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SACRAMENTO, CALIF (CDCAN) [Updated 07/07/2010 06:00 PM (Pacific Time)] – The Department of Health Care Services, the state agency that oversees the State’s Medi-Cal program, announced officially today on its Medi-Cal website, the reinstatement of the adult Medi-Cal optometry benefit that was previously eliminated as of July 1, 2009. The optometry benefit for adults was restored in order to comply with federal law which specifically prohibited states from eliminating that benefit under certain conditions.

There is no change in the status however for the other 8 adult Medi-Cal “optional benefits” that were also eliminated for adults (with some exceptions) as of July 1, 2009, however remain eliminated. Children in the Medi-Cal program and certain adults, including those in most long term care facilities, were exempted from the elimination of the 9 Medi-Cal “optional benefits”.

The Medi-Cal optometry optional benefit, according to Department of Health Care Services estimates, was used by over 731,000 adults. The figure does not include the numbers of adults who would have used this Medi-Cal optional benefit in Medi-Cal managed health care plans or children who were not impacted directly by the by elimination of the optional benefits last year.

The benefit is called “optional” because the federal government does not require the states to provide that specific service and several others as part of their Medicaid program (called “Medi-Cal” in California ).

System Changes To Be Implemented July 26 To Reinstate Optometry Benefit

· The July 7, 2010 announcement stated that necessary “system changes” will be implemented on July 26, 2010 “to reinstate optometry services as a covered benefit for adult beneficiaries under the Medi-Cal program.”

· Those previously eliminated optometry services for adults that are reinstated include, according to the Department of Health Care Services, “…diagnostic, ancillary and supplemental procedures used for the evaluation of the visual system.”

· The Department of Health Care Services, in its announcement, state that some optometry services would remain eliminated or with limited exceptions, noting that “…Current Optional Benefit Exclusion policy involving services relating to eyeglasses and other eye appliances will remain unchanged with the reinstatement of optometry services, with the exception of bandaged contact lenses HCPCS code V2599, which will be covered for eligible beneficiaries based on Medi-Cal necessity”

· The Department of Health Services in its announcement today referred to a now outdated 5 page section from its Medi-Cal Vision Manual, for the complete list of the restored optometry services. Even though the 5 page section (attached to this CDCAN Report and also available on the CDCAN website at www.cdcan.us ) is outdated – it still mentions persons who are excluded from the covered optometry benefits – it does list the services that are now reinstated.

Federal Law Required Reinstatement

The federal law cited by the Schwarzenegger Administration as the reason for the restoration of the optometry benefit for adults was 42 USC Section 1396d(e), prohibits the elimination specifically of the optometry service if physicians could still provide the services and the State previously funded these services. This reinstatement does not apply to the other 8 optional benefits that were eliminated for adults as of July 1, 2009.

It is not clear if the State is liable for any costs incurred by adults in the Medi-Cal program who were forced to seek other optometry services after July 1, 2009, if in fact the State was not in compliance with federal law by eliminating that specific benefit.

It is not clear when the Schwarzenegger Administration was informed of the federal law that prohibited the elimination of the Medi-Cal optometry optional benefit for adults or the impact on people who lost this services since July 1, 2009 or when the Legislature was specifically informed of the restoration.

The issue of the eliminated Medi-Cal optional benefits was one of the issues raised March 24 by the Assembly Budget Subcommittee #1 on Health and Human Services in their marathon informational hearing (“Toll on Californians on Enacted and Proposed Health and Human Services Budget Cuts”) on the impact of various health and human services budget cuts resulting from the 2009-2010 State Budget.

The Schwarzenegger Administration indicated at the Assembly Budget Subcommittee hearing on May 27th that while it is reinstating the optometry benefit for adults as required by federal law, it will continue to explore ways to see if the elimination of that benefit could be allowed.

There was no indication mentioned or raised by the Assembly subcommittee then on how the Department of Health Care Services would move to restore the optometry benefit for adults and how and when Medi-Cal recipients and Medi-Cal providers who provide this service would be notified.

Official Announcement of Reinstatement of Optometry Benefit for Adults

The following announcement was posted on the Department of Health Care Services’ Medi-Cal website page at:

http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_11608.asp

OPTOMETRY SERVICES REINSTATED AS MEDI-CAL COVERED BENEFIT

July 7, 2010

On July 1, 2009, the Department of Health Care Services (DHCS) excluded several optional benefits, including optometry services, from coverage for adult beneficiaries under the Medi-Cal program pursuant to Assembly Bill X3 5 (Chapter 20, Statutes of 2009-10, Third Extraordinary Session).

System changes will be implemented July 26, 2010 to reinstate optometry services as a covered benefit for adult beneficiaries under the Medi-Cal program. Optometry services include diagnostic, ancillary and supplemental procedures used for the evaluation of the visual system. Current Optional Benefit Exclusion policy involving services relating to eyeglasses and other eye appliances will remain unchanged with the reinstatement of optometry services, with the exception of bandaged contact lenses HCPCS code V2599, which will be covered for eligible beneficiaries based on Medi-Cal necessity.

For a list of optometry services now payable for adult beneficiaries under the Medi-Cal program, refer to the Rates: Maximum Reimbursement for Optometry Services section of the Medi-Cal Vision Care manual.

[CDCAN NOTE: See 5 page attachment referred to by the Department of Health Care Services in its announcement today, from the Medi-Cal Vision Care manual that lists those optometry benefits that were reinstated. That 5 page secton is dated June 2009, just before the elimination of the benefit for most adults in the Medi-Cal Program. The 5 page attachment refers to children in the Medi-Cal Program and certain adults who still qualified for the optometry benefit because they met certain conditions. The department referred to that attachment in today’s announcement for a complete list of what optometry services are reinstated for all adults in the Medi-Cal program, even though it still contains incorrect information about them being excluded] ]

Governor’s May Budget Revision Included Reinstatement of Benefit

As previously reported on June 3 (CDCAN Report #101-2010), the Governor’s budget revision released on May 14th included funding for the restoration of the previously eliminated Medi-Cal optometry optional benefit for adults in order to comply with federal law that specifically prohibits states from eliminating that benefit under certain conditions.

The Governor’s May 14th budget revision reported an adjustment to the Medi-Cal program budget due to the restoration of the Medi-Cal optometry optional benefit for adults, with an increase of $1.3 million in state general funds, to provide funding for that purpose.

Elimination of 9 Medi-Cal Benefits Passed as Part of 2009-2010 Budget

· As part of the 2009-2010 State Budget that was passed four months early in February 2009 (and revised in July 2009), 9 Medi-Cal “optional benefits” were eliminated for adults (the benefit remained for children and persons in nursing homes and intermediate care facilities for the developmentally disabled, and also exceptions for certain other people impacting more than 1 million adults across California.

· Adults with developmental disabilities served outside a nursing home or ICF/DD through regional center coordinated services could retain these benefits going through the regional centers as part of their Individual Program Plan).

Over 1 Million People in the Medi-Cal Program Impacted by the Elimination of the 9 Medi-Cal Optional Benefits

Below are the Medi-Cal optional benefits for adults that were eliminated as of July 1, 2009, with the numbers of people in the Medi-Cal “fee for service” program who accessed those services (the figures do not include persons who accessed these benefits in Medi-Cal managed health care plans, which would be higher). The numbers were provided by the Department of Health Care Services to the Assembly Budget Subcommittee #1 on Health and Human Services for its March 24th informational hearing on the impact of enacted and proposed budget cuts:

1. Acupuncture (use of small needles to treat pain and other problems) – 32,906 people impacted

2. Adult dental services – 932,114 people impacted

3. Audiology services (hearing exam) – 28,061 people impacted

4. Chiropractic services – 12,439 people impacted

5. Incontinence washes and creams – 65,591 people impacted

6. Optometry services/Dispensing Optician/Fabricating Optical Lab (eye exam and eye glasses) – 731,906 people impacted *** REINSTATED***

7. Podiatry services (care of the feet) – 85,129 people impacted

8. Psychology services – 4,970 people impacted

9. Speech therapy services – 1,593 people impacted

Reinstatement Raises Several Issues Regarding Notification, Possible Reimbursement and Other Issues

The reinstatement of the Medi-Cal optometry “optional benefit” for adults raises several issues that apparently have not yet been addressed either by the Schwarzenegger Administration or by the Legislature including

· Notices to Medi-Cal Adult Recipients – Except for the notice posted today (July 7th) on the Department of Health Care Services’ Medi-Cal Program website, there has not yet been any other official notice either to adults in the Medi-Cal program who lost the benefit, or to Medi-Cal providers who provided the optometry services. There is, as of today (July 7th), no “All County Letter” (or notice) to county welfare directors and other county agencies posted on the Department of Health Care Services website.

· Optometry Benefit Still Listed As Eliminated In Other Department Website Information – as of July 7, 2010, information about what Medi-Cal optional benefits were eliminated as of July 1, 2009, still lists, optometry benefits as one of the eliminated benefits. This includes information for Medi-Cal individuals on the following department webpages: http://www.dhcs.ca.gov/services/medi-cal/Pages/ReductionMedi-CalBenefits.aspx and http://www.dhcs.ca.gov/Pages/ChangeinCaliforniaStateLawforMedi-CalBenefits.aspx

· The issue of the reinstatement also has impact on other budget areas potentially, including regional center funded community-based services for 240,000 children and adults with developmental disabilities.

No Legislative Approval Was Needed To Reinstate Optometry Benefit

· The 2009-2010 State Budget included provisions that specified that the elimination of any of the 10 Medi-Cal optional benefits could be made (effective July 1, 2009) to the extent that federal law allowed it, so no approval to reinstate the optometry adult benefit is needed, since federal law does not allow it.

· With that provision, no change in State law was required to reinstate the optometry Medi-Cal optional benefit for adults (the eliminated 9 “optional benefits” applied only to adults and not to children or to persons living in long term care facilities and intermediate care facilities).

· The Assembly Budget Subcommittee #1 on Health and Human Services did hear the issue on May 27th, though the hearing agenda mentioned that no action actually was needed by either house.

· A lawsuit to block the elimination of the 10 Medi-Cal optional benefits for adults was filed in federal court last year by the Novato-based Medicaid Defense Fund headed by 82 year old attorney Lynn Carman, but was unsuccessful. That lawsuit was centered on the State’s compliance of the provisions of the federal American Recovery and Reinvestment Act (ARRA). The Medicaid Defense Fund was successful the year before in stopping many of the cuts to Medi-Cal providers, which the US Supreme Court is now considering an appeal by the State to take up the case.