California

A CITIZEN’S GUIDE TO PARTICIPATION
CPT Codes being used by Minnesota
http://uslca.org/wp-content/uploads/2013/02/CPT_Codes.pdf
98960 Education And Training For Patient Self-Management By A Qualified, Nonphysician 

Health Care Professional Using A Standardized Curriculum, Face-To-Face With The
Patient (Could Include Caregiver/Family) Each 30 Minutes; Individual Patient (Rate: $19.44/30min /patient )

98961 Education And Training For Patient Self-Management By A Qualified, Nonphysician
Health Care Professional Using A Standardized Curriculum, Face-To-Face With The
Patient (Could Include Caregiver/Family) Each 30 Minutes; 2-4 Patients( Rate $9.60/30min/patient)
98962 Education And Training For Patient Self-Management By A Qualified, Nonphysician
Health Care Professional Using A Standardized Curriculum, Face-To-Face With The
Patient (Could Include Caregiver/Family) Each 30 Minutes; 5-8 Patients ( Rate $6.56/30min/patient)

HHS Organizational Chart

Director of Government Affairs

Sarah de Guia is a graduate of Santa Clara University School of Law, where she was awarded the 2011 Student Award for Social Justice and was the 2010 recipient of the Herman Wildman Social Justice Writing Award. She earned her Bachelor of Arts from the University of California, Berkeley in Ethnic Studies and Public Policy in 1999.

Sarah previously worked with CPEHN in 2008 as Project Manager for the Having Our Say Coalition, where she organized the statewide coalition to advocate on behalf of communities of color for health care reform. Sarah has also served as the Health Program Manager for Latino Issues Forum and as Legislative Analyst for the Mexican American Legal Defense and Educational Fund. Sarah has advocated on women’s health and reproductive justice, language access, immigrants’ rights, and expanding health care to communities of color through legislative, budgetary and regulatory processes.

– See more at: http://cpehn.org/about/staff#sthash.g0qnCHEp.dpuf

California SB 1322 ( Hernandez) 
 RAMPlogo_CMYK

Dear advocates,

Thanks for your continued interest in the CMS preventive services rule that would broaden the range of providers (both licensed and non-licensed) that can be reimbursed for providing preventive services here in California. (If you need a refresher about the rule and its implications for asthma, check out this helpful one pager.) I’m writing with a brief update on our collective work to make this rule a reality for Medi-Cal and the populations it serves.

The latest news

Over the last few months, the most timely and pressing question was whether or not legislation would be an effective vehicle for rule implementation. State Senator Hernandez authored legislative “spot language” that would have authorized the Department of Health Care Services (DHCS) to move forward with a State Plan Amendment; such an amendment is a required step to put the rule into practice. After consultation with a variety of stakeholders, the Senator decided to pull the bill, anticipating that it would have attracted more controversy than support.

Frankly, the decision wasn’t a surprise. Over the last few years the legislature has seen some rather bruising battles related to scope of practice within California’s medical system. While the bill as originally envisioned would not have addressed scope of practice (rather, it simply would have authorized DHCS to figure it out), the sense among stakeholders is that it would have been perceived as such.

While the legislative option is off the table for now, the overall prospects for implementing the rule remain the same. Now it’s simply more likely implementation will happen through more administrative means by working directly with DHCS.

What comes next?

We’re pursuing three different albeit interconnected approaches:

1.       Clarifying preventive services: Since the rule doesn’t change the definition of preventive services – just who can provide them – we want to be really clear about the types of preventive services provided here in California. Over the next month or so RAMP along with some of our allies will dig deeper into the issue to see what definitions are already on the books as well as what services are particularly relevant to asthma and other chronic health conditions. Our hope is that developing a list will keep the conversation moving and help gain some traction with the state.

2.       Engaging DHCS: While we had an initial and positive conversation with DHCS staff, we have more work to do in this area. Our colleagues at First Five and the Statewide Screening Collaborative that have been active on the rule are also interested in talking with DHCS. We hope to meet with some of the agency’s leadership in June.

3.       Continuing to engage other stakeholders and processes: Implementing the rule will continue to be a collaborative effort, so as before we’re reaching out to other groups that likely connections to this rule. For example, I recently spoke at a meeting of the CA Health Workforce Alliance/CA Health Professions Consortium. Among other things, advocates there have been working on strengthening the Community Health Worker workforce in California. Similarly, there are efforts underway as part of Medi-Cal’s “Health Home” pilot projects to better delineate the roles of CHWs in the provision of care. Since CHWs are one of the groups that may benefit from the adoption of this rule, we hope the lessons being learned in these other processes can inform rule implementation.

Can you help?

The short answer is, “Yes, absolutely!”

First, at some point soon we’ll circle back to you with what we’ve learned while taking a closer look at the definition of preventive services here in California. We’d appreciate your feedback – particularly from those of you directly involved in direct patient care – as the definition will help frame exactly how the rule is implemented. Second, if you hear of other groups that have expressed interest in the rule or are already working on it, don’t hesitate to connect us. Working on this in a coordinated fashion is particularly important given the complexity of the rule and the Medi-Cal system.

As always, we appreciate your support. Do let me know if you have any questions or information to share. We’ll be in touch again soon.

All the best,

Joel

Joel Ervice

Associate Director Regional Asthma Management & Prevention (RAMP); Project of the Public Health Institute;180 Grand Ave., Suite 750; Oakland, CA 94612; Phone: 510-302-3316; Fax: 510-451-8606; joel@rampasthma.org; www.rampasthma.org

Working together to reduce the burden of asthma

 

 

 

Have You Heard the News?

CMS’s Final Rule Expands Reimbursement for Preventive Services

Medicaid Will Allow Reimbursement for
Community Health Worker Preventive Services!

Community Health Worker (CHW) Health Disparities Initiative partners — have you heard about the CMS ruling announced last month? The Centers for Medicare and Medicaid Services (CMS) created a new rule which allows state Medicaid agencies to reimburse for preventive services provided by professionals that may fall outside of a state’s clinical licensure system, as long as the services have been initially recommended by a physician or other licensed practitioner. The new rule for the first time offers state Medicaid agencies the option to reimburse for more community-based preventive services, including those of CHWs. The rule goes into effect on January 1, 2014.

The announcement of the CMS ruling marked a wonderful moment in time, providing a new opportunity to recognize and advance the role of CHWs! We encourage you to begin discussions with your own national, state and local networks to see how you can contribute to the conversation about reimbursement for preventive services provided by CHWs in your state. Please see below for the actual ruling and links to the relevant sections.

The new rule now states,

“(c) Preventive services means services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice under State law to—

  1. Prevent disease, disability, and other health conditions or their progression;
  2. Prolong life; and
  3. Promote physical and mental health and efficiency.”

The citation for the ruling is:

Medicaid and children’s health insurance programs: essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeal processes, premiums and cost sharing, exchanges: eligibility and enrollment; final rule. Centers for Medicare & Medicaid Services. 78 Fed Reg 42160 (July 15, 2013). The relevant section is, “a. Diagnostic, Screening, Preventive, and Rehabilitative Services (Preventive Services) (§ 440.130)” (paragraph citation: 78 FR 42226)

The rule can be found here: http://www.ofr.gov/OFRUpload/OFRData/2013-16271_PI.pdf

To visit the CHW Health Disparities Initiative website:
http://www.nhlbi.nih.gov/health/healthdisp


 

 

SB 1322 ( Hernandez) Amended April 2014 

California Health Care Quality Improvement and Cost Containment
Commission.

Comisión de contención de calidad asistencial del Cuidado de Salud  de
California

http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB1322

http://www.legtrack.com/bill.html?bill=201320140SB1322

Summary

Existing law establishes health care coverage programs to provide
health care to segments of the population meeting specified criteria who
are otherwise unable to afford health care coverage and provides for the
licensure and regulation of health insurers and health care service
plans.

This bill would state the intent of the Legislature to make available
valid performance information to encourage health care providers and
facilities to provide care that is safe, medically effective,
patient-centered, timely, efficient, and equitable. The bill would
require the Governor to convene the California Health Care Quality
Improvement and Cost Containment Commission and would specify the
composition of the commission. The bill would require the commission to
examine and address specified health care issues. The bill would require
the commission to issue a report to the Legislature and the Governor, on
or before July 1, 2015, or within 6 months of the commission being
convened, whichever occurs later, making recommendations for health care
quality improvement and cost containment. The bill would provide that
the commission not be convened until sufficient private or federal funds
have been received and appropriated for that purpose.

Dicen que tal vez el proximo ano  se trate otra vez.

 

CALIFORNIA LEGISLATURE— 2013–2014 REGULAR SESSION

 

SENATE BILL No. 1322

 

Introduced by Senator Hernandez
February 21, 2014

 

An act to add Section 14132.04 to the Welfare and Institutions Code, relating to Medi-Cal. Sections 127670 and 127671 to the Health and Safety Code, relating to health care.



SB 1322, as amended, Hernandez. Medi-Cal: preventive services: providers. California Health Care Quality Improvement and Cost Containment Commission.
Existing law establishes health care coverage programs to provide health care to segments of the population meeting specified criteria who are otherwise unable to afford health care coverage and provides for the licensure and regulation of health insurers and health care service plans.
This bill would state the intent of the Legislature to make available valid performance information to encourage health care providers and facilities to provide care that is safe, medically effective, patient-centered, timely, efficient, and equitable. The bill would require the Governor to convene the California Health Care Quality Improvement and Cost Containment Commission and would specify the composition of the commission. The bill would require the commission to examine and address specified health care issues. The bill would require the commission to issue a report to the Legislature and the Governor, on or before July 1, 2015, or within 6 months of the commission being convened, whichever occurs later, making recommendations for health care quality improvement and cost containment. The bill would provide that the commission not be convened until sufficient private or federal funds have been received and appropriated for that purpose.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides for a schedule of benefits under the Medi-Cal program, which includes specified preventive services.

This bill would require the department to reimburse Medi-Cal providers for, and would require Medi-Cal managed care plans to cover, preventive services provided by a health care practitioner not subject to professional licensure by the state, that have been recommended by a physician or other licensed practitioner of healing arts acting within the scope of that physician’s or practitioner’s license. The bill would provide that this coverage is available only to the extent that federal financial participation in the cost of providing these services is available. The bill would require the department to convene a working group, as specified, to determine the types of health care practitioners eligible to provide preventive services pursuant to these provisions and to develop a summary of practitioner qualifications for those practitioners to be included in any state plan amendment necessary to implement these provisions.

DIGEST KEY

Vote: majority   Appropriation: no   Fiscal Committee: yes   Local Program: no


BILL TEXT

THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1.

Section 127670 is added to the Health and Safety Code, to be added to Chapter 8 (formerly commencing with Section 127670) of Part 2 of Division 107, to read:

 

127670.

(a) It is the intent of the Legislature to make available valid performance information to encourage health care providers and facilities to provide care that is safe, medically effective, patient-centered, timely, efficient, and equitable. It is also the intent of the Legislature to put provider performance information into the hands of consumers and purchasers so that they are able to understand their financial liability and find the best quality and value.

(b) It is the intent of the Legislature to encourage health care service plans, health insurers, and providers to develop innovative approaches, services, and programs that may have the potential to deliver health care that is both cost effective and responsive to the needs of enrollees.

 

SEC. 2.

Section 127671 is added to the Health and Safety Code, to be added to Chapter 8 (formerly commencing with Section 127670) of Part 2 of Division 107, to read:

 

127671.

(a) The Governor shall convene the California Health Care Quality Improvement and Cost Containment Commission to research and recommend appropriate and timely strategies for promoting high-quality care and containing health care costs.

(b) The commission shall be composed of 13 members who are knowledgeable about the health care system and health care spending.
(c) The Governor shall appoint five members of the commission, the Senate Committee on Rules shall appoint three members, and the Speaker of the Assembly shall appoint three members. The membership shall be comprised of at least one of each of the following:
(1) A representative of California’s business community.
(2) A representative from organized labor.
(3) A representative of consumers.
(4) A health care practitioner.
(5) A hospital industry representative.
(6) A representative of the health insurance industry.
(7) A representative of the legal community with expertise in health and ethics.
(8) A representative of persons with disabilities.
(9) A health care economist.
(d) The Secretary of the California Health and Human Services Agency and the Executive Director of Covered California shall serve as members of the commission.
(e) The Governor shall appoint the chairperson of the commission.
(f) The commission shall, on or before July 1, 2015, or within six months of the convening of the commission, whichever occurs later, issue a report to the Legislature and the Governor making recommendations for health care quality improvement and cost containment. The commission shall, at a minimum, examine and address the following issues:
(1) Assessing California health care needs and available resources.
(2) Containing the cost of health care services and coverage.
(3) Improving the quality of health care.
(4) Increasing the transparency of health care costs and the relative efficiency with which care is delivered.
(5) Use of disease management, wellness, prevention, and other innovative programs to keep people healthy while reducing costs and improving health outcomes.
(6) Consolidation of existing state programs to achieve efficiencies where possible.
(7) Efficient utilization of prescription drugs and technology.
(g) The commission established pursuant to this section shall not be convened until sufficient private or federal funds have been received and appropriated for that purpose.

 

SECTION 1.(a)The Legislature finds and declares both of the following:

(1)Research suggests that 50 percent of a physician’s time is spent providing preventive care and screenings, much of which can be provided by other health care practitioners.

(2)On July 15, 2013, the Centers for Medicare and Medicaid Services released an update to federal Medicaid regulations that permits state Medicaid programs to reimburse for preventive services recommended by a physician or other licensed health care practitioner.

(b)It is the intent of the Legislature in enacting this act to maximize federal funds to provide critical preventive services to Medi-Cal beneficiaries by amending state law to reflect the July 15, 2013, update to federal Medicaid regulations.

SEC. 2.Section 14132.04 is added to the Welfare and Institutions Code, to read:

14132.04.(a)(1)The department shall reimburse Medi-Cal providers for preventive services, as defined in Section 440.130(c) of Title 42 of the Code of Federal Regulations, provided by a health care practitioner not subject to professional licensure by the state, including, but not limited to, a community health worker, that have been recommended by a physician or other licensed practitioner of healing arts acting within the scope of that physician’s or practitioner’s license.

(2)Medi-Cal managed care plans shall cover preventive services, as defined in Section 440.130(c) of Title 42 of the Code of Federal Regulations, provided by a health care practitioner not subject to professional licensure by the state, including, but not limited to, a community health worker, that have been recommended by a physician or other licensed practitioner of healing arts acting within the scope of that physician’s or practitioner’s license.

(3)Coverage for preventive services pursuant to this section shall be available only to the extent that federal financial participation in the cost of providing these services is available.

(b)By June 30, 2015, the department shall convene a working group to determine the types of health care practitioners eligible to provide preventive services pursuant to this section and the summary of qualifications for those practitioners to be included in any state plan amendment that may be necessary to implement this section. The working group shall include representatives from consumer advocacy groups, community health worker organizations, community clinics, physicians’ groups, and health plans. The summary of practitioner qualifications shall reflect widely supported perspectives.

 

_______________________________________________________________________________________________________

ORIGINAL 

SB1322 ( Hernandez Fact Sheet)  

SB 1322 ( Hernandez) Medi-Cal: Preventive services: Providers.

An act to add Section 14132.04 to the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 1322, as introduced, Hernandez. Medi-Cal: preventive services: providers.

Existing law provides for the Medi-Cal program, which is  administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides for a schedule of benefits under the Medi-Cal program, which includes specified preventive services.

This bill would require the department to reimburse Medi-Cal providers for, and would require Medi-Cal managed care plans to cover, preventive services provided by a health care practitioner not subject to professional licensure by the state, that have been recommended by a physician or other licensed practitioner of healing arts acting within the scope of that physician’s or practitioner’s license.

The bill would provide that this coverage is available only to the extent that federal financial participation in the cost of providing these services is available.

The bill would require the department to convene a working group, as specified, to determine the types of health care practitioners eligible to provide preventive services pursuant to these provisions and to develop a summary of practitioner qualifications for those practitioners to be included in any state plan amendment necessary to implement these provisions.

Vote: majority. Appropriation: no. Fiscal committee: yes.  State-mandated local program: no.

THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1. (a) The Legislature finds and declares both of the following:

(1) Research suggests that 50 percent of a physician’s time is spent providing preventive care and screenings, much of which can be provided by other health care practitioners.

(2) On July 15, 2013, the Centers for Medicare and Medicaid  Services released an update to federal Medicaid regulations that permits state Medicaid programs to reimburse for preventive services recommended by a physician or other licensed health care practitioner.

(b) It is the intent of the Legislature in enacting this act to maximize federal funds to provide critical preventive services to Medi-Cal beneficiaries by amending state law to reflect the July 15, 2013, update to federal Medicaid regulations.

SEC. 2. Section 14132.04 is added to the Welfare and Institutions

Code, to read:

14132.04. (a) (1) The department shall reimburse Medi-Cal providers for preventive services, as defined in Section 440.130(c) of Title 42 of the Code of Federal Regulations, provided by a health care practitioner not subject to professional licensure by the state, including, but not limited to, a community health worker, that have been recommended by a physician or other licensed practitioner of healing arts acting within the scope of that physician’s or practitioner’s license.

(2) Medi-Cal managed care plans shall cover preventive services, as defined in Section 440.130(c) of Title 42 of the Code of Federal  Regulations, provided by a health care practitioner not subject to professional licensure by the state, including, but not limited to, a community health worker, that have been recommended by a physician or other licensed practitioner of healing arts acting within the scope of that physician’s or practitioner’s license. 

(3) Coverage for preventive services pursuant to this section shall be available only to the extent that federal financial participation in the cost of providing these services is available.  (b) By June 30, 2015, the department shall convene a working group to determine the types of health care practitioners eligible to provide preventive services pursuant to this section and the summary of qualifications for those practitioners to be included in any state  plan amendment that may be necessary to implement this section.

The working group shall include representatives from consumer advocacy groups, community health worker organizations, community clinics, physicians’ groups, and health plans. The summary of practitioner qualifications shall reflect widely supported perspectives.

 

Author:   Sarah de Guia, JD

Director of Government Affairs
Sarah de Guia is a graduate of Santa Clara University School of Law, where she was awarded the 2011 Student Award for Social Justice and was the 2010 recipient of the Herman Wildman Social Justice Writing Award. She earned her Bachelor of Arts from the University of California, Berkeley in Ethnic Studies and Public Policy in 1999.

– See more at: http://cpehn.org/about/staff#sthash.6q7hxXqM.dpuf
RAMP
Regional Asthma Management and Prevention

Joel Ervice

The Regional Asthma Management and Prevention (RAMP) program is a collaborative that promotes strategies for reducing asthma through a broad and comprehensive approach that includes clinical management and environmental protection. RAMP brings together diverse partners such as public health and community-based organizations, schools, medical providers, and environmental health and justice groups to join forces in reducing the burden of asthma with a focus on communities inequitably affected by the disease.