BILL NUMBER: AB 361 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 19, 2013
AMENDED IN ASSEMBLY MAY 24, 2013
AMENDED IN ASSEMBLY APRIL 4, 2013
INTRODUCED BY Assembly Member Mitchell
(Principal coauthor: Assembly Member Atkins)
(Coauthor: Assembly Member Ammiano)
(Coauthor: Senator Beall)
FEBRUARY 14, 2013
An act to add Article 3.9 (commencing with Section 14127) to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 361, as amended, Mitchell. Medi-Cal: Health Homes for Medi-Cal
Enrollees and Section 1115 Waiver Demonstration Populations with
Chronic and Complex Conditions.
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 federal law authorizes a state,
subject to federal approval of a state plan amendment, to offer
health home services, as defined, to eligible individuals with
chronic conditions.
This bill would authorize the department, subject to federal
approval, to create a health home program for enrollees with chronic
conditions, as prescribed, as authorized under federal law. This bill
would provide that those provisions shall not be implemented unless
federal financial participation is available and additional General
Fund moneys are not used to fund the administration and service
costs, except as specified. This bill would require the department to
ensure that an evaluation of the program is completed, if created by
the department, and would require that the department submit a
report to the appropriate policy and fiscal committees of the
Legislature within 2 years after implementation of the program.
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) The Health Homes for Enrollees with Chronic Conditions option
(Health Homes option) under Section 2703 of the federal Patient
Protection and Affordable Care Act (Affordable Care Act) (42 U.S.C.
Sec. 1396w-4) offers an opportunity for California to address chronic
and complex health conditions, including social determinants that
lead to poor health outcomes and high costs among Medi-Cal
beneficiaries.
(b) For example, people who frequently use hospitals for reasons
that could have been avoided with more appropriate care incur high
Medi-Cal costs and suffer high rates of early mortality due to the
complexity of their conditions and, often, their negative social
determinants of health. Frequent users have difficulties accessing
regular or preventive care and complying with treatment protocols,
and the significant number who are homeless have no place to store
medications, cannot adhere to a healthy diet or maintain appropriate
hygiene, face frequent victimization, and lack rest when recovering
from illness.
(c) Increasingly, health providers are partnering with community
behavioral health and social services providers to offer a
person-centered interdisciplinary system of care that effectively
addresses the needs of enrollees with multiple chronic or complex
conditions, including frequent hospital users and people experiencing
chronic homelessness. These health homes help people with chronic
and complex conditions to access better care and better health, while
decreasing costs.
(d) Federal guidelines allow the state to access enhanced federal
matching rates for health home services under the Health Homes option
for multiple target populations to achieve more than one policy
goal.
SEC. 2. Article 3.9 (commencing with Section 14127) is added to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, to read:
Article 3.9. Health Homes for Medi-Cal Enrollees and Section
1115 Waiver Demonstration Populations with Chronic and Complex
Conditions
14127. For the purposes of this article, the following
definitions shall apply:
(a) "Department" means the State Department of Health Care
Services.
(b) "Federal guidelines" means all federal statutes, and all
regulatory and policy guidelines issued by the federal Centers for
Medicare and Medicaid Services regarding the Health Homes for
Enrollees with Chronic Conditions option under Section 2703 of the
federal Patient Protection and Affordable Care Act (Affordable Care
Act) (42 U.S.C. Sec. 1396w-4), including the State Medicaid Director
Letter issued on November 16, 2010.
(c) (1) "Health home" means a provider or team of providers
designated by the department that satisfies all of the following:
(A) Meets the criteria described in federal guidelines.
(B) Offers a whole person approach, including, but not limited to,
coordinating other available services that address needs affecting a
participating individual's health.
(C) Offers services in a range of settings, as appropriate, to
meet the needs of an individual eligible for health home services.
(2) Health home partners may include, but are not limited
to, team members may include a health plan,
community clinic, a mental health plan, a hospital, physicians, a
clinical practice or clinical group practice, rural health clinic,
community health center, community mental health center,
substance use disorder treatment professionals, school-based health
centers, community health workers, community-based service
organizations, promotor es, home health agency,
nurse practitioners, physician's assistants, social
workers, and other paraprofessionals ,
. Health home teams shall also partner with and provide linkages
to housing navigators , and housing
providers.
(3) For purposes of serving targeted beneficiaries
the population identified in subdivision (c) of
Section 14127.3, the department shall may
require a lead provider to be a physician, a community clinic,
a mental health plan, a community-based nonprofit organization, a
county health system, a substance use disorder treatment
professional or facility, or a hospital.
(4) The department may determine the model of health home it
intends to create, including any entity, provider, or group of
providers operating as a health team, as a team of health care
professionals, or as a designated provider, as those terms are
defined in Sections 3502(c)(2) and 1945(h)(5) and (h)(6) of
the Affordable Care Act, 256a-1 and 1396w-4(h)(5)
and (h)(6) of Title 42 of the United States Code,
respectively.
(d) "Homeless" has the same meaning as that term is defined in
Section 91.5 of Title 24 of the Code of Federal Regulations. A
"chronically homeless individual" means an individual whose
conditions limit his or her activities of daily living and who has
experienced homelessness for longer than a year or for four or more
episodes over three years. An unaccompanied homeless
individual with a condition limiting his or her activities of daily
living who has been continuously homeless for a year or more, or has
had at least four episodes of homelessness in the past three years.
For purposes of this article, an individual who is currently
residing in transitional housing or who has been residing in
permanent supportive housing for less than two years shall be
considered a chronically homeless individual if the individual was
chronically homeless prior to his or her residence.
(e) "Targeted beneficiary" means an individual who meets the
criteria specified in subdivision (c) of Section 14127.3.
14127.1. Subject to federal approval, the department may do all
of the following to create a California Health Home Program
(Health Home Program) , as authorized under Section 2703 of the
Affordable Care Act:
(a) Design, with opportunity for public comment, a program to
provide health home services to Medi-Cal beneficiaries and Section
1115 waiver demonstration populations with chronic conditions.
In designing the Health Home Program, the department shall give
consideration to ensuring continuity of care and avoiding disruption
of care among a beneficiary's existing providers.
(b) Contract with new providers, new managed care plans,
existing Medi-Cal providers, existing managed care plans,
or counties , or one or more of these entities, to provide
health home services, as provided in Section 14128.
(c) Submit any necessary applications to the federal Centers for
Medicare and Medicaid Services for one or more state plan amendments
to provide health home services to Medi-Cal beneficiaries, to newly
eligible Medi-Cal beneficiaries upon Medicaid expansion under the
Affordable Care Act, and, if applicable, to Low Income Health Program
(LIHP) enrollees in counties with LIHPs willing to match federal
funds.
(d) Define the populations of eligible individuals.
(e) Develop a payment methodology, including, but not limited to,
fee-for-service or per member, per month payment structures that
may include tiered payment rates that take into account the
intensity of services necessary to outreach to, engage, and serve the
populations the department identifies.
(f) Identify health home services, consistent with federal
guidelines.
(f) Identify the specific health home services needed for each
population targeted in the Health Home Program, consistent with
subdivision (b) of Section 14127.2.
(g) The department may submit Submit
applications and operate, to the extent permitted by federal law and
to the extent federal approval is obtained, more than one health
home program state plan amendment and any
necessary Section 1115 waiver amendments for distinct
populations, different providers or contractors, or specific
geographic areas.
(h) Limit the availability of health home services geographically.
14127.2. (a) The department may design one or more state plan
amendments and any necessary Section 1115 waiver amendments
to provide health home services to children and
or adults , or both, pursuant to
Section 14127.1, and, in based on
consultation with stakeholders, shall develop the geographic
criteria, beneficiary eligibility criteria, and provider eligibility
criteria for each state plan amendment.
(b) (1) Subject to federal
approval for receipt of the enhanced federal match, services provided
under the program Health Home Program
established pursuant to this article shall include all of the
following:
(A) Comprehensive and individualized care management.
(B) Care coordination and health promotion, including connection
to medical, mental health, and substance use disorder
care.
(C) Comprehensive transitional care from inpatient to other
settings, including appropriate followup.
(D) Individual and family support, including authorized
representatives.
(E) Referral to relevant community and social services supports,
including, but not limited to, connection to housing for participants
who are homeless or unstably housed, transportation to appointments
needed to managed manage health needs,
healthy lifestyle supports, quality child care when appropriate,
and peer recovery support.
(F) Health information technology to identify eligible individuals
and link services, if feasible and appropriate.
(2) According to beneficiary needs, the health home provider may
provide less intensive services or graduate the beneficiary
completely from the program upon stabilization.
14127.3. (a) If the department creates a health home
program Health Home Program pursuant to this
article, the department shall determine whether a health home
program state plan amendment that
targets adults is operationally viable.
(b) (1) In determining whether a health home program
state plan amendment that targets adults is
operationally viable, the department shall consider whether a state
plan amendment and any necessary Section 1115 waiver amendments
could be designed in a manner that minimizes the impact on the
General Fund, whether the department has the capacity to administer
the program home health state plan amendment
through the state, a contracting entity, a county, or regional
approach , and whether a sufficient provider network exists for
providing health home services to targeted beneficiaries
populations the department intends to target,
including the populations described in subdivision (c).
(2) If the department determines that a health home
program state plan amendment that targets adults
is operationally viable pursuant to paragraph (1), then the
department shall design a state plan amendment and any necessary
Sect ion 1115 waiver amendments to target and
provide health home services to beneficiaries who meet the
criteria specified in subdivision (c).
(3) (A) If the department determines a health home
program state plan amendment that targets adults
is not operationally viable, then the department shall report
to the appropriate policy and fiscal committees of the Legislature
the basis for this determination, as well as a plan to
address the health needs of the service delivery
changes needed to improve care among chronically homeless
beneficiaries and frequent hospital users to the appropriate
policy and fiscal committees of the Legislature .
(B) The requirement for submitting the report and plan
under subparagraph (A) is inoperative four years after the
date the report is due, pursuant to Section 10231.5 of the Government
Code.
(c) A state plan amendment and any necessary Section 1115
waiver amendments submitted pursuant to this section shall
target adult beneficiaries who meet both of the following criteria:
(1) Have current diagnoses of chronic, co-occurring
physical health, mental health, or substance use disorders
prevalent among frequent hospital users.
(2) Have a level of severity in conditions established by the
department, based on one or more of the following factors:
(A) Frequent inpatient hospital admissions, including
hospitalization for medical, psychiatric, or substance use related
conditions.
(B) Excessive use of crisis or emergency services.
(C) Chronic homelessness.
(d) (1) For the purposes of providing health home services to
targeted beneficiaries who meet the criteria
the population identified in subdivision (c), the department
shall select designated health home providers
, managed care organizations subcontracting with providers,
or counties acting as or subcontracting with providers operating as a
health home team that have or providers who plan to
subcontract with health home team members with all of the
following:
(A) Demonstrated experience working with frequent hospital or
emergency department users.
(B) Demonstrated experience working with people who are
chronically homeless.
(C) The capacity and administrative infrastructure to participate
in the program Health Home Program ,
including the ability to meet requirements of federal guidelines.
(D) A viable plan, with roles identified among providers of the
health home, to do all of the following:
(i) Reach out to and engage frequent hospital or emergency
department users and chronically homeless eligible individuals.
(ii) Link eligible individuals who are homeless or experiencing
housing instability to permanent housing, such as supportive housing.
(iii) Ensure coordination and linkages to services needed to
access and maintain health stability, including medical, mental
health, and substance use care, and
as well as social services and supports to
address social determinants of health.
(2) The department may design additional provider criteria to
those identified in paragraph (1) after consultation with stakeholder
groups who have expertise in engagement and services for
targeted beneficiaries described in this section the
population identified in subdivision (c) .
(3) The department may authorize health home providers eligible
under this subdivision to serve Medi-Cal enrollees through a
fee-for-service or managed care delivery system, and shall
may allow for both
county-operated and other public and private providers to
participate in the California Health Home program
this program .
(4) The If the department
designs a state plan amendment designed to serve the population
identified in subdivision (c), the department shall design
strategies to outreach to, engage, and provide health home services
to the targeted beneficiaries the population
identified in subdivision (c), based on consultation with
stakeholder groups stakeholders who
have expertise in engaging and ,
providing services to these targeted beneficiaries
, and designing programs addressing the needs of, the
population .
(5) The department shall design other health home elements,
including provider rates specific to targeted beneficiaries described
in subdivision (c), after consultation with stakeholder groups who
have expertise in engaging and providing services to these targeted
beneficiaries.
(6)
(5) If the department creates a health home program
that targets adults described in subdivision (c), the department may
also submit state plan amendments and any necessary waiver
amendments targeting other adult populations.
14127.4. (a) The department shall administer this article in a
manner that attempts to maximize federal financial participation,
consistent with federal law.
(b) Except as provided in Section 14127.6, the nonfederal share
shall be provided by funds from local governments, private
foundations, or any other source permitted under federal law. The
department, or counties contracting with the department, may also
enter into risk-sharing and social impact bond program agreements to
fund services under this article.
(c) In accordance with federal guidelines, the state may limit
availability of health home or enhanced health home services
geographically.
14127.5. (a) If the department creates a health home
program Health Home Program , the department
shall ensure that an evaluation of the program is completed and
shall, within two years after implementation, submit a report to the
appropriate policy and fiscal committees of the Legislature.
(b) The requirement for submitting the report under subdivision
(a) is inoperative four years after the date the report is due,
pursuant to Section 10231.5 of the Government Code.
14127.6. (a) This article shall be implemented
The department shall fund health home services only if
and to the extent federal financial participation is available and
the federal Centers for Medicare and Medicaid Services approves any
state plan amendments sought pursuant to this article.
(b) Except as provided in subdivisions (c) and (d)
subdivision (c) , this article shall be
implemented only if no additional General Fund moneys are used to
fund the administration and costs of services.
(c) Notwithstanding subdivision (b), prior to and during
the first eight quarters of implementation, if the
department projects, based on analysis of current and projected
expenditures for health home services , prior
to, during, or after the first eight quarters of implementation,
that this article can be implemented in a manner that does not
or will not result in a net increase in ongoing General
Fund costs for the Medi-Cal program, the department may use state
funds to fund any program Health Home Program
costs.
(d) Notwithstanding subdivision (b), if the department projects,
after the first eight quarters of implementation, that implementation
of this article has not resulted in a net increase in ongoing
General Fund costs for the Medi-Cal program, the department may use
state funds to fund any program costs.
(e)
( d) The department may use new funding in
the form of enhanced federal financial participation for health home
services that are currently funded to fund any
additional costs for new health home program
Health Home Program services.
(f)
( e) The department shall seek to fund the
creation, implementation, and administration of the program with
funding other than state general funds.
(g)
( f) The department may revise or terminate
the health home program Health Home Program
any time after the first eight quarters of implementation if
the department finds that the program fails to result in
improved health outcomes reduced inpatient stays,
hospital admission rates, and emergency department visits, or
results in substantial General Fund expense without commensurate
decreases in Medi-Cal costs among program participants.
14128. (a) In the event of a judicial challenge of the provisions
of this article, this article shall not be construed to create an
obligation on the part of the state to fund any payment from state
funds due to the absence or shortfall of federal funding.
(b) For the purposes of implementing this article, the department
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 under this article. Contracts may be
statewide or on a more limited geographic basis. Contracts entered
into or amended under 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 the Government Code, and
shall be exempt from the review or approval of any division of the
Department of General Services.
(c) (1) 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 the process
set forth in this article by means of all-county letters, plan
letters, plan or provider bulletins, or similar instructions, without
taking regulatory action, until such time as regulations are
adopted. It is the intent of the Legislature that the department be
provided temporary authority as necessary to implement program
changes until completion of the regulatory process.
(2) The department shall adopt emergency regulations no later than
two years after implementation of this article. The department may
readopt, up to two times, any emergency regulation authorized by this
section that is the same as or substantially equivalent to an
emergency regulation previously adopted pursuant to this section.
(3) The initial adoption of emergency regulations implementing
this article and the readoptions of emergency regulations authorized
by this section shall be deemed an emergency and necessary for the
immediate preservation of the public peace, health, safety, or
general welfare. Initial emergency regulations and readoptions
authorized by this section shall be exempt from review by the Office
of Administrative Law. The initial emergency regulations and
readoptions authorized by this section shall be submitted to the
Office of Administrative Law for filing with the Secretary of State
and shall remain in effect for no more than 180 days, by which time
final regulations may be adopted.