SB 407
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Date of Hearing: June 23, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB 407 (Morrell) – As Amended June 17, 2015
SENATE VOTE: 36-0
SUBJECT: Comprehensive Perinatal Services Program: licensed midwives.
SUMMARY: Expands the definition of a comprehensive perinatal provider, as used in the
Comprehensive Perinatal Services Program (CPSP) for the purposes of reimbursement for MediCal services, to include a licensed midwife, and authorizes a health care provider to employ or
contract with a licensed midwife, as specified. Clarifies that this bill is not intended to expand or
revise the scope of practice of licensed midwives.
EXISTING LAW:
1) Establishes the Medi-Cal Program under the direction of the Department of Health Care
Services (DHCS) to provide qualifying individuals health care and a uniform schedule of
benefits, including comprehensive perinatal services.
2) Requires midwifery services provided by a licensed midwife to be covered under the Medi-
Cal program, to the extent that federal financial participation is available.
3) Establishes the CPSP under the direction of the Department of Public Health (DPH).
4) For the purposes of reimbursement for Medi-Cal services, defines a comprehensive perinatal
provider as any general practice physician, family practice physician, obstetriciangynecologist, pediatrician, certified nurse midwife (CNM), a physician group, as specified, or
any preferred provider organization or clinic enrolled in the Medi-Cal program and certified
pursuant to the standards of existing law.
5) Requires comprehensive perinatal providers to schedule visits with appropriate providers and
ensure the provision of specified services.
6) Authorizes a health care provider to employ or contract with specified medical practitioners
for the purpose of providing comprehensive perinatal services, including physicians, CNMs,
nurses, nurse practitioners, physician assistants, social workers, health and childbirth
educators, and registered dietiticians.
FISCAL EFFECT: According to the Senate Appropriations Committee, one-time costs, less
than $50,000, to revise existing regulations and develop a state plan amendment to allow
licensed midwives to provide services in the CPSP, under Medi-Cal (General Fund (GF) and
federal funds).
No significant impact to the utilization of services in Medi-Cal managed care (MCMC) is
anticipated. Under current law and practice, the services that are authorized under the CPSP are
required benefits for Medi-Cal managed care beneficiaries. Because those beneficiaries already
have access to those services through managed care, it is not likely that adding an additional
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authorized provider will increase the utilization of those services. (For example, if a licensed
midwife who is seeing a pregnant woman in MCMC wished to order a covered service, that
midwife could simply work with another eligible practitioner to order the services.)
Unknown potential increase in costs to provide services in fee-for-service (FFS) Medi-Cal (local
funds and federal funds). Under current practice, Medi-Cal beneficiaries in FFS can receive
CPSP services from their healthcare provider. In FFS, those costs are paid for with local funds
and federal matching funds. The state does not provide GF support for those costs. It is possible
that there could be an increase in the utilization of services under this bill, to the extent that
Medi-Cal beneficiaries are being provided care by a licensed midwife and it is not easy for that
provider to get another authorized provider to order the specified services. The extent to which
the fact that licensed midwives are not eligible to provide the specified services is actually a
barrier to women getting those services in not known, so it is difficult to estimate whether there
would actually be an increase is service utilization. This bill does not create a new program or
mandate a higher level of service (the legal test for whether a state mandate is reimbursable).
Therefore, it is not likely that the state would be required to reimburse counties for any increased
costs under the bill, even if utilization of services does increase.
COMMENTS:
1) PURPOSE OF THIS BILL. According to the author, studies have shown that women who
receive comprehensive childbirth, pre-natal health, and breastfeeding education services
during pregnancy have healthier pregnancies and less complicated births. The author
contends that expectant mothers of all income levels should have options when deciding
where and how their child is brought into the world, however existing law limits these
choices for low-income individuals by the exclusion of licensed midwives on the list of
eligible Medi-Cal providers for these services. The author states that increasing the number
of comprehensive perinatal Medi-Cal providers alleviates wait times and access issues within
the overall perinatal health delivery system, allowing women to receive timely and
personalized care. The author also contends that the authorization of licensed midwives as
comprehensive perinatal service providers will save the state financial resources. The author
maintains births at home or at birth centers with licensed midwives can save the state up to
80% when compared to the cost of a birth in a hospital. The author concludes that this bill
will expand health care access and choices to low-income, pregnant women, and drive down
the cost in the state health care system, while also ensuring safe, quality care for pregnancy
and childbirth.
2) BACKGROUND.
a) CPSP. The CPSP, under the direction of DPH, provides a wide range of services to
pregnant Medi-Cal beneficiaries, from conception through 60 days postpartum.
Beneficiaries receive enhanced nutrition, psychosocial, and health education services, in
addition to standard obstetric services under the program. The goals of the CPSP are to:
decrease the incidence of premature births; improve pregnancy outcomes; give every
baby a health start in life; and, lower health care costs by preventing catastrophic illness
in infants and children. According to DPH, there are over 1,500 Medi-Cal providers
approved to for the CPSP, in both FFS and MCMC. The CPSP is administered by
Federal Title V Maternal and Child Health block grant funds, Federal Title XIX Medicaid
funds, and the Maternal, Child, and Adolescent Health program.
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b) Midwifery. Existing law defines the practice of midwifery as the furthering or
undertaking by any licensed midwife to assist a woman in childbirth, as long as progress
of the birth meets criteria accepted as normal. Licensed midwives are authorized to
attend cases of normal pregnancy and childbirth, as defined by existing law, and provide
prenatal, intrapartum, and postpartum care, including family-planning care, for the
mother, and immediate care for the newborn. Midwives are not authorized to practice
medicine or perform surgery, and are not authorized to assist childbirths by any artificial,
forcible, or mechanical means. Licensed midwives are authorized to directly obtain
supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and
receive reports that are necessary to the practice of midwifery and consistent with his or
her scope of practice. As of December 31, 2014, there were 332 licensed midwives in
California.
CNMs are a different designation of the midwifery profession, licensed by the California
Board of Registered Nursing. CNMs are registered nurses who acquired additional
training in the field of obstetrics and are certified by the American College of Nurse
Midwives. These professionals commonly work in hospitals and birthing centers that are
licensed by the state. CNMs have an independent scope of practice and work in
collaboration and consultation with physicians, depending on the medical needs of the
individual woman or infant and the practice setting. Existing law requires nursemidwifery care to be performed under the supervision of a licensed physician and
surgeon, but supervision does not require physical presence of the physician. All
complications are referred to a physician immediately and CNMs provide emergency
care until physician assistance can be obtained. As of March 1, 2015, there were 1,136
CNMs in California.
3) SUPPORT. The California Association of Midwives, the sponsor of this bill, states there is
an increasing demand for prenatal care with midwives in birth centers, and that this bill will
allow more California mothers to receive care in safe, specialized settings. The sponsor
contends many rural and medically underserved communities have no health care providers
who accept CPSP, and licensed midwives are ready to fill this gap.
Supporters of this bill state allowing licensed midwives to offer comprehensive perinatal
services lowers state health care costs, and makes quality prenatal health care possible for a
larger portion of the state’s low-income pregnant women and their infants. Supporters also
contend that by increasing the number of maternity care providers who accept Medi-Cal, this
bill will help rural communities, where families on Medi-Cal have limited options for
maternity care. Supporters state this bill will make it easier for women to receive quality
prenatal care early in their pregnancy, resulting in better health outcomes for themselves and
their babies, at a lower cost to state taxpayers.
4) OPPOSITION. The American Congress of Obstetricians and Gynecologists, District IX
(California) is opposed unless amended to a prior version of this bill, stating that licensed
midwives do not have the qualifications to be a lead CPSP; however the organization has no
opposition to adding licensed midwives as a provider of comprehensive perinatal services.
The opposition writes it would remove its opposition if the language only added licensed
midwives as a provider of services in subsection (e) of this bill’s provisions, and deleted the
right to lead from subsection (a).
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5) RELATED LEGISLATION.
a) AB 1306 (Burke) removes the physician supervision requirement for CNMs allowing
them to manage a full range of primary health services, perform peripartum care, provide
emergency care when a physician is not present and perform and repair episiotomies in
all practice settings. AB 1306 is currently pending referral at the Senate Desk.
b) SB 408 (Morrell) establishes minimum training requirements and duties that may be
performed by a midwife assistant. SB 408 is currently in the Assembly Business and
Professions Committee.
6) PREVIOUS LEGISLATION.
a) AB 1308 (Bonilla), Chapter 665, Statutes of 2013, authorizes a midwife to directly obtain
supplies and devices, obtain and administer drugs and diagnostic tests, order testing and
receive reports that are necessary to his/her practice of midwifery and consistent with
his/her scope of practice; expands the disclosures required to be made by a midwife to a
prospective client to include the specific procedures that warrant consultation with a
physician and surgeon; and, makes other correcting and conforming changes.
b) SB 614 (Figueroa), Chapter 614, Statutes of 2005, expands the scope of practice for
CNMs to include furnishing or ordering Schedule II controlled substances outside a
hospital, as specified.
7) DOUBLE REFFERAL. This bill has been doubled referred. Upon successful passage of
this Committee, this bill will be referred to the Assembly Business and Professions
Committee.
REGISTERED SUPPORT / OPPOSITION:
Support
California Association of Midwives (sponsor)
Association of California Healthcare Districts
California Black Health Network
California Families for Access to Midwives
Capital OB/GYN, Inc. (prior version)
Central California Alliance for Health (prior version)
Monterey County Board of Supervisors (prior version)
Planned Parenthood Affiliates of California
Santa Cruz County
WellSpace Health (prior version)
Two individuals
Opposition
American Congress of Obstetricians and Gynecologists (prior version)
Analysis Prepared by: An-Chi Tsou / HEALTH / (916) 319-2097