BILL NUMBER: AB 62	AMENDED
	BILL TEXT

	AMENDED IN SENATE  JUNE 27, 2011
	AMENDED IN ASSEMBLY  APRIL 28, 2011

INTRODUCED BY   Assembly Member Monning

                        DECEMBER 7, 2010

   An act to amend Section 14132.275 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 62, as amended, Monning. Medi-Cal: dual eligibles: pilot
projects.
   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 provisions. Existing federal law provides for the
federal Medicare Program, which is a public health insurance program
for persons 65 years of age and older and specified persons with
disabilities who are under 65 years of age. Existing law, to the
extent that federal financial participation is available, and
pursuant to a demonstration project or waiver of federal law,
requires the department to establish pilot projects in up to 4
counties, to develop effective health care models to provide services
to persons who are dually eligible under both the Medi-Cal and
Medicare programs. Existing law requires the department to, not
sooner than March 1, 2011, identify health care models that may be
included in a pilot project, develop a timeline and process for
selecting, financing, monitoring, and evaluating the pilot projects,
and provide this timeline and process to certain committees of the
Legislature.
   This bill would  provide that, in relation to the
requirement that the department seek federal approval to establish
the pilot projects, the department may seek federal approval pursuant
to a response   authorize the department to also
establish these pilot projects pursuant  to a request for
proposal from the federal Centers for Medicare and Medicaid Services.
This bill would require the department to consult with stakeholders,
including, among others, representatives of advocacy organizations,
persons with disabilities, seniors, and representatives of legal
services agencies that serve dual eligibles  ,  on a regular
basis throughout the development and implementation of the pilot
projects.
   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 14132.275 of the Welfare and Institutions Code
is amended to read:
   14132.275.  (a) The department shall seek federal approval to
establish pilot projects described in this section pursuant to a
Medicare or a Medicaid demonstration project or waiver,  or 
a combination thereof  , or in response to a request for
proposal from the federal Centers for Medicare and Medicaid Services
 . Under a Medicare demonstration, the department may
operate the Medicare component of a pilot project as a delegated
Medicare benefit administrator, and may enter into financing
arrangements with the federal Centers for Medicare and Medicaid
Services to share in any Medicare program savings generated by the
operation of any pilot project.  The department may also
establish pilot projects described in this section pursuant to a
request for proposal from the federal Centers for Medicare and
Medicaid Services. 
   (b) After federal approval is obtained, the department shall
establish pilot projects that enable dual eligibles to receive a
continuum of services, and that maximize the coordination of benefits
between the Medi-Cal and Medicare programs and access to the
continuum of services needed. The purpose of the pilot projects is to
develop effective health care models that integrate services
authorized under the federal Medicaid Program (Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the
federal Medicare Program (Title XVIII of the federal Social Security
Act (42 U.S.C. Sec. 1395 et seq.)). These pilot projects may also
include additional services as approved through a demonstration
project or waiver, or a combination thereof.
   (c) Not sooner than March 1, 2011, the department shall identify
health care models that may be included in a pilot project, shall
develop a timeline and process for selecting, financing, monitoring,
and evaluating these pilot projects, and shall provide this timeline
and process to the appropriate fiscal and policy committees of the
Legislature. The department may implement these pilot projects in
phases.
   (d) Goals for the pilot projects shall include all of the
following:
   (1) Coordinating Medi-Cal benefits, Medicare benefits, or both,
across health care settings and improving continuity of acute care,
long-term care, and home- and community-based services.
   (2) Coordinating access to acute and long-term care services for
dual eligibles.
   (3) Maximizing the ability of dual eligibles to remain in their
homes and communities with appropriate services and supports in lieu
of institutional care.
   (4) Increasing the availability of and access to home- and
community-based alternatives.
   (e) Pilot projects shall be established in up to four counties,
and shall include at least one county that provides Medi-Cal services
via a two-plan model pursuant to Article 2.7 (commencing with
Section 14087.3) and at least one county that provides Medi-Cal
services under a county organized health system pursuant to Article
2.8 (commencing with Section 14087.5). In determining the counties in
which to establish a pilot project, the director shall consider the
following:
   (1) Local support for integrating medical care, long-term care,
and home- and community-based services networks.
   (2) A local stakeholder process that includes health plans,
providers, community programs, consumers, and other interested
stakeholders in the development, implementation, and continued
operation of the pilot project.
   (f) The director may enter into exclusive or nonexclusive
contracts on a bid or negotiated basis and may amend existing managed
care contracts to provide or arrange for services provided under
this section. Contracts entered into or amended pursuant to this
section shall be exempt from the provisions of Chapter 2 (commencing
with Section 10290) of Part 2 of Division 2 of the Public Contract
Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of
Division 3 of Title 2 of the Government Code.
   (g) Services under Section 14132.95 or 14132.952, or Article 7
(commencing with Section 12300) of Chapter 3 that are provided under
the pilot projects established by this section shall be provided
through direct hiring of personnel, contract, or establishment of a
public authority or nonprofit consortium, in accordance with, and
subject to, the requirements of Section 12302 or 12301.6, as
applicable.
   (h) Notwithstanding any other provision of state law, the
department may require that dual eligibles be assigned as mandatory
enrollees into managed care plans established or expanded as part of
a pilot project established under this section. Mandatory enrollment
in managed care for dual eligibles shall be applicable to the
beneficiary's Medi-Cal benefits only. Dual eligibles shall have the
option to enroll in a Medicare Advantage special needs plan (SNP)
offered by the managed care plan established or expanded as part of a
pilot project established pursuant to subdivision (e). To the extent
that mandatory enrollment is required, any requirement of the
department and the health plans, and any requirement of continuity of
care protections for enrollees, as specified in Section 14182, shall
be applicable to this section. Dual eligibles shall have the option
to forgo receiving Medicare benefits under a pilot project. Nothing
in this section shall be interpreted to reduce benefits otherwise
available under the Medi-Cal program or the Medicare Program.
   (i) For purposes of this section, a "dual eligible" means an
individual who is simultaneously eligible for full scope benefits
under Medi-Cal and the federal Medicare Program.
   (j) Persons meeting requirements for the Program of All-Inclusive
Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with
Section 14590), may select a PACE plan if one is available in that
county.
   (k) Notwithstanding Section 10231.5 of the Government Code, the
department shall conduct an evaluation to assess outcomes and the
experience of dual eligibles in these pilot projects and shall
provide a report to the Legislature after the first full year of
pilot operation, and annually thereafter. A report submitted to the
Legislature pursuant to this subdivision shall be submitted in
compliance with Section 9795 of the Government Code. The department
shall consult with stakeholders regarding the scope and structure of
the evaluation.
   (l) This section shall be implemented only if and to the extent
that federal financial participation or funding is available to
establish these pilot projects.
   (m) The department shall consult with stakeholders, including, but
not limited to, representatives of advocacy organizations, persons
with disabilities, seniors, representatives of legal services
agencies that serve dual eligibles, specialty care providers,
provider associations, labor, health plans, county government, and
the Legislature, on a regular basis throughout the development and
implementation of the pilot projects.
   (n) 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, interpret, or make specific this section
and any applicable federal waivers and state plan amendments by means
of all-county letters, plan letters, plan or provider bulletins, or
similar instructions, without taking regulatory action. Prior to
issuing any letter or similar instrument authorized pursuant to this
section, the department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries. The department
shall notify the appropriate policy and fiscal committees of the
Legislature of its intent to issue instructions under this section at
least five days in advance of the issuance.