-cent increase per enrollee to specialized health plans. To the extent this bill and others result in an additional assessment on health plans, consumers could face increased premiums.

1. The Department of Insurance estimates costs of $21,000 in FY 2024-25 (Insurance Fund).

According to the Legislative Analyst’s Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years. 

COMMENTS:

1. Purpose. This bill is sponsored by California Professional Firefighters. According to the author:
   

This bill is attempting to solve a reimbursement issue for [CPP, TADP, and MIHPs]. Fire departments and EMS providers have not been able to develop pathways for reimbursement for these services. As a result, fire agencies have simply covered the cost for these programs within existing budgets, despite the benefits that they provide to the entire health system.

This bill would require that health plan contracts…establish a process to include these programs as covered services. It also requires that Medi-Cal programs cover these programs upon federal approval and state funding.

1. Background. In 2014, California sponsored a pilot project that implemented 10 CPPs and 10 TADPs for six years across the state. The programs were intended to improve the efficiency and effectiveness of emergency medical and health care services by expanding the role of specially trained paramedics in the field. Of the 20 pilot projects launched in California between 2015 and 2020, one CPP and four TADPs remain operational. In addition, there are at least two MIHPs in California. EMSA requires LEMSAs apply for approval of CPP and TADPs. MIHPs are not subject to this process because they include licensed medical professionals. In California, CPPs, TADPs, and MIHPs have been funded by grants, public EMS or local government agencies, or private EMSAs and health care partner organizations – not through payments from health plans or insurance or the Medi-Cal program.
   
   AB 1544 (Gipson), Chapter 138, Statutes of 2020, codified the Community Paramedicine or Triage to Alternate Destination Act of 2019, permitting LEMSAs, with approval by EMSA, to provide CPP services in one of the following specialties: a) directly observed tuberculosis therapy; b) case management services to frequent EMS users; c) hospice services to treat patients in their homes; and, d) providing triage to an alternate destination, which may be either a mental health facility or sobering center.

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

Date of Hearing: June 18, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

SBPCA Bill Id:SB 1180

Author:(Ashby) – As Amended Ver:May 16, 2024

SENATE VOTE: 35-0

SUBJECT: Health care coverage: emergency medical services.

SUMMARY: Requires a health plan contract or health insurance policy to establish a process to reimburse for services provided by a community paramedicine program (CPP), a triage to alternate destination program (TADP), and a mobile integrated health program (MIHP), as defined. Requires coverage of these programs under Medi-Cal, upon appropriation, receipt of any necessary federal approvals, and the availability of federal financial participation (FFP). Specifically, this bill:

1. Requires a health plan contract or insurance policy, issued, amended, or renewed on or after January 1, 2025, to establish a process to reimburse for services provided by a CPP, TADP, or MIHP.
2. Prohibits a health plan contract or insurance policy issued, amended, or renewed on or after January 1, 2025, from requiring an enrollee or insured who receives covered services from a noncontracting program pursuant to 1) above, from paying more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services.
3. Specifies that the reimbursement for a noncontracting program pursuant to 1) above to follow the same process as described in 4) below under existing law.
4. Mandates coverage of services provided by a CPP, TADP, or MIHP under the Medi-Cal program. Provides for implementation only to the extent that the Department of Health Care Services (DHCS) obtains any necessary federal waivers or other federal approvals; that FFP is available and not otherwise jeopardized; and, subject to appropriation by the Legislature.
5. Requires DHCS to develop rates of reimbursement for services pursuant to 4) above in consultation with CPPs, TADPs, and MIHPs.
6. Defines the following for purposes of this bill:
   1. CPP as defined under 13) of existing law below;
   2. MIHP as a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the Emergency Medical Services (EMS) System; and,
   3. TADP as defined under 14) of existing law below.

EXISTING LAW:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans and the California Department of Insurance (CDI) to regulate health insurance. [Health and Safety Code (HSC) § 1340, et seq. and Insurance Code (INS) § 106, et seq.]
2. Establishes as California's essential health benefits (EHBs) benchmark under the Patient Protection and Affordable Care Act (ACA), the Kaiser Small Group Health Maintenance Organization, existing California health insurance mandates, and the 10 ACA mandated EHBs. [HSC § 1367.005 and INS § 10112.27]
3. Requires health plans and health insurers to provide basic health care services, including: physician services; hospital inpatient and ambulatory care services; diagnostic laboratory and diagnostic and therapeutic radiologic services; home health services; preventive health services; emergency health care services; including ambulance and ambulance transport services and out of area coverage; and, hospice care. Defines basic health care services to include ambulance and ambulance transport services provided through the “911” emergency response system. [HSC § 1345 and INS § 10112.281]
4. Requires a health plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider. Prohibits a noncontracting ground ambulance provider from billing or sending to collections a higher amount, and prohibits a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. Requires a plan or insurer to reimburse for ground ambulance services at the rate established or approved by the governing board of the local government having jurisdiction for that area or subarea, including an exclusive operating area, as specified. [HSC § 1371.56 and INS § 10126.66]
5. Establishes the EMS System and the Prehospital Emergency Medical Care Personnel Act to provide for a statewide system for EMS, and establishes the Emergency Medical Services Agency (EMSA), which is responsible for the coordination and integration of all state activities concerning EMS, including the establishment of minimum standards, policies, and procedures. [HSC § 1797, et seq.]
6. Authorizes counties to develop an EMS program and designate a local EMS agency (LEMSA) responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations. [HSC § 1797.200, et seq.]
7. Requires every LEMSA to have a licensed physician as medical director, to assure medical accountability throughout the planning, implementation, and evaluation of the EMS system. Requires the medical direction and management of an EMS system to be under the medical control of the medical director. [HSC § 1797.202 and HSC § 1798]
8. Requires every 911 system to include police, firefighting, and emergency medical and ambulance services. Requires every 911 system, in those areas in which a public safety agency provides ambulance emergency services, to include such public safety agencies. Permits 911 systems to incorporate private ambulance services. [Government Code § 53110]
9. Requires a county to enter into a written agreement with the city or fire district regarding the provision of prehospital EMS for that city or fire district. [HSC § 1797.201]
10. Authorizes a LEMSA to create one or more exclusive operating areas in the development of a local plan, if a competitive process is utilized to select the provider or providers of the services pursuant to the plan. [HSC § 1797.224]
11. Establishes the Community Paramedicine or Triage to Alternate Destination Act of 2020, and states the intent of the Legislature that, among other provisions, delivery of community paramedicine or triage to alternate destination services is a public good and is complementary to the existing emergency response system. [HSC §1800]
12. Requires EMSA to develop regulations that establish minimum standards for the development of a community paramedicine or triage to alternate destination program, and requires the Commission on EMS to review and approve the regulations. [HSC §1830]
    
13. Defines CPP as a program developed by a LEMSA and approved by EMSA to provide community paramedicine services consisting of one or more of the following the program specialties under the direction of medical protocols developed by the LEMSA that are consistent with the minimum protocols established by EMSA. Permits community paramedic services to consist of the following specialties:
    1. Providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency; and,
    2. Providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources. [HSC §1815]
14. Defines TADP as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments consisting of one or more of the following specialties operating under triage and assessment protocols developed by the LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA:
    1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient;
    2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility; and,
    3. Providing transport services for patients who identify as veterans and desire transport to a local veterans administration emergency department (ED) when appropriate. [HSC §1819]
       

FISCAL EFFECT: According to the Senate Appropriations Committee, DMHC estimates costs of approximately $294,000 in 2024-25, $368,000 in 2025-26, $432,000 in 2026-27, $434,000 in 2027-28, $436,000 in 2028-29, and $438,000 in 2029-30 and annually thereafter for state administration (Managed Care Fund). Unknown costs for CDI for state administration (Insurance Fund). Unknown, ongoing costs for the Medi-Cal program to cover the new benefit; and unknown ongoing costs for DHCS for state administration (General Fund and federal funds).

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, substance abuse centers and mental health facilities, both mandated in this bill, offer a cost-effective solution to ED overcrowding and help to better address patients with acute needs, particularly for our vulnerable communities. Drug addiction and mental illnesses are consistent risk factors associated with entering into homelessness, a population with little access to healthcare, which is a significant barrier to finding stable employment or securing permanent housing. The author writes that substance abuse centers and mental health facilities offer specialized alternatives to EDs while providing the extensive resources needed to address intensive care. It is vital that we deliver the resources needed to protect our most vulnerable populations by allowing our emergency medical response teams to connect patients with appropriate services. The author concludes that this bill will ensure that California can provide proper medical transportation to the best health resource for each patients individualized needs.
2. BACKGROUND.
   1. EMS in California. EMSA is responsible for statewide coordination and leadership for planning, developing, and implementing local EMS systems and local trauma care systems in California. It also sets training standards and scope of practice for emergency services workers (e.g., paramedics, emergency medical technicians, mobile intensive care nurses, firefighters) among other duties. There are 34 LEMSAs that serve California’s 58 counties. The state oversees the actions and compliance of these local agencies. The LEMSAs coordinate and contract with EMS transport entities.
   2. CPP and TADP pilots. According to the California Health Benefits Review Program (CHBRP), an emerging area within the EMS field involves alternative models of care delivery that expand EMS professionals’ scope of practice beyond responding to 911 calls and transporting patients to EDs. This may involve providing additional services such as nonemergency care and transporting patients to non-ED destinations. The specific programs may be developed and led by EMSAs, fire departments, hospitals or health systems, insurers, or independent companies, and the services may be targeted to vulnerable populations such as seniors, individuals with chronic conditions, underserved communities, or those who frequently use emergency services. In 2014, California sponsored a six year pilot project that implemented 10 CPP and 10 TADPs across the state. According to CHBRP, many programs have since ended. These are funded by grants, public EMS or city/county government agencies, or private EMS agencies (and health care partner organizations). These pilot projects intended to improve the efficiency and effectiveness of emergency medical and health care services by expanding the role of specially trained paramedics in the field. Of the 20 pilot projects launched in California between 2015 and 2020, five remain operational, one CPP and four TADPs. In addition, CHBRP is aware of two MIHPs in California. EMSA requires that LEMSAs apply for approval of CPP and TADPs. MIHPs are not subject to this process since they include staff who are licensed medical professionals. In California, CPP, TADP, and MIHPs have been and are currently funded by grants, public EMS or city/county government agencies, or private EMSAs (and health care partner organizations), not through payments from health plans or policies, or the Medi-Cal program. CHBRP is not aware of any California health plans or policies that currently pay for services provided by existing CPP, TADP, or MIHPs, as defined in this bill. Some state Medicaid programs cover community paramedicine services, as do some commercial insurers in other states. However, there is no standardized approach by insurers on how the services are delivered and covered, and coding for the covered services is not standardized between state Medicaid programs or insurers.
   3. California laws. AB 1544 (Gipson), Chapter 138, Statutes of 2020, codified the Community Paramedicine or Triage to Alternate Destination Act of 2019, permitting LEMSAs, with approval by EMSA, to develop programs to provide CPP or TADP services in one of the following specialties: i) providing directly observed tuberculosis therapy; ii) providing case management services to frequent EMS users; iii) providing hospice services to treat patients in their homes; and, iv) providing patients with TADP, which can either be an authorized mental health facility, or an authorized sobering center. AB 767 (Gipson), Chapter 767, Statues of 2023, extended the sunset in AB 1544 to 2031.

In 2023, DHCS received its approval of the State Plan Amendment to add community-based mobile crisis intervention services (mobile crisis services) as a Medi-Cal benefit. Mobile crisis services are a community-based intervention designed to provide de-escalation and relief to individuals experiencing a behavioral health or substance use-related crisis wherever they are, including at home, work, school, or in the community. As part of its California Advancing and Innovating Medi-Cal program’s Mobile Crisis Services Initiative, mobile crisis services are provided by a multidisciplinary team of trained behavioral health professionals. Mobile crisis services provide rapid response, individual assessment and community-based stabilization to Medi-Cal beneficiaries who are experiencing a behavioral health crisis. Mobile crisis services are designed to provide relief to beneficiaries experiencing a behavioral health crisis, including through de-escalation and stabilization techniques; reduce the immediate risk of danger and subsequent harm; and, avoid unnecessary ED care, psychiatric inpatient hospitalizations, and law enforcement involvement. 

1. SUPPORT. The California Professional Firefighters, sponsor, writes under current law, fire departments may not seek reimbursement for the cost of CPP services or TADP transports as they are not considered emergency services. As a result, such programs must either operate at a loss or rely on limited-term grant funding that is not guaranteed to continue. This also has the unintended consequence of limited CPP, TADP, and MIHP to larger, more well-funded departments that are able to either absorb the costs of the programs or dedicate personnel to pursuing funding. The sponsor states that this bill will ensure that departments are able to recover the necessary costs for the services that they provide outside of the traditional EMS system. The implementation of these programs has already resulted in decreases in hospital readmissions, follow-up transport, and emergency room overcrowding, and their further expansion throughout California to departments that would otherwise not have been able to operate them will provide continued benefits. The sponsor concludes that California’s firefighters are dedicated to serving their communities and seeking innovative solutions to the issues impacting the state, and this bill will ensure that they have the supportive framework that is needed to do so.
2. OPPOSITION. The California Association of Health Plans, the Association of California Life and Health Insurance Companies, and America’s Health Insurance Plans, write that this bill will lead to higher premiums, harming affordability and access for small businesses and individual market consumers.
3. PREVIOUS LEGISLATION.
   1. AB 716 (Boerner), Chapter 454, Statutes of 2023, requires a health plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider. Prohibits a noncontracting ground ambulance provider from billing or sending to collections a higher amount, and prohibits a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. Requires a plan or insurer to reimburse for ground ambulance services at a rate established or approved by the governing board of the local government having jurisdiction for that area or subarea, including an exclusive operating area, as specified.
   2. AB 767 adds short-term, post discharge follow-up for persons recently discharged from a hospital to the list of eligible CPP services and requires EMSA to amend existing regulations to include that service. Extends the sunset date of the CPP from January 1, 2024, to January 1, 2031.
4. AUTHOR’S AMENDMENTS. The author wishes to amend this bill to allow for a different reimbursement rate of noncontracting providers and to delay implementation to July 1, 2025.

REGISTERED SUPPORT / OPPOSITION:

Support

California Professional Firefighters (sponsor)

Pat Hume, Sacramento County Supervisor, District 5
California Agents & Health Insurance Professionals
California Chiropractic Association
California Life Sciences
California State Association of Psychiatrists
City and County of San Francisco

County of Sacramento
Elderly Care Everywhere
Emergency Medical Services Administrators' Association of California
Sacramento Metropolitan Fire District
San Francisco Fire Department

Opposition

America's Health Insurance Plans
Association of California Life & Health Insurance Companies
California Association of Health Plans

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

 THIRD READING  

Bill No: SB 1180

Author: Ashby (D)

Amended: 5/16/24

Vote: 21

SENATE HEALTH COMMITTEE: 10-0, 4/24/24

AYES: Roth, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Smallwood-Cuevas, Wiener

NO VOTE RECORDED: Nguyen

SENATE APPROPRIATIONS COMMITTEE: 5-0, 5/16/24

AYES: Caballero, Ashby, Becker, Bradford, Wahab

NO VOTE RECORDED: Jones, Seyarto

SUBJECT: Health care coverage: emergency medical services

SOURCE: California Professional Firefighters

DIGEST:

This bill requires a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025 to establish a process to reimburse services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program. Makes these services a covered Medi-Cal benefit and requires the Department of Health Care Services to establish Medi-Cal rates for these services. Requires the Medi-Cal provisions to be implemented only to the extent federal financial participation is available and the Legislature appropriates funding.

ANALYSIS:

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [HSC §1340, et seq., INS §106, et seq., and WIC §14000, et seq.]
   
2. Establishes the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act (EMS Act) to provide for a statewide system for emergency medical services (EMS), and establishes the Emergency Medical Services Authority (EMSA), which is responsible for the coordination and integration of all state activities concerning EMS, including the establishment of minimum standards, policies, and procedures. [HSC §1797, et seq.]
3. Authorizes counties to develop an EMS program and designate a local EMS agency (LEMSA) responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations. [HSC §1797.200, et seq.]
   
4. Defines “community paramedicine program,” as a program developed by a LEMSA and approved by EMSA to provide community paramedicine services consisting of one or more of the program specialties as described under the direction of medical protocols developed by the LEMSA that are consistent with the minimum medical protocols established by EMSA. Authorizes community paramedicine to consist of the following program specialties:
   • 1. Providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency to ensure effective treatment of the tuberculosis and to prevent spread of the disease;
     2. Providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources; and,
     3. Providing short-term, post discharge follow-up for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. [HSC §1815]
        
5. Defines “triage to alternate destination program,” as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments operating under triage and assessment protocols developed by the LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA. Permits triage paramedic assessments to consist of the following program specialties:
   • 1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient;
     2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility (authorized mental health facility or authorized sobering center); and,

• • 1. Providing transport services for patients who identify as veterans and desire transport to a local Veteran’s Administration emergency department for treatment, when appropriate. [HSC §1819]
       

This bill:

1. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025 to establish a process to reimburse services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program.
   
2. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025 to require an enrollee or insured who receives covered services from a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting community paramedicine program, triage to alternative destination program, or mobile integrated program.
   
3. Requires reimbursement for a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to follow the same process as described in existing law, as specified.
   
4. Requires DHCS to develop rates of reimbursement for services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program and makes these services a covered benefit under Medi-Cal. Requires this to be implemented only to the extent federal waivers or approvals are obtained and federal financial participation is available, and subject to an appropriation by the Legislature.
   
5. Defines “mobile integrated health program” as a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the EMS system.

Comments

Author’s statement. According to the author, programs like community paramedicine, alternate destination triage, and mobile integrated health are critical for fire departments to deliver proper healthcare. However, with the lack of health insurance reimbursements, there is no clear path for these programs – leading to more reliance on emergency rooms for patients requiring mental health intervention or a sobering center. Sobering centers and mental health facilities offer a cost-effective solution and provide a monitored environment for individuals to receive treatment. These locations offer specialized alternatives to hospitalization while providing resources to treat substance use disorders and mental health crises. The implementation of these programs has already resulted in decreases in hospital readmissions, follow-up transports, and emergency room overcrowding – a proven method for also decreasing healthcare costs and improving treatment outcomes. Despite the willingness of fire departments to develop these programs, many are limited by the lack of financial resources available to support them. This bill will ensure that fire departments are able to recover necessary costs for services provided outside of the traditional EMS system, particularly for our homeless population and individuals with the most acute needs.

State regulated health insurance coverage requirements. Under recent legislation, health plans and insurers are required to cover behavioral health crisis services provided by a 988 center, mobile crisis team, or other provider of behavioral health crisis services regardless of whether the services are provided by an in-network or out-of-network provider or facility. Plans and insurers are required to cover all items and services that are eligible for coverage under the Medi-Cal program. Additionally, plans and insurers are required to pay noncontracting and contracting ground ambulance providers for covered emergency and nonemergency services. Enrollees and insureds are required to pay the in-network cost-sharing and the provider may not advance to collections any amount greater than the in-network cost-sharing.

California Health Benefits Review Program (CHBRP) report:

1. CHBRP indicates EMS alternative models of care may be developed and led by EMS agencies, fire departments, hospitals or health systems, insurers, or independent companies and the services may be targeted to vulnerable populations such as seniors, individuals with chronic conditions, underserved communities, or those who frequently use emergency services. EMSA provides guidance on training and curriculum for program specialties, such as hospice, mental health and substance use. Since 2015, California has begun some trials of these expanded community models of EMS, through a number of pilot projects across the state. Of the 20 pilot projects, five remain operational: one community paramedicine, and four triage to alternate destination (see table below). In addition, CHBRP is aware of two mobile integrated health programs. These programs pair a firefighter/paramedic with a nurse practitioner or physician assistant to help frequent 911 callers with non-emergency issues. The teams assess, treat, and release patients in the field without the need for ambulance transport or an ED visit, and the LA program may also transport patients to alternate destinations. CHBRP indicates all of these program types are funded by grants, public EMS or city/county governmental agencies, or private EMS agencies (and other health care partner organizations) not through payments from plans or Medi-Cal. CHBRP is not aware of any health plans that currently pay for services provided by existing programs. CHBRP also notes that this bill defines mobile integrated health more narrowly than the published literature. There are some instances in the CHBRP report, particularly where there is published literature on mobile integrated health programs, where CHBRP relies on the broader definition used in the field.

Source: CHBRP, 2024

1. Medical effectiveness. CHBRP found limited evidence that community paramedicine, triage to alternate destinations, and mobile integrated health programs are safe and effective; and, insufficient evidence that the programs impact clinical outcomes. Specifically:
   1. There is a preponderance of evidence from 15 studies that, for patients who frequently use EMS services, community paramedicine and mobile integrated health programs are effective at reducing hospitalizations and avoidable ED visits.
   2. There is limited evidence based on two evaluation studies of pilot projects in California that triage to alternate destination programs can safely and appropriately identify patients with behavioral health concerns for triage to an alternate mental health destination.
   3. There is limited evidence based on one evaluation study of pilot projects in California, that patients who are acutely intoxicated but do not have acute medical or mental health needs can be safely and appropriately identified by triage to alternate destinations programs and then triaged to sobering centers.
   4. There is insufficient evidence that, for patients who frequently use EMS services, community paramedicine and mobile integrated health programs are effective at improving clinical outcomes.
   5. There is limited evidence from four studies that a community paramedicine or mobile integrated health program with short-term follow-up for patients recently discharged from the hospital due to a chronic condition (e.g. heart failure) can improve post-hospital discharge outcomes.
   6. There is limited evidence from two studies that a community paramedicine or mobile integrated health program with short-term follow-up for patients recently discharged from the hospital can increase primary care visits.
      
2. Utilization. CHBRP estimates no significant utilization increase in the short term. CHBRP notes that the availability of these programs will likely remain low. Existing programs are reliant on other funding, and to be reimbursed the programs will need to identify reimbursement codes and develop contracts with health plans and policies to establish services and reimbursement rates.
   

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

According to the Senate Appropriations Committee, DMHC estimates costs of approximately $294,000 in 2024-25, $368,000 in 2025-26, $432,000 in 2026-27, $434,000 in 2027-28, $436,000 in 2028-29, and $438,000 in 2029-30 and annually thereafter for state administration (Managed Care Fund). Unknown costs for CDI for state administration (Insurance Fund). Unknown, ongoing costs for the Medi-Cal program to cover the new benefit; and unknown ongoing costs for DHCS for state administration (General Fund and federal funds).

SUPPORT: (Verified 4/30/24)

California Professional Firefighters (source)

California Agents & Health Insurance Professionals

California Life Sciences

City and County of San Francisco

County of Sacramento, Board of Supervisors

Emergency Medical Service Administrators Association of California

Sacramento County Supervisor, Pat Hume

San Francisco Fire Department

OPPOSITION: (Verified 4/30/24)

America’s Health Insurance plans

Association of California Life & Health Insurance Companies

California Association of Health Plans

ARGUMENTS IN SUPPORT: The California Professional Firefighters, state council of the International Association of Fire Fighters is the sponsor of this bill and writes the healthcare needs of Californians have changed dramatically in recent years, compounded by the COVID-19 pandemic as well as the behavioral health and homelessness crises. Many people now rely on both emergency medical care and the emergency department of the hospital for their primary medical care, resulting in overcrowding and long delays that lead to impacts across the emergency system. In order to manage these needs new paradigms of medical care have developed in order to divert cases from the emergency department that can be effectively treated elsewhere, as well as connecting patients with needed services to reduce hospital readmissions and future 911 calls. Fire departments throughout California have been at the forefront of these efforts, piloting and implementing community paramedicine and triage to alternate destination programs as well as developing mobile integrated health units to meet their community members where they are needed. However, despite the willingness of departments to develop programs that are well suited to the needs of their communities, many are limited by the lack of resources available to support them. As public agencies, fire departments often work with strictly defined budgets leaving little room for programs that are not sustainable. In order to ensure that current programs are continued and departments that have not yet established programs are able to do so, departments must be able to seek cost-sharing reimbursement for the services that are provided by community paramedicine, triage to alternate destination, or mobile integrated healthcare programs. Under current law, departments may not seek reimbursement for the cost of community paramedicine services or triage to alternate destination transports, as they are not considered emergency services. As a result, such programs must either operate at a loss or rely on limited-term grant funding that is not guaranteed to continue.

ARGUMENTS IN OPPOSITION: The California Association of Health Plans, Association of California Life and Health Insurance Companies, and America’s Health Insurance Plans write to oppose this bill because it is one of 14 health insurance mandate bills that will increase costs, reduce choice and competition, and further incent some employers and individuals to avoid state regulation by seeking alternative coverage options. Benefit mandates impose a one-size-fits-all approach to medical care and benefit design driven by the legislature rather than consumer choice. These bills will lead to higher premiums, harming affordability and access for small businesses and individual market consumers. These opponents urge legislators to also consider the cumulative impacts of these mandates on premiums and access to coverage. All of these bills will increase costs and limit employer flexibility. The legislature created the Office of Health Care Affordability to contain cost drivers. With this office in place and the state budget deficit, the legislature should take a wait-and-see approach when considering costly mandates. The health plans have continued to be engaged and look forward to the work ahead.

Click here to enter text.

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

5/18/24 18:25:02

**** END ****

SENATE COMMITTEE ON

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

SB 1180 (Ashby) - Health care coverage: emergency medical services

Bill Summary:

SB 1180 would require health plans and health insurers to establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program, as specified; and provide that these services are covered benefits under the Medi-Cal program.

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on May 16, 2024

Fiscal Impact:

• The Department of Managed Health Care (DMHC) estimates costs of approximately $294,000 in 2024-25, $368,000 in 2025-26, $432,000 in 2026-27, $434,000 in 2027-28, $436,000 in 2028-29, and $438,000 in 2029-30 and annually thereafter for state administration (Managed Care Fund).
• Unknown costs for the California Department of Insurance (CDI) for state administration (Insurance Fund).
• Unknown, ongoing costs for the Medi-Cal program to cover the new benefit; and unknown ongoing costs for the Department of Health Care Services (DHCS) for state administration (General Fund and federal funds).

Committee Amendments:

Condition implementation of the Medi-Cal benefit upon federal approval, federal financial participation, and appropriation by the Legislature.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anna Caballero, Chair

2023 - 2024 Regular Session

SB 1180 (Ashby) - Health care coverage: emergency medical services

Bill Summary:

SB 1180 would require health plans and health insurers to establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program, as specified; and provide that these services are covered benefits under the Medi-Cal program.

Fiscal Impact:

• The Department of Managed Health Care (DMHC) estimates costs of approximately $294,000 in 2024-25, $368,000 in 2025-26, $432,000 in 2026-27, $434,000 in 2027-28, $436,000 in 2028-29, and $438,000 in 2029-30 and annually thereafter for state administration (Managed Care Fund).
• Unknown costs for the California Department of Insurance (CDI) for state administration (Insurance Fund).
• Unknown, ongoing costs for the Medi-Cal program to cover the new benefit; and unknown ongoing costs for the Department of Health Care Services (DHCS) for state administration (General Fund and federal funds).

Background:

Current law defines “community paramedicine program,” as a program developed by a local emergency medical services agency (LEMSA) and approved by the state Emergency Medical Services Authority (EMSA) to provide community paramedicine services consisting of one or more of the program specialties as described under the direction of medical protocols developed by the LEMSA that are consistent with the minimum medical protocols established by EMSA. Current law authorizes community paramedicine to consist of the following program specialties:

• Providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency to ensure effective treatment of the tuberculosis and to prevent spread of the disease;
• Providing case management services to frequent emergency medical services (EMS) users in collaboration with, and by providing referral to, existing appropriate community resources; and,
• Providing short-term, post discharge follow-up for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible.

Current law defines “triage to alternate destination program,” as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments operating under triage and assessment protocols developed by the LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA. Triage paramedic assessments may consist of the following program specialties:

• Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient;
• Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility (authorized mental health facility or authorized sobering center); and,
• Providing transport services for patients who identify as veterans and desire transport to a local Veteran’s Administration emergency department for treatment, when appropriate.

The DMHC regulates health plans under the Knox-Keene Act and the CDI regulates health and other insurance. The DHCS administers the Medi-Cal program which provides health coverage to eligible low-income individuals.

The Medi-Cal program’s community-based mobile crisis intervention services (“mobile crisis services”) provide rapid response, individual assessment and community-based stabilization to Medi-Cal beneficiaries who are experiencing a mental health and/or substance use disorder crisis. Mobile crisis services are designed to provide relief to beneficiaries experiencing a behavioral health crisis, including through de-escalation and stabilization techniques; reducing the immediate risk of danger and subsequent harm; and, avoiding unnecessary emergency department care, psychiatric inpatient hospitalizations, and law enforcement involvement.

Proposed Law:

Specific provisions of the bill would:

• Require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025, to establish a process to reimburse for services provided by a community paramedicine program, a triage to alternate destination program, and a mobile integrated health program, as specified.
• Provide that services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program are covered benefits under the Medi-Cal program.
• Define “mobile integrated health program” as a team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the emergency medical services system.

Staff Comments:

According to the California Health Benefits Review Program (CHBRP) analysis of SB 1180 (introduced version), CHBRP estimates no measurable fiscal impact or significant utilization increase in the short term because: (1) the availability of these programs/services in California will likely remain low; (2) existing programs/services have been largely reliant on grants and local public or private agency investments; and (3) to be reimbursed, programs will need to develop contracts with health plans and policies with regard to services and reimbursement rates. CHBRP assumes if SB 1180 were enacted, over time, there would be growth/expansion of these programs/services.

CHBRP indicates that in California, these programs/services are currently funded by grants, public EMS or city/county government agencies, or private EMS agencies, not through payments from health plans or policies, or the Medi-Cal program. CHBRP is not aware of any California health plans or policies that currently pay for services provided by existing programs/services as defined in SB 1180. Some state Medicaid programs cover community paramedicine services, as do some commercial insurers in other states. However, there is no standardized approach by insurers on how the services are delivered and covered, and coding for the covered services is not standardized between state Medicaid programs or insurers.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: SB 1180

SUBJECT: Health care coverage: emergency medical services

SUMMARY:

1. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025 to include coverage for services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program. Makes these services a covered Medi-Cal benefit and requires the Department of Health Care Services to establish Medi-Cal rates for these services.
   

Existing law:

1. Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [HSC §1340, et seq., INS §106, et seq., and WIC §14000, et seq.]
   
2. Establishes the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act (EMS Act) to provide for a statewide system for emergency medical services (EMS), and establishes the Emergency Medical Services Authority (EMSA), which is responsible for the coordination and integration of all state activities concerning EMS, including the establishment of minimum standards, policies, and procedures. [HSC §1797, et seq.]
3. Authorizes counties to develop an EMS program and designate a local EMS agency (LEMSA) responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations. [HSC §1797.200, et seq.]
   
4. Defines “community paramedicine program,” as a program developed by a LEMSA and approved by EMSA to provide community paramedicine services consisting of one or more of the program specialties as described under the direction of medical protocols developed by the LEMSA that are consistent with the minimum medical protocols established by EMSA. Authorizes community paramedicine to consist of the following program specialties:
   1. Providing directly observed therapy to persons with tuberculosis in collaboration with a public health agency to ensure effective treatment of the tuberculosis and to prevent spread of the disease;
   2. Providing case management services to frequent EMS users in collaboration with, and by providing referral to, existing appropriate community resources; and,
   3. Providing short-term, post discharge follow-up for persons recently discharged from a hospital due to a serious health condition, including collaboration with, and by providing referral to, home health services when eligible. [HSC §1815]
      
5. Defines “triage to alternate destination program,” as a program developed by a LEMSA and approved by EMSA to provide triage paramedic assessments operating under triage and assessment protocols developed by the LEMSA that are consistent with the minimum triage and assessment protocols established by EMSA. Permits triage paramedic assessments to consist of the following program specialties:
   1. Providing care and comfort services to hospice patients in their homes in response to 911 calls by providing for the patient’s and family’s immediate care needs, including grief support, in collaboration with the patient’s hospice agency until the hospice nurse arrives to treat the patient;
   2. Providing patients with advanced life support triage and assessment by a triage paramedic and transportation to an alternate destination facility (authorized mental health facility or authorized sobering center); and,
   3. Providing transport services for patients who identify as veterans and desire transport to a local Veteran’s Administration emergency department for treatment, when appropriate. [HSC §1819]
      
6. Requires, unless otherwise agreed to by the noncontracting ground ambulance provider and the health plan or health insurer, direct reimbursement to a noncontracting ground ambulance provider the difference between the in-network cost-sharing amount and an amount for ground ambulance services described as follows:
   1. At a rate established or approved by a local government having jurisdiction for the area or subarea, if any, including an exclusive operating area, as specified; or,
   2. The amount established by regulations, as specified, if the local government having jurisdiction where the service was provided does not have an established or approved rate for that service. [HSC §1371.56 and INS §10126.66]
      
7. Indicates a local government has jurisdiction over the transport if either applies:
   1. The ground ambulance transport is initiated within the boundaries of the local government’s regulatory jurisdiction; or,
   2. In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based. [HSC §1371.56 and INS §10126.66]
      
8. Requires every health plan contract and insurance policy that provides hospital, medical, or surgical coverage to provide coverage for medically necessary treatment of mental health and substance use disorders under the same terms and conditions applied to other medical conditions, as specified. [HSC §1374.72 and INS §10144.5]

This bill:

1. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025 to include coverage for services provided by a community paramedicine program, triage to alternative destination program, or mobile integrated health program.
   
2. Requires a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025 to require an enrollee or insured who receives covered services from a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting community paramedicine program, triage to alternative destination program, or mobile integrated program.
   
3. Requires reimbursement for a noncontracting community paramedicine program, triage to alternate destination program, or mobile integrated health program to follow the same process as described in 6) of existing law above.
   
4. Requires DHCS to develop rates of reimbursement for services provided by a community paramedicine program, triage to alternate destination program, or mobile integrated health program and makes these services a covered benefit under Medi-Cal.
   
5. Defines “mobile integrated health program” as a fire department-based team of licensed health care practitioners, operating within their scope of practice, who provide mobile health services to support the EMS system.
   

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, programs like community paramedicine, alternate destination triage, and mobile integrated health are critical for fire departments to deliver proper healthcare. However, with the lack of health insurance reimbursements, there is no clear path for these programs – leading to more reliance on emergency rooms for patients requiring mental health intervention or a sobering center. Sobering centers and mental health facilities offer a cost-effective solution and provide a monitored environment for individuals to receive treatment. These locations offer specialized alternatives to hospitalization while providing resources to treat substance use disorders and mental health crises. The implementation of these programs has already resulted in decreases in hospital readmissions, follow-up transports, and emergency room overcrowding – a proven method for also decreasing healthcare costs and improving treatment outcomes. Despite the willingness of fire departments to develop these programs, many are limited by the lack of financial resources available to support them. This bill will ensure that fire departments are able to recover necessary costs for services provided outside of the traditional EMS system, particularly for our homeless population and individuals with the most acute needs.
   
2. Medi-Cal Community-Based Mobile Crisis Intervention. Community-based mobile crisis intervention services (“mobile crisis services”) provide rapid response, individual assessment and community-based stabilization to Medi-Cal beneficiaries who are experiencing a mental health and/or substance use disorder (“behavioral health”) crisis. Mobile crisis services are designed to provide relief to beneficiaries experiencing a behavioral health crisis, including through de-escalation and stabilization techniques; reducing the immediate risk of danger and subsequent harm; and, avoiding unnecessary emergency department care, psychiatric inpatient hospitalizations, and law enforcement involvement. Mobile crisis services include warm handoffs to appropriate settings and providers when the beneficiary requires additional stabilization and/or treatment services; coordination with and referrals to appropriate health, social, and other services and supports; and, short-term follow-up support to help ensure the crisis is resolved and the beneficiary is connected to ongoing care. Mobile crisis services are directed toward the beneficiary in crisis, but may include contact with family members or other significant support collaterals if the purpose of the collateral’s participation is to assist the beneficiary in addressing their behavioral health crisis and restoring the beneficiary to the highest possible functional level. Mobile crisis services are provided by a multidisciplinary team at the location where the individual is experiencing the behavioral health crisis. Locations may include the individual’s home, school or workplace; on the street; or, where an individual socializes. Mobile crisis services cannot be provided in hospitals or other facility settings, and must be available 24 hours a day, seven days a week, and 365 days a year. Emergency medical technicians, advanced emergency medical technicians, paramedics, and community paramedics are included as mobile crisis team members as long as they are licensed, certified, and/or accredited. Reimbursement of rehabilitative mental health and targeted case management services provided by eligible private providers is limited to the lower of the provider’s reasonable and allowable cost, as determined in the Centers for Medicare and Medicaid Services (CMS)-reviewed State-developed cost report, or usual and customary charge for the type of service provided for the reporting period. Reimbursement of rehabilitative mental health and targeted case management services provided by county owned and operated providers and county owned and operated hospital-based providers will be based upon the provider’s certified public expenditures pursuant to federal regulations.
   
3. State regulated health insurance coverage requirements. Under recent legislation, health plans and insurers are required to cover behavioral health crisis services provided by a 988 center, mobile crisis team, or other provider of behavioral health crisis services regardless of whether the services are provided by an in-network or out-of-network provider or facility. Plans and insurers are required to cover all items and services that are eligible for coverage under the Medi-Cal program. Additionally, plans and insurers are required to pay noncontracting and contracting ground ambulance providers for covered emergency and nonemergency services. Enrollees and insureds are required to pay the in-network cost-sharing and the provider may not advance to collections any amount greater than the in-network cost-sharing.
   
4. California Health Benefits Review Program (CHBRP) report. 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 this bill. Key findings include:
   1. Background. CHBRP indicates EMS alternative models of care may be developed and led by EMS agencies, fire departments, hospitals or health systems, insurers, or independent companies and the services may be targeted to vulnerable populations such as seniors, individuals with chronic conditions, underserved communities, or those who frequently use emergency services. EMSA provides guidance on training and curriculum for program specialties, such as hospice, mental health and substance use. Since 2015, California has begun some trials of these expanded community models of EMS, through a number of pilot projects across the state. Of the 20 pilot projects, five remain operational: one community paramedicine, and four triage to alternate destination (see table below). In addition, CHBRP is aware of two mobile integrated health programs. These programs pair a firefighter/paramedic with a nurse practitioner or physician assistant to help frequent 911 callers with non-emergency issues. The teams assess, treat, and release patients in the field without the need for ambulance transport or an ED visit, and the LA program may also transport patients to alternate destinations. CHBRP indicates all of these program types are funded by grants, public EMS or city/county governmental agencies, or private EMS agencies (and other health care partner organizations) not through payments from plans or Medi-Cal. CHBRP is not aware of any health plans that currently pay for services provided by existing programs. CHBRP also notes that this bill defines mobile integrated health more narrowly than the published literature. There are some instances in the CHBRP report, particularly where there is published literature on mobile integrated health programs, where CHBRP relies on the broader definition used in the field.
      

Source: CHBRP, 2024

• 1. Medical effectiveness. CHBRP found limited evidence that community paramedicine, triage to alternate destinations, and mobile integrated health programs are safe and effective; and, insufficient evidence that the programs impact clinical outcomes. Specifically:
     1. There is a preponderance of evidence from 15 studies that, for patients who frequently use EMS services, community paramedicine and mobile integrated health programs are effective at reducing hospitalizations and avoidable ED visits.
     2. There is limited evidence based on two evaluation studies of pilot projects in California that triage to alternate destination programs can safely and appropriately identify patients with behavioral health concerns for triage to an alternate mental health destination.
     3. There is limited evidence based on one evaluation study of pilot projects in California, that patients who are acutely intoxicated but do not have acute medical or mental health needs can be safely and appropriately identified by triage to alternate destinations programs and then triaged to sobering centers.
     4. There is insufficient evidence that, for patients who frequently use EMS services, community paramedicine and mobile integrated health programs are effective at improving clinical outcomes.
     5. There is limited evidence from four studies that a community paramedicine or mobile integrated health program with short-term follow-up for patients recently discharged from the hospital due to a chronic condition (e.g. heart failure) can improve post-hospital discharge outcomes.
     6. There is limited evidence from two studies that a community paramedicine or mobile integrated health program with short-term follow-up for patients recently discharged from the hospital can increase primary care visits.
        
  2. Utilization. CHBRP estimates no significant utilization increase in the short term. CHBRP notes that the availability of these programs will likely remain low. Existing programs are reliant on other funding, and to be reimbursed the programs will need to identify reimbursement codes and develop contracts with health plans and policies to establish services and reimbursement rates.
     
  3. Impact on expenditures. CHBRP estimates no measurable fiscal impact.
     
  4. Public health. CHBRP estimates no measurable impact on public health due to no measurable change in utilization in the first 12 months post mandate and insufficient evidence on clinical outcomes.
     
  5. Other states. In 14 states (Arizona, Colorado, Georgia, Idaho, Maine, Michigan, Minnesota, Nevada, North Carolina, Oregon, Texas, Utah, Wisconsin, and Wyoming), Medicaid reimburses for treatment without transport on 911 calls. In seven states (Arizona, Georgia, Indiana, Minnesota, Nevada, North Dakota, and Wyoming), Medicaid reimburses community paramedicine services. In 12 states (Colorado, Connecticut, Kentucky, Maine, Michigan, Missouri, New Hampshire, New York, Ohio, Texas, Virginia, and Wisconsin), only commercial health plans reimburse community paramedicine services. In four states (Georgia, Indiana, Minnesota, and Nevada), both Medicaid and commercial health plans reimburse CP services.
  6. Medicare. Medicare does not pay for ambulance responses to calls for service that do not result in a patient transport. In 2021, CMS introduced the Emergency Triage, Treat, and Transport Model, which offered reimbursement to providers for: (1) treatment in place by a qualified EMS crew or by telehealth; and (2) ambulance transport to alternative destinations. However, by December 2023, the program was terminated by CMS due to lower-than-expected program participation. Subsequently, federal legislation S. 3236 ‘‘Emergency Medical Services Reimbursement for On-Scene Care and Support Act’’ was introduced in November 2023 allowing Medicare coverage of ambulance services that do not include transportation.

1. Prior legislation. AB 767, (Gibson, Chapter 270, Statutes of 2023) extends the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031, and adds short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program.
   

AB 716 (Boerner, Chapter 454, Statutes of 2023) limits the amount a health plan enrollee, insured, or uninsured person who receives services from a ground ambulance provider has to pay for services, prohibits the ground ambulance provider from billing more than a specified amount, and requires the health plan or insurer to directly reimburse a ground ambulance provider according to established or approved amounts, as specified.

AB 118 (Committee on Budget, Chapter 42, Statutes of 2023). One of many provisions in this health budget trailer bill is an amendment to the health insurance mandate related to behavioral health crisis and 998 centers. Specifically, the trailer bill revises existing law to require coverage of mental health and substance use disorder treatment provided by a 988 center, mobile crisis team, or other provide of behavioral health crisis services. At a minimum, all items and services must be covered that are covered under the Medi-Cal program. The trailer bill requires payment for behavioral health crisis stabilization unless it is reasonably determined that services were never performed. The trailer bill allows for prior authorization that complies with existing law, but also requires actions to be taken after stabilization for the plan to respond to a provider requesting authorization, and to transfer the care to another provider after stabilization.

AB 988 (Bauer-Kahan, Chapter 747, Statutes of 2022) establishes requirements associated with 988 suicide and behavioral health crisis assistance, including requiring health plan and insurer coverage of 988 center services when medically necessary and without prior authorization.

AB 1544 (Gipson and Gloria, Chapter 138, Statutes of 2020) enacts the Community Paramedicine or Triage to Alternate Destination Act of 2019, which permits LEMSAs, with approval by the EMSA, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: (1) providing directly observed tuberculosis therapy; (2) providing case management services to frequent emergency medical services users; (3) providing hospice services to treat patients in their homes; and, (4) providing patients with transport to an alternate destination, which can either be an authorized mental health facility, or an authorized sobering center. This bill sunsets the provisions on January 1, 2024.

1. Support. The California Professional Firefighters (CPF), state council of the International Association of Fire Fighters is the sponsor of this bill and writes the healthcare needs of Californians have changed dramatically in recent years, compounded by the COVID-19 pandemic as well as the behavioral health and homelessness crises. Many people now rely on both emergency medical care and the emergency department of the hospital for their primary medical care, resulting in overcrowding and long delays that lead to impacts across the emergency system. In order to manage these needs new paradigms of medical care have developed in order to divert cases from the emergency department that can be effectively treated elsewhere, as well as connecting patients with needed services to reduce hospital readmissions and future 911 calls. Fire departments throughout California have been at the forefront of these efforts, piloting and implementing community paramedicine and triage to alternate destination programs as well as developing mobile integrated health units to meet their community members where they are needed. However, despite the willingness of departments to develop programs that are well suited to the needs of their communities, many are limited by the lack of resources available to support them. As public agencies, fire departments often work with strictly defined budgets leaving little room for programs that are not sustainable. In order to ensure that current programs are continued and departments that have not yet established programs are able to do so, departments must be able to seek cost-sharing reimbursement for the services that are provided by community paramedicine, triage to alternate destination, or mobile integrated healthcare programs. Under current law, departments may not seek reimbursement for the cost of community paramedicine services or triage to alternate destination transports, as they are not considered emergency services. As a result, such programs must either operate at a loss or rely on limited-term grant funding that is not guaranteed to continue.
   
2. Opposition. The Emergency Medical Service Administrators Association of California (EMSAAC) writes to express concerns related to the bill’s definition of “mobile integrated health program” as it would exclude reimbursement for these service provided by non-fire department-based entities (i.e., fire districts, other public EMS providers, hospital based EMS providers, and private EMS providers). EMSAAC believes reasonable reimbursement should be available to all applicable/approved EMS system providers. The California Association of Health Plans, Association of California Life and Health Insurance Companies, and America’s Health Insurance Plans write to oppose this bill because it is one of 14 health insurance mandate bills that will increase costs, reduce choice and competition, and further incent some employers and individuals to avoid state regulation by seeking alternative coverage options. Benefit mandates impose a one-size-fits-all approach to medical care and benefit design driven by the legislature rather than consumer choice. These bills will lead to higher premiums, harming affordability and access for small businesses and individual market consumers. These opponents urge legislators to also consider the cumulative impacts of these mandates on premiums and access to coverage. All of these bills will increase costs and limit employer flexibility. The legislature created the Office of Health Care Affordability to contain cost drivers. With this office in place and the state budget deficit, the legislature should take a wait-and-see approach when considering costly mandates. The health plans have continued to be engaged and look forward to the work ahead.
   
3. Amendments. It may be premature to establish a mandate on plans to cover services provided under five to seven programs that are not available statewide and serve a limited number of communities in California. The bill should be amended to require plans and insurers to establish a process to reimburse covered services by these programs.

SUPPORT AND OPPOSITION:

Support: California Professional Firefights (sponsor)

California Agents & Health Insurance Professionals

California Life Sciences

Oppose: America’s Health Insurance plans

Association of California Life & Health Insurance Companies

California Association of Health Plans

Emergency Medical Service Administrators Association of California (unless amended)

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