California Legislature—2013–14 Regular Session

Assembly Bill No. 776

Introduced by Assembly Member Yamada

February 21, 2013

An act to amend Sections 14186.1, 14186.36, and 14186.4 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

AB 776, as introduced, Yamada. Medi-Cal.

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, to the extent that federal financial participation is available, and pursuant to a demonstration project or waiver of federal law, the department to establish specified pilot projects in up to 8 counties, and requires long-term services and supports, as defined, to be available to beneficiaries residing in counties participating in those pilot projects.

In implementing the requirements that beneficiaries residing in counties participating in those pilot projects be provided long-term services and supports, existing law requires the department to consult stakeholders. For the purposes of existing law, specified terms are defined.

This bill would additionally define the term “stakeholder” to include area agencies on aging and independent living centers. The bill would also make related conforming changes.

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 14186.1 of the Welfare and Institutions
Code is amended to read:

14186.1.  

For purposes of this article, the following definitions
shall apply unless otherwise specified:

(a) “Home- and community-based services” means services
provided pursuant to paragraphs (1), (2), and (3) of subdivision
(b).

(b) “Long-term services and supports” or “LTSS” means all of
the following:

(1) In-home supportive services (IHSS) provided pursuant to
Article 7 (commencing with Section 12300) of Chapter 3, and
Sections 14132.95, 14132.952, and 14132.956.

(2) Community-Based Adult Services (CBAS).

(3) Multipurpose Senior Services Program (MSSP) services
include those services approved under a federal home- and
community-based services waiver or, beginning January 1, 2015,
equivalent services.

(4) Skilled nursing facility services and subacute care services
established under subdivision (c) of Section 14132, including those
services described in Sections 51511 and 51511.5 of Title 22 of
the California Code of Regulations, regardless of whether the
service is included in the basic daily rate or billed separately, and
any leave of absence or bed hold provided consistent with Section
72520 of Title 22 of the California Code of Regulations or the
state plan.

However, services provided by any category of intermediate
care facility for the developmentally disabled shall not be
considered long-term services and supports.

(c) “Home- and community-based services (HCBS) plan
benefits” may include in-home and out-of-home respite, nutritional
assessment, counseling, and supplements, minor home or
environmental adaptations, habilitation, and other services that
may be deemed necessary by the managed care health plan,
including its care coordination team. The department, in
consultation with stakeholders, may determine whether health
plans shall be required to include these benefits in their scope of
service, and may establish guidelines for the scope, duration, and
intensity of these benefits. The grievance process for these benefits
shall be the same process as used for other benefits authorized by
managed care health plans, and shall comply with Section 14450,
and Sections 1368 and 1368.1 of the Health and Safety Code.

(d) “Managed care health plan” means an individual,
organization, or entity that enters into a contract with the
department pursuant to Article 2.7 (commencing with Section
14087.3), Article 2.8 (commencing with Section 14087.5), Article
2.81 (commencing with Section 14087.96), or Article 2.91
(commencing with Section 14089), of this chapter, or Chapter 8
(commencing with Section 14200). For the purposes of this article,
“managed care health plan” shall not include an individual,
organization, or entity that enters into a contract with the
department to provide services pursuant to Chapter 8.75
(commencing with Section 14591) or the Senior Care Action
Network.

(e) “Other health coverage” means health coverage providing
the same full or partial benefits as the Medi-Cal program, health
coverage under another state or federal medical care program
except for the Medicare Program (Title XVIII of the federal Social
Security Act (42 U.S.C. Sec. 1395 et seq.)), or health coverage
under a contractual or legal entitlement, including, but not limited
to, a private group or indemnification insurance program.

(f) “Recipient” means a Medi-Cal beneficiary eligible for IHSS
provided pursuant to Article 7 (commencing with Section 12300)
of Chapter 3, and Sections 14132.95, 14132.952, and 14132.956.

begin insert

(g) “Stakeholder” shall include, but shall not be limited to, area
agencies on aging and independent living centers.

end insert

SEC. 2.  

Section 14186.36 of the Welfare and Institutions Code
is amended to read:

14186.36.  

(a) It is the intent of the Legislature that a universal
assessment process for LTSS be developed and tested. The initial
uses of this tool may inform future decisions about whether to
amend existing law regarding the assessment processes that
currently apply to LTSS programs, including IHSS.

(b) (1) In addition to the activities set forth in paragraph (9) of
subdivision (a) of Section 14186.35, county agencies shall continue
IHSS assessment and authorization processes, including making
final determinations of IHSS hours pursuant to Article 7
(commencing with Section 12300) of Chapter 3 and regulations
promulgated by the State Department of Social Services.

(2) No sooner than January 1, 2015, for the counties and
beneficiary categories specified in subdivision (e), counties shall
also utilize the universal assessment tool, as described in
subdivision (c), if one is available and upon completion of the
stakeholder process, system design and testing, and county training
described in subdivisions (c) and (e), for the provision of IHSS
services. This paragraph shall only apply to beneficiaries who
consent to the use of the universal assessment process. The
managed care health plans shall be required to cover IHSS services
based on the results of the universal assessment process specified
in this section.

(c) (1) No later than June 1, 2013, the department, the State
Department of Social Services, and the California Department of
Aging shall establish a stakeholder workgroup to develop the
universal assessment process, including a universal assessment
tool, for home- and community-based services, as defined in
subdivision (a) of Section 14186.1. The stakeholder workgroup
shall include, but not be limited to, consumers of IHSS and other
home- and community-based services and their authorized
representatives, managed care health plans, counties, IHSS, MSSP,
and CBAS providers, begin insert area agencies on aging, independent living
centers, end insert and legislative staff. The universal assessment process
shall be used for all home- and community-based services,
including IHSS. In developing the process, the workgroup shall
build upon the IHSS uniform assessment process and hourly task
guidelines, the MSSP assessment process, and other appropriate
home- and community-based assessment tools.

(2) (A) In developing the universal assessment process, the
departments described in paragraph (1) shall develop a universal
assessment tool that will inform the universal assessment process
and facilitate the development of plans of care based on the
individual needs of the consumer. The workgroup shall consider
issues including, but not limited to, the following:

(i) The roles and responsibilities of the health plans, counties,
and home- and community-based services providers administering
the assessment.

(ii) The criteria for reassessment.

(iii) How the results of new assessments would be used for the
oversight and quality monitoring of home- and community-based
services providers.

(iv) How the appeals process would be affected by the
assessment.

(v) The ability to automate and exchange data and information
between home- and community-based services providers.

(vi) How the universal assessment process would incorporate
person-centered principles and protections.

(vii) How the universal assessment process would meet the
legislative intent of this article and the goals of the demonstration
project pursuant to Section 14132.275.

(viii) The qualifications for, and how to provide guidance to,
the individuals conducting the assessments.

(B) The workgroup shall also consider how this assessment may
be used to assess the need for nursing facility care and divert
individuals from nursing facility care to home- and
community-based services.

(d) No later than March 1, 2014, the department, the State
Department of Social Services, and the California Department of
Aging shall report to the Legislature on the stakeholder
workgroup’s progress in developing the universal assessment
process, and shall identify the counties and beneficiary categories
for which the universal assessment process may be implemented
pursuant to subdivision (e).

(e) (1) No sooner than January 1, 2015, upon completion of
the design and development of a new universal assessment tool,
managed care health plans, counties, and other home- and
community-based services providers may test the use of the tool
for a specific and limited number of beneficiaries who receive or
are potentially eligible to receive home- and community-based
services pursuant to this article in no fewer than two, and no more
than four, of the counties where the provisions of this article are
implemented, if the following conditions have been met:

(A) The department has obtained any federal approvals through
necessary federal waivers or amendments, or state plan
amendments, whichever is later.

(B) The system used to calculate the results of the tool has been
tested.

(C) Any entity responsible for using the tool has been trained
in its usage.

(2) To the extent the universal assessment tool or universal
assessment process results in changes to the authorization process
and provision of IHSS services, those changes shall be automated
in the Case Management Information and Payroll System.

(3) The department shall develop materials to inform consumers
of the option to participate in the universal assessment tool testing
phase pursuant to this paragraph.

(f) The department, the State Department of Social Services,
and the California Department of Aging shall implement a
rapid-cycle quality improvement system to monitor the
implementation of the universal assessment process, identify
significant changes in assessment results, and make modifications
to the universal assessment process to more closely meet the
legislative intent of this article and the goals of the demonstration
project pursuant to Section 14132.275.

(g) Until existing law relating to the IHSS assessment process
pursuant to Article 7 (commencing with Section 12300) of Chapter
3 is amended, beneficiaries shall have the option to request an
additional assessment using the previous assessment process for
those home- and community-based services and to receive services
according to the results of the additional assessment.

(h) No later than nine months after the implementation of the
universal assessment process, the department, the State Department
of Social Services, and the California Department of Aging, in
consultation with stakeholders, shall report to the Legislature on
the results of the initial use of the universal assessment process,
and may identify proposed additional beneficiary categories or
counties for expanded use of this process and any necessary
changes to provide statutory authority for the continued use of the
universal assessment process. These departments shall report
annually thereafter to the Legislature on the status and results of
the universal assessment process.

(i) The provisions of this section shall remain operative only
until July 1, 2017.

SEC. 3.  

Section 14186.4 of the Welfare and Institutions Code
is amended to read:

14186.4.  

(a) This article shall be implemented only to the
extent that all necessary federal approvals and waivers have been
obtained and only if and to the extent that federal financial
participation is available.

(b) Notwithstanding any other law, the director, after consulting
with the Director of Finance, stakeholders, and the Legislature,
retains the discretion to forgo the provision of services in the
manner specified in this article in its entirety, or partially, if and
to the extent that the director determines that the quality of care
for managed care beneficiaries, efficiency, or cost-effectiveness
of the program would be jeopardized. In the event the director
discontinues the provision of services in the manner specified in
this article, contracts implemented pursuant to this article shall
accordingly be modified or terminated, to suspend new enrollment
or disenroll beneficiaries in an orderly manner that provides for
continuity of care and the safety of beneficiaries.

(c) To implement this article, the department may contract with
public or private entities. Contracts, or amendments to current
contracts, entered into under this article may be on a
noncompetitive bid basis and shall be exempt from all of the
following:

(1) Part 2 (commencing with Section 10100) of Division 2 of
the Public Contract Code and any policies, procedures, or
regulations authorized by that part.

(2) Article 4 (commencing with Section 19130) of Chapter 5
of Part 2 of Division 5 of Title 2 of the Government Code.

(3) Review or approval of contracts by the Department of
General Services.

(4) Review or approval of feasibility study reports and the
requirements of Sections 4819.35 to 4819.37, inclusive, and
Sections 4920 to 4928, inclusive, of the State Administrative
Manual.

(d) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the State Department of Health Care Services and State Department
of Social Services may implement, interpret, or make specific this
section 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 departments shall notify and consult with
stakeholders, including beneficiaries, providers, begin insert area agencies on
aging, independent living centers, end insert and advocates.

(e) Beginning July 1, 2012, the department shall provide the
fiscal and appropriate policy committees of the Legislature with
a copy of any report submitted to CMS that is required under an
approved federal waiver or waiver amendments or any state plan
amendment for any LTSS.

(f) The department shall enter into an interagency agreement
with the Department of Managed Health Care to perform some or
all of the department’s oversight and readiness review activities
specified in this article. These activities may include providing
consumer assistance to beneficiaries affected by this article, and
conducting financial audits, medical surveys, and a review of the
provider networks of the managed care health plans participating
in this article. The interagency agreement shall be updated, as
necessary, on an annual basis in order to maintain functional clarity
regarding the roles and responsibilities of the Department of
Managed Health Care and the department. The department shall
not delegate its authority as the single state Medicaid agency under
this article to the Department of Managed Health Care.

(g) (1) Beginning with the May Revision to the 2013-14
Governor’s Budget, and annually thereafter, the department shall
report to the Legislature on the enrollment status, quality measures,
and state costs of the actions taken pursuant to this article.

(2) (A) By January 1, 2013, or as soon thereafter as practicable,
the department shall develop, in consultation with CMS and
stakeholders, quality and fiscal measures for managed care health
plans to reflect the short- and long-term results of the
implementation of this article. The department shall also develop
quality thresholds and milestones for these measures. The
department shall update these measures periodically to reflect
changes in this program due to implementation factors and the
structure and design of the benefits and services being coordinated
by the health plans.

(B) The department shall require managed care health plans to
submit Medicare and Medi-Cal data to determine the results of
these measures. If the department finds that a health plan is not in
compliance with one or more of the measures set forth in this
section, the health plan shall, within 60 days, submit a corrective
action plan to the department for approval. The corrective action
plan shall, at a minimum, include steps that the health plan shall
take to improve its performance based on the standard or standards
with which the health plan is out of compliance. The corrective
action plan shall establish interim benchmarks for improvement
that shall be expected to be met by the health plan in order to avoid
a sanction pursuant to Section 14304. Nothing in this paragraph
is intended to limit the application of Section 14304.

(C) The department shall publish the results of these measures,
including via posting on the department’s Internet Web site, on a
quarterly basis.