BILL NUMBER: AB 2073 INTRODUCED
BILL TEXT
INTRODUCED BY Assembly Member Bonnie Lowenthal
(Coauthors: Assembly Members Beall, Brownley, Eng, Jones, and
Swanson)
FEBRUARY 18, 2010
An act to amend Sections 14132, 14522.4, 14525.1, and 14526.2 of
the Welfare and Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 2073, as introduced, Bonnie Lowenthal. Medi-Cal: adult day
health care services.
Existing law establishes the Medi-Cal program, administered by the
State Department of Health Care Services, under which basic health
care services are provided to qualified low-income persons.
The Adult Day Health Medi-Cal Law establishes adult day health
care services as a Medi-Cal benefit for Medi-Cal beneficiaries who
meet certain adult day health care eligibility criteria. Existing law
provides that certain criteria shall only apply on the date the
Director of Health Care Services executes a declaration, as
specified. These criteria include requirements that beneficiaries
have two or more functional impairments involving activities that
include bathing, dressing, and self-feeding and, depending upon the
type of beneficiary, the beneficiary either requires substantial
human assistance or assistance, as defined, in performing those
activities.
This bill would, instead, upon the date the director executes the
aforementioned declaration, establish adult day health care services
as a Medi-Cal benefit for Medi-Cal beneficiaries who meet certain
criteria, including, requiring beneficiaries to have two or more
functional impairments involving the above-described activities and
require assistance, as defined, in performing those activities.
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. Section 14132 of the Welfare and Institutions Code is
amended to read:
14132. The following is the schedule of benefits under this
chapter:
(a) Outpatient services are covered as follows:
Physician, hospital or clinic outpatient, surgical center,
respiratory care, optometric, chiropractic, psychology, podiatric,
occupational therapy, physical therapy, speech therapy, audiology,
acupuncture to the extent federal matching funds are provided for
acupuncture, and services of persons rendering treatment by prayer or
healing by spiritual means in the practice of any church or
religious denomination insofar as these can be encompassed by federal
participation under an approved plan, subject to utilization
controls.
(b) Inpatient hospital services, including, but not limited to,
physician and podiatric services, physical therapy and occupational
therapy, are covered subject to utilization controls.
(c) Nursing facility services, subacute care services, and
services provided by any category of intermediate care facility for
the developmentally disabled, including podiatry, physician, nurse
practitioner services, and prescribed drugs, as described in
subdivision (d), are covered subject to utilization controls.
Respiratory care, physical therapy, occupational therapy, speech
therapy, and audiology services for patients in nursing facilities
and any category of intermediate care facility for the
developmentally disabled are covered subject to utilization controls.
(d) (1) Purchase of prescribed drugs is covered subject to the
Medi-Cal List of Contract Drugs and utilization controls.
(2) Purchase of drugs used to treat erectile dysfunction or any
off-label uses of those drugs are covered only to the extent that
federal financial participation is available.
(3) (A) To the extent required by federal law, the purchase of
outpatient prescribed drugs, for which the prescription is executed
by a prescriber in written, nonelectronic form on or after April 1,
2008, is covered only when executed on a tamper resistant
prescription form. The implementation of this paragraph shall conform
to the guidance issued by the federal Centers of Medicare and
Medicaid Services but shall not conflict with state statutes on the
characteristics of tamper resistant prescriptions for controlled
substances, including Section 11162.1 of the Health and Safety Code.
The department shall provide providers and beneficiaries with as much
flexibility in implementing these rules as allowed by the federal
government. The department shall notify and consult with appropriate
stakeholders in implementing, interpreting, or making specific this
paragraph.
(B) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may take the actions specified in subparagraph (A) by
means of a provider bulletin or notice, policy letter, or other
similar instructions without taking regulatory action.
(e) Outpatient dialysis services and home hemodialysis services,
including physician services, medical supplies, drugs and equipment
required for dialysis, are covered, subject to utilization controls.
(f) Anesthesiologist services when provided as part of an
outpatient medical procedure, nurse anesthetist services when
rendered in an inpatient or outpatient setting under conditions set
forth by the director, outpatient laboratory services, and X-ray
services are covered, subject to utilization controls. Nothing in
this subdivision shall be construed to require prior authorization
for anesthesiologist services provided as part of an outpatient
medical procedure or for portable X-ray services in a nursing
facility or any category of intermediate care facility for the
developmentally disabled.
(g) Blood and blood derivatives are covered.
(h) (1) Emergency and essential diagnostic and restorative dental
services, except for orthodontic, fixed bridgework, and partial
dentures that are not necessary for balance of a complete artificial
denture, are covered, subject to utilization controls. The
utilization controls shall allow emergency and essential diagnostic
and restorative dental services and prostheses that are necessary to
prevent a significant disability or to replace previously furnished
prostheses which are lost or destroyed due to circumstances beyond
the beneficiary's control. Notwithstanding the foregoing, the
director may by regulation provide for certain fixed artificial
dentures necessary for obtaining employment or for medical conditions
that preclude the use of removable dental prostheses, and for
orthodontic services in cleft palate deformities administered by the
department's California Children Services Program.
(2) For persons 21 years of age or older, the services specified
in paragraph (1) shall be provided subject to the following
conditions:
(A) Periodontal treatment is not a benefit.
(B) Endodontic therapy is not a benefit except for vital
pulpotomy.
(C) Laboratory processed crowns are not a benefit.
(D) Removable prosthetics shall be a benefit only for patients as
a requirement for employment.
(E) The director may, by regulation, provide for the provision of
fixed artificial dentures that are necessary for medical conditions
that preclude the use of removable dental prostheses.
(F) Notwithstanding the conditions specified in subparagraphs (A)
to (E), inclusive, the department may approve services for persons
with special medical disorders subject to utilization review.
(3) Paragraph (2) shall become inoperative July 1, 1995.
(i) Medical transportation is covered, subject to utilization
controls.
(j) Home health care services are covered, subject to utilization
controls.
(k) Prosthetic and orthotic devices and eyeglasses are covered,
subject to utilization controls. Utilization controls shall allow
replacement of prosthetic and orthotic devices and eyeglasses
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control. Frame styles for eyeglasses replaced
pursuant to this subdivision shall not change more than once every
two years, unless the department so directs.
Orthopedic and conventional shoes are covered when provided by a
prosthetic and orthotic supplier on the prescription of a physician
and when at least one of the shoes will be attached to a prosthesis
or brace, subject to utilization controls. Modification of stock
conventional or orthopedic shoes when medically indicated, is covered
subject to utilization controls. When there is a clearly established
medical need that cannot be satisfied by the modification of stock
conventional or orthopedic shoes, custom-made orthopedic shoes are
covered, subject to utilization controls.
Therapeutic shoes and inserts are covered when provided to
beneficiaries with a diagnosis of diabetes, subject to utilization
controls, to the extent that federal financial participation is
available.
(l) Hearing aids are covered, subject to utilization controls.
Utilization controls shall allow replacement of hearing aids
necessary because of loss or destruction due to circumstances beyond
the beneficiary's control.
(m) Durable medical equipment and medical supplies are covered,
subject to utilization controls. The utilization controls shall allow
the replacement of durable medical equipment and medical supplies
when necessary because of loss or destruction due to circumstances
beyond the beneficiary's control. The utilization controls shall
allow authorization of durable medical equipment needed to assist a
disabled beneficiary in caring for a child for whom the disabled
beneficiary is a parent, stepparent, foster parent, or legal
guardian, subject to the availability of federal financial
participation. The department shall adopt emergency regulations to
define and establish criteria for assistive durable medical equipment
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code).
(n) Family planning services are covered, subject to utilization
controls.
(o) Inpatient intensive rehabilitation hospital services,
including respiratory rehabilitation services, in a general acute
care hospital are covered, subject to utilization controls, when
either of the following criteria are met:
(1) A patient with a permanent disability or severe impairment
requires an inpatient intensive rehabilitation hospital program as
described in Section 14064 to develop function beyond the limited
amount that would occur in the normal course of recovery.
(2) A patient with a chronic or progressive disease requires an
inpatient intensive rehabilitation hospital program as described in
Section 14064 to maintain the patient's present functional level as
long as possible.
(p) (1) Adult day health care is covered in accordance with
Chapter 8.7 (commencing with Section 14520).
(2) Commencing 30 days after the effective date of the act that
added this paragraph, and notwithstanding the number of days
previously approved through a treatment authorization request, adult
day health care is covered for a maximum of three days per week.
(3) As provided in accordance with paragraph (4), adult day health
care is covered for a maximum of five days per week.
(4) As of the date that the director makes the declaration
described in subdivision (g) (f) of
Section 14525.1, paragraph (2) shall become inoperative and paragraph
(3) shall become operative.
(q) (1) Application of fluoride, or other appropriate fluoride
treatment as defined by the department, other prophylaxis treatment
for children 17 years of age and under, are covered.
(2) All dental hygiene services provided by a registered dental
hygienist in alternative practice pursuant to Sections 1768 and 1770
of the Business and Professions Code may be covered as long as they
are within the scope of Denti-Cal benefits and they are necessary
services provided by a registered dental hygienist in alternative
practice.
(r) (1) Paramedic services performed by a city, county, or special
district, or pursuant to a contract with a city, county, or special
district, and pursuant to a program established under Article 3
(commencing with Section 1480) of Chapter 2.5 of Division 2 of the
Health and Safety Code by a paramedic certified pursuant to that
article, and consisting of defibrillation and those services
specified in subdivision (3) of Section 1482 of the article.
(2) All providers enrolled under this subdivision shall satisfy
all applicable statutory and regulatory requirements for becoming a
Medi-Cal provider.
(3) This subdivision shall be implemented only to the extent
funding is available under Section 14106.6.
(s) In-home medical care services are covered when medically
appropriate and subject to utilization controls, for beneficiaries
who would otherwise require care for an extended period of time in an
acute care hospital at a cost higher than in-home medical care
services. The director shall have the authority under this section to
contract with organizations qualified to provide in-home medical
care services to those persons. These services may be provided to
patients placed in shared or congregate living arrangements, if a
home setting is not medically appropriate or available to the
beneficiary. As used in this section, "in-home medical care service"
includes utility bills directly attributable to continuous, 24-hour
operation of life-sustaining medical equipment, to the extent that
federal financial participation is available.
As used in this subdivision, in-home medical care services,
include, but are not limited to:
(1) Level of care and cost of care evaluations.
(2) Expenses, directly attributable to home care activities, for
materials.
(3) Physician fees for home visits.
(4) Expenses directly attributable to home care activities for
shelter and modification to shelter.
(5) Expenses directly attributable to additional costs of special
diets, including tube feeding.
(6) Medically related personal services.
(7) Home nursing education.
(8) Emergency maintenance repair.
(9) Home health agency personnel benefits which permit coverage of
care during periods when regular personnel are on vacation or using
sick leave.
(10) All services needed to maintain antiseptic conditions at
stoma or shunt sites on the body.
(11) Emergency and nonemergency medical transportation.
(12) Medical supplies.
(13) Medical equipment, including, but not limited to, scales,
gurneys, and equipment racks suitable for paralyzed patients.
(14) Utility use directly attributable to the requirements of home
care activities which are in addition to normal utility use.
(15) Special drugs and medications.
(16) Home health agency supervision of visiting staff which is
medically necessary, but not included in the home health agency rate.
(17) Therapy services.
(18) Household appliances and household utensil costs directly
attributable to home care activities.
(19) Modification of medical equipment for home use.
(20) Training and orientation for use of life-support systems,
including, but not limited to, support of respiratory functions.
(21) Respiratory care practitioner services as defined in Sections
3702 and 3703 of the Business and Professions Code, subject to
prescription by a physician and surgeon.
Beneficiaries receiving in-home medical care services are entitled
to the full range of services within the Medi-Cal scope of benefits
as defined by this section, subject to medical necessity and
applicable utilization control. Services provided pursuant to this
subdivision, which are not otherwise included in the Medi-Cal
schedule of benefits, shall be available only to the extent that
federal financial participation for these services is available in
accordance with a home- and community-based services waiver.
(t) Home- and community-based services approved by the United
States Department of Health and Human Services may be covered to the
extent that federal financial participation is available for those
services under waivers granted in accordance with Section 1396n of
Title 42 of the United States Code. The director may seek waivers for
any or all home- and community-based services approvable under
Section 1396n of Title 42 of the United States Code. Coverage for
those services shall be limited by the terms, conditions, and
duration of the federal waivers.
(u) Comprehensive perinatal services, as provided through an
agreement with a health care provider designated in Section 14134.5
and meeting the standards developed by the department pursuant to
Section 14134.5, subject to utilization controls.
The department shall seek any federal waivers necessary to
implement the provisions of this subdivision. The provisions for
which appropriate federal waivers cannot be obtained shall not be
implemented. Provisions for which waivers are obtained or for which
waivers are not required shall be implemented notwithstanding any
inability to obtain federal waivers for the other provisions. No
provision of this subdivision shall be implemented unless matching
funds from Subchapter XIX (commencing with Section 1396) of Chapter 7
of Title 42 of the United States Code are available.
(v) Early and periodic screening, diagnosis, and treatment for any
individual under 21 years of age is covered, consistent with the
requirements of Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code.
(w) Hospice service which is Medicare-certified hospice service is
covered, subject to utilization controls. Coverage shall be
available only to the extent that no additional net program costs are
incurred.
(x) When a claim for treatment provided to a beneficiary includes
both services which are authorized and reimbursable under this
chapter, and services which are not reimbursable under this chapter,
that portion of the claim for the treatment and services authorized
and reimbursable under this chapter shall be payable.
(y) Home- and community-based services approved by the United
States Department of Health and Human Services for beneficiaries with
a diagnosis of AIDS or ARC, who require intermediate care or a
higher level of care.
Services provided pursuant to a waiver obtained from the Secretary
of the United States Department of Health and Human Services
pursuant to this subdivision, and which are not otherwise included in
the Medi-Cal schedule of benefits, shall be available only to the
extent that federal financial participation for these services is
available in accordance with the waiver, and subject to the terms,
conditions, and duration of the waiver. These services shall be
provided to individual beneficiaries in accordance with the client's
needs as identified in the plan of care, and subject to medical
necessity and applicable utilization control.
The director may under this section contract with organizations
qualified to provide, directly or by subcontract, services provided
for in this subdivision to eligible beneficiaries. Contracts or
agreements entered into pursuant to this division shall not be
subject to the Public Contract Code.
(z) Respiratory care when provided in organized health care
systems as defined in Section 3701 of the Business and Professions
Code, and as an in-home medical service as outlined in subdivision
(s).
(aa) (1) There is hereby established in the department, a program
to provide comprehensive clinical family planning services to any
person who has a family income at or below 200 percent of the federal
poverty level, as revised annually, and who is eligible to receive
these services pursuant to the waiver identified in paragraph (2).
This program shall be known as the Family Planning, Access, Care, and
Treatment (Family PACT) Waiver Program.
(2) The department shall seek a waiver for a program to provide
comprehensive clinical family planning services as described in
paragraph (8). The program shall be operated only in accordance with
the waiver and the statutes and regulations in paragraph (4) and
subject to the terms, conditions, and duration of the waiver. The
services shall be provided under the program only if the waiver is
approved by the federal Centers for Medicare and Medicaid Services in
accordance with Section 1396n of Title 42 of the United States Code
and only to the extent that federal financial participation is
available for the services.
(3) Solely for the purposes of the waiver and notwithstanding any
other provision of law, the collection and use of an individual's
social security number shall be necessary only to the extent required
by federal law.
(4) Sections 14105.3 to 14105.39, inclusive, 14107.11, 24005, and
24013, and any regulations adopted under these statutes shall apply
to the program provided for under this subdivision. No other
provision of law under the Medi-Cal program or the State-Only Family
Planning Program shall apply to the program provided for under this
subdivision.
(5) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, without taking regulatory action, the
provisions of the waiver after its approval by the federal Health
Care Financing Administration and the provisions of this section by
means of an all-county letter or similar instruction to providers.
Thereafter, the department shall adopt regulations to implement this
section and the approved waiver in accordance with the requirements
of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division
3 of Title 2 of the Government Code. Beginning six months after the
effective date of the act adding this subdivision, the department
shall provide a status report to the Legislature on a semiannual
basis until regulations have been adopted.
(6) In the event that the Department of Finance determines that
the program operated under the authority of the waiver described in
paragraph (2) is no longer cost effective, this subdivision shall
become inoperative on the first day of the first month following the
issuance of a 30-day notification of that determination in writing by
the Department of Finance to the chairperson in each house that
considers appropriations, the chairpersons of the committees, and the
appropriate subcommittees in each house that considers the State
Budget, and the Chairperson of the Joint Legislative Budget
Committee.
(7) If this subdivision ceases to be operative, all persons who
have received or are eligible to receive comprehensive clinical
family planning services pursuant to the waiver described in
paragraph (2) shall receive family planning services under the
Medi-Cal program pursuant to subdivision (n) if they are otherwise
eligible for Medi-Cal with no share of cost, or shall receive
comprehensive clinical family planning services under the program
established in Division 24 (commencing with Section 24000) either if
they are eligible for Medi-Cal with a share of cost or if they are
otherwise eligible under Section 24003.
(8) For purposes of this subdivision, "comprehensive clinical
family planning services" means the process of establishing
objectives for the number and spacing of children, and selecting the
means by which those objectives may be achieved. These means include
a broad range of acceptable and effective methods and services to
limit or enhance fertility, including contraceptive methods, federal
Food and Drug Administration approved contraceptive drugs, devices,
and supplies, natural family planning, abstinence methods, and basic,
limited fertility management. Comprehensive clinical family planning
services include, but are not limited to, preconception counseling,
maternal and fetal health counseling, general reproductive health
care, including diagnosis and treatment of infections and conditions,
including cancer, that threaten reproductive capability, medical
family planning treatment and procedures, including supplies and
followup, and informational, counseling, and educational services.
Comprehensive clinical family planning services shall not include
abortion, pregnancy testing solely for the purposes of referral for
abortion or services ancillary to abortions, or pregnancy care that
is not incident to the diagnosis of pregnancy. Comprehensive clinical
family planning services shall be subject to utilization control and
include all of the following:
(A) Family planning related services and male and female
sterilization. Family planning services for men and women shall
include emergency services and services for complications directly
related to the contraceptive method, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies,
and followup, consultation, and referral services, as indicated,
which may require treatment authorization requests.
(B) All United States Department of Agriculture, federal Food and
Drug Administration approved contraceptive drugs, devices, and
supplies that are in keeping with current standards of practice and
from which the individual may choose.
(C) Culturally and linguistically appropriate health education and
counseling services, including informed consent, that include all of
the following:
(i) Psychosocial and medical aspects of contraception.
(ii) Sexuality.
(iii) Fertility.
(iv) Pregnancy.
(v) Parenthood.
(vi) Infertility.
(vii) Reproductive health care.
(viii) Preconception and nutrition counseling.
(ix) Prevention and treatment of sexually transmitted infection.
(x) Use of contraceptive methods, federal Food and Drug
Administration approved contraceptive drugs, devices, and supplies.
(xi) Possible contraceptive consequences and followup.
(xii) Interpersonal communication and negotiation of relationships
to assist individuals and couples in effective contraceptive method
use and planning families.
(D) A comprehensive health history, updated at the next periodic
visit (between 11 and 24 months after initial examination) that
includes a complete obstetrical history, gynecological history,
contraceptive history, personal medical history, health risk factors,
and family health history, including genetic or hereditary
conditions.
(E) A complete physical examination on initial and subsequent
periodic visits.
(ab) Purchase of prescribed enteral formulae is covered, subject
to the Medi-Cal list of enteral formulae and utilization controls.
(ac) Diabetic testing supplies are covered when provided by a
pharmacy, subject to utilization controls.
SEC. 2. Section 14522.4 of the Welfare and Institutions Code is
amended to read:
14522.4. (a) The following definitions shall apply for the
purposes of this chapter:
(1) "Activities of daily living (ADL)" means activities performed
by the participant for essential living purposes, including bathing,
dressing, self-feeding, toileting, ambulation, and transferring.
(2) "Instrumental activities of daily living (IADL)" means
functions or tasks of independent living limited to hygiene and
medication management.
(3) "Personal health care provider" means the participant's
personal physician, physician's assistant, or nurse practitioner,
operating within his or her scope of practice.
(4) "Care coordination" means the process of obtaining information
from, or providing information to, the participant, the participant'
s family, the participant's personal health care provider, or social
services agencies to facilitate the delivery of services designed to
meet the needs of the participant, as identified by one or more
members of the multidisciplinary team.
(5) "Facilitated participation" means an interaction to support a
participant's involvement in a group or individual activity, whether
or not the participant takes active part in the activity itself.
(6) "Group work" means a social work service in which a variety of
therapeutic methods are applied within a small group setting to
promote participants' self-expression and positive adaptation to
their environment.
(7) "Professional nursing" means services provided by a registered
nurse or licensed vocational nurse functioning within his or her
scope of practice.
(8) "Psychosocial" means a participant's psychological status in
relation to the participant's social and physical environment.
(9) "Assistance" means verbal or physical prompting or aid,
including cueing, supervision, stand-by assistance, or hands-on
support to complete the task correctly
perform the essential elements of the ADL
and the IADL .
(10) "Substantial human assistance" means direct, hands-on
assistance provided by a qualified caregiver, which entails
physically helping the participant perform the essential elements of
the ADLs and IADLs. It entails more than cueing, supervision, or
stand-by assistance to perform the ADLs and IADLs. It also includes
the performance of the entire ADL or IADL for participants totally
dependent on human assistance.
(11)
(10) (a) "Cognitive impairment" means the loss or
deterioration of intellectual capacity characterized by impairments
in short- or long-term memory, language, concentration and attention,
orientation to people, place, or time, visual-spatial abilities or
executive functions, or both, including, but not limited to,
judgment, reasoning, or the ability to inhibit behaviors that
interfere with social, occupational, or everyday functioning due to
conditions, including, but not limited to, mild cognitive impairment,
Alzheimer's disease or other form of dementia, or brain injury.
(b) Upon the date of execution of the declaration described under
subdivision (g) (f) of Section 14525.1,
this section shall become operative and Section 14522.3 shall become
inoperative and on that date is repealed.
SEC. 3. Section 14525.1 of the Welfare and Institutions Code is
amended to read:
14525.1. (a) Except as provided in subdivisions (b) and (c), any
adult eligible for benefits under Chapter 7 (commencing with Section
14000) shall be eligible for adult day health care services if that
person meets all of the following criteria:
(1) The person is 18 years of age or older and has one or more
chronic or postacute medical, cognitive, or mental health conditions,
and a physician, nurse practitioner, or other health care provider
has, within his or her scope of practice, requested adult day health
care services for the person.
(2) The person has two or more functional impairments involving
ambulation, bathing, dressing, self-feeding, toileting, transferring,
medication management, and hygiene , and the person
requires assistance in performing those activities .
(3) (A) Except as provided under subparagraph (B), the person
requires substantial human assistance in performing these activities.
(B) The persons described in subdivisions (b) and (c) shall only
require assistance in performing these activities.
(4)
(3) The person requires ongoing or intermittent
protective supervision, assessment, or intervention by a skilled
health or mental health professional to improve, stabilize, maintain,
or minimize deterioration of the medical, cognitive, or mental
health condition.
(5)
(4) The person requires adult day health care services,
as defined in Section 14550, that are individualized and planned,
including, when necessary, the coordination of formal and informal
services outside of the adult day health care program to support the
individual and his or her family or caregiver in the living
arrangement of his or her choice and to avoid or delay the use of
institutional services, including, but not limited to, hospital
emergency department services, inpatient acute care hospital
services, inpatient mental health services, or placement in a nursing
facility or a nursing or intermediate care facility for the
developmentally disabled providing continuous nursing care.
(6)
(5) The person meets the level of care set forth in
Section 51120 of Title 22 of the California Code of Regulations.
(b) A resident of an intermediate care facility for the
developmentally disabled-habilitative shall be eligible for adult day
health care services if that resident meets the criteria set forth
in paragraphs (1) to (5) (4) ,
inclusive, of subdivision (a) and has disabilities and a level of
functioning that are of such a nature that, without supplemental
intervention through adult day health care, placement to a more
costly institutional level of care would be likely to occur.
(c) Persons having chronic mental illness or moderate to severe
Alzheimer's disease or other cognitive impairments shall be eligible
for adult day health care services if they meet the criteria
established in paragraphs (1) to (5), inclusive, of subdivision (a).
(d)
(c) This section shall only be implemented to the
extent permitted by federal law.
(e)
(d) Notwithstanding Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code, the department may implement the provisions of this section by
means of all-county letters, provider bulletins, or similar
instructions without taking further regulatory action.
(f)
(e) Prior to implementing this section, the department
shall meet and confer with provider representatives, including, but
not limited to, adult day health care, home- and community-based
services, and nursing facilities for the purpose of presenting and
discussing information and evidence to assist the department as it
determines the methods and procedures necessary to implement this
section.
(g)
(f) Upon the determination of the director that all
necessary methods and procedures described in subdivision
(f) (e) have been ascertained and are sufficient
to implement the purposes of this section, the director shall
execute and retain a declaration indicating that this determination
has been made. Subdivisions (a) to (e) (d)
, inclusive, shall be inoperative, until the date of execution
of the declaration. Upon the date of execution of such a declaration,
subdivisions (a) to (e) (d) ,
inclusive of this section shall become operative and Section 14525
shall become inoperative.
SEC. 4. Section 14526.2 of the Welfare and Institutions Code is
amended to read:
14526.2. (a) Initial and subsequent treatment authorization
requests may be granted for up to six calendar months, initial and
subsequent treatment authorization requests may, at the discretion of
the department, be granted for up to 12 calendar months.
(b) Treatment authorization requests shall be initiated by the
adult day health care center, and shall include all of the following:
(1) A complete history and physical form, including a request for
adult day health care services signed by the participant's personal
health care provider shall be obtained annually. A copy of the
history and physical form shall be submitted with an initial
treatment authorization request and maintained in the participant's
health record. This history and physical form shall be developed by
the department and published in the inpatient/outpatient provider
manual.
(2) The participant's individual plan of care, pursuant to Section
54211 of Title 22 of the California Code of Regulations.
(c) Whenever a subsequent treatment authorization request is
submitted, the adult day health care center shall obtain and submit
an updated history and physical form from the participant's personal
health care provider using a standard update form that shall be
maintained in the participant's health record. This update form shall
be developed by the department for that use and shall be published
in the inpatient/outpatient provider manual.
(d) Authorization or reauthorization of an adult day health care
treatment authorization request shall be granted only if the
participant meets all of the following medical necessity criteria:
(1) The participant has one or more chronic or post acute medical,
cognitive, or mental health conditions that are identified by the
participant's personal health care provider as requiring one or more
of the following, without which the participant's condition will
likely deteriorate and require emergency department visits,
hospitalization, or other institutionalization:
(A) Assessment and monitoring.
(B) Treatment.
(C) Intervention.
(2) The participant has a condition or conditions resulting in
both of the following:
(A) Two or more functional impairments involving ambulation,
bathing, dressing, self-feeding, toileting, transferring, medication
management, and hygiene.
(B) As set forth in subparagraph (A) and (B) of paragraph
(3) paragraph (2) of subdivision (a) of Section
14525.1, the need for assistance or substantial human
assistance in performing the activities identified in
subparagraph (A) as related to the condition or conditions specified
in paragraph (1). That assistance or substantial human
assistance shall be in addition to any other nonadult day
health care support the participant is currently receiving in his or
her place of residence.
(3) Except for participants residing in an intermediate care
facility/developmentally disabled-habilitative, the participant's
network of nonadult day health care center supports is insufficient
to maintain the individual in the community, demonstrated by at least
one of the following:
(A) The participant lives alone and has no family or caregivers
available to provide sufficient and necessary care or supervision.
(B) The participant resides with one or more related or unrelated
individuals, but they are unwilling or unable to provide sufficient
and necessary care or supervision to the participant.
(4) A high potential exists for the deterioration of the
participant's medical, cognitive, or mental health condition or
conditions in a manner likely to result in emergency department
visits, hospitalization, or other institutionalization if adult day
health care services are not provided.
(5) The participant's condition or conditions require adult day
health care services specified in subdivisions (a) to (d), inclusive,
of Section 14550.6, on each day of attendance, that are
individualized and designed to maintain the ability of the
participant to remain in the community and avoid emergency department
visits, hospitalizations, or other institutionalization.
(e) When determining whether a provider has demonstrated that a
participant meets the medical necessity criteria, the department may
enter an adult day health care center and review participants'
medical records and observe participants receiving care identified in
the individual plan of care in addition to reviewing the information
provided on or with the TAR.
(f) Reauthorization of an adult day health care treatment
authorization request shall be granted when the criteria specified in
subdivision (d) or (g), as appropriate, have been met and the
participant's condition would likely deteriorate if the adult day
health care services were denied.
(g) For individuals residing in an intermediate care
facility/developmentally disabled-habilitative, authorization or
reauthorization of an adult day health care treatment authorization
request shall be granted only if the resident has disabilities and a
level of functioning that are of such a nature that, without
supplemental intervention through adult day health care, placement to
a more costly institutional level of care would be likely to occur.
(h) This section shall only be implemented to the extent permitted
by federal law.
(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement the provisions of this section by means of
all-county letters, provider bulletins, or similar instructions
without taking further regulatory action.
(j) Upon the date of execution of the declaration described under
subdivision (g) (f) of Section 14525.1,
this section shall become operative and Section 14526.1 shall become
inoperative and on that date is repealed.