BILL NUMBER: AB 667	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 11, 2011

INTRODUCED BY   Assembly Member Mitchell

                        FEBRUARY 17, 2011

   An act to amend Section 14132.25 of the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 667, as amended, Mitchell. Medi-Cal: subacute care program.
   Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
The Medi-Cal program is, in part, governed and funded by federal
Medicaid Program provisions. Existing law requires the department to
establish a subacute care program in health facilities in order to
more effectively use limited Medi-Cal dollars while ensuring needed
services for patients who meet subacute care criteria, as established
by the department. Existing law provides that, for the purposes of
this program, subacute care may be provided by any facility
designated by the Director of Health Care Services as meeting
subacute care criteria and that has an approved provider
participation agreement with the department. Existing law also
provides that subacute patient care shall be defined by the
department based on the results of a specified study.
   This bill would delete the requirement that the department define
subacute patient care based on the results of the study  and
  . This bill  would  provide that
  require  , for the purposes of the subacute care
program, medical necessity for pediatric subacute care services, as
defined,  shall   to  be substantiated in
one of  4   5  ways. This bill would also
make technical, nonsubstantive changes to 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.    The Legislature finds and declares all
of the following:  
   (a) California has 10 pediatric subacute care hospitals providing
cost-effective health care services to about 400 children under 21
years of age who rely on life-sustaining medical technology due to
their loss of vital bodily functions.  
   (b) The regulatory criteria used to evaluate or authorize
admissions into the Medi-Cal subacute care program have not been
adjusted since the program's inception 16 years ago.  
   (c) Pediatric subacute care is a fraction of the cost of care
provided in a pediatric intensive care unit of an acute care hospital
or a state developmental center. There are substantial Medi-Cal
savings every time a child is successfully discharged from an acute
care hospital to a subacute care facility.  
   (d) Therefore, it is in the intent of the Legislature to update
the criteria for admissions from an acute care hospital to a
pediatric subacute care facility to allow an individual's need for
other complex treatment to be utilized as qualifying criteria for
patient transfer. 
   SECTION 1.   SEC. 2.   Section 14132.25
of the Welfare and Institutions Code is amended to read:
   14132.25.  (a) On or before July 1, 1983, the State Department of
Health Care Services shall establish a subacute care program in
health facilities in order to more effectively use the limited
Medi-Cal dollars available while at the same time ensuring needed
services for these patients. The subacute care program shall be
available to patients in health facilities who meet subacute care
criteria. Subacute care may be provided by any facility designated by
the director as meeting the subacute care criteria that has an
approved provider participation agreement with the department.
   (b) The department shall develop a rate of reimbursement for this
subacute care program. Reimbursement rates shall be determined in
accordance with methodology developed by the department, specified in
regulation, and may include the following:
   (1) All-inclusive per diem rates.
   (2) Individual patient-specific rates according to the needs of
the individual subacute care patient.
   (3) Other rates subject to negotiation with the health facility.
   (c) Reimbursement at subacute care rates, as specified in
subdivision (b), shall only be implemented if funds are available for
this purpose pursuant to the annual Budget Act.
   (d) The department may negotiate and execute an agreement with any
health facility that meets the standards for providing subacute
care. An agreement may be negotiated or established between the
health facility and the department for subacute care based on
individual patient assessment. The department shall establish level
of care criteria and appropriate utilization controls for patients
eligible for the subacute care program.
   (e) For the purposes of this section, pediatric subacute services
are the health care services needed by a person under 21 years of age
who uses a medical technology that compensates for the loss of a
vital bodily function.
   (f) Medical necessity for pediatric subacute care services shall
be substantiated in any one of the following ways:
   (1) A tracheostomy with dependence on mechanical ventilation for a
minimum of six hours each day.
   (2) Dependence on tracheostomy care requiring suctioning at least
every six hours, and room air mist or oxygen as needed, and
dependence on one of the  following treatment procedures:
  five treatment procedures listed in subparagraphs (B)
to (F), inclusive:  
   (A) Dependence on intermittent suctioning at least every eight
hours and room air mist and oxygen as needed.  
   (A) 
    (B)  Dependence on continuous intravenous therapy,
including administration of a therapeutic agent necessary for
hydration or of intravenous pharmaceuticals, or intravenous
pharmaceutical administration of more than one agent, via a
peripheral or central line, without continuous infusion. 
   (B) 
    (C)  Dependence on peritoneal dialysis treatments
requiring at least four exchanges every 24 hours. 
   (C) 
    (D)  Dependence on tube feeding by means of a
nasogastric or gastrostomy tube. 
   (D) 
    (E)  Dependence on  at least one  other
medical technology   technologies 
required continuously, which, in the opinion of the attending
physician and the Medi-Cal consultant,  requires 
 require  the services of a professional nurse  ,
including, but not limited to, the following:   . 

   (i) Variable/bilevel positive airway pressure (BiPAP) device.
 
   (ii) Wound care.  
   (iii) Glucose stabilization for pediatric diabetic patients.
 
   (iv) Breathing treatment at least four times per day. 

   (F) Dependence on biphasic positive airway pressure at least six
hours a day, including assessment or intervention every three hours
and lacking either cognitive or physical ability of the patient to
protect his or her airway. 
   (3) Dependence on total parenteral nutrition or other intravenous
nutritional support, and dependence on one of the  following
treatment procedures:   treatment procedures specified
in subparagraphs (A) to (F), inclusive, of paragraph (2). 

   (i)  Dependence on intermittent suctioning at least every eight
hours and room air mist or oxygen as needed.  
   (ii) One of the treatment procedures specified in subparagraphs
(A) to (D), inclusive, of paragraph (2). 
   (4) Dependence on skilled nursing care in the administration
 of any three of the following treatment procedures:
  of any three of the six treatment procedures specified
in subparagraphs (A) to (F), inclusive, of paragraph (2). 

   (i)  Dependence on intermittent suctioning at least every eight
hours and room air mist or oxygen as needed.  
   (ii) Any of the treatment procedures specified in subparagraphs
(A) to (D), inclusive, of paragraph (2).  
   (5) Dependence on biphasic positive airway pressure or continuous
positive airway pressure at least six hours a day, including
assessment or intervention every three hours and lacking either
cognitive or physical ability of the patient to protect his or her
airway and dependence on one of the five treatment procedures
specified in subparagraphs (A) to (E), inclusive, of paragraph (2).
 
   (g) The medical necessity determination outlined in subdivision
(f) is intended solely for the evaluation of a patient who is
potentially eligible and meets the criteria to be transferred from an
acute care setting to a subacute level of care.