BILL ANALYSIS �
AB 776
Page 1
Date of Hearing: April 9, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 776 (Yamada) - As Introduced: February 21, 2013
SUBJECT : Medi-Cal.
SUMMARY : Defines Stakeholder for purposes of the Medi-Cal Long
Term Services and Support Integration (LTSS) Demonstration
Project as including but not limited to, area agencies on aging
(AAA) and independent living centers (ILCs). Adds AAAs and ILCs
to the stakeholder group currently required to be established by
June 1, 2013 to develop a uniform assessment tool for In Home
Support Services (IHSS) and other Home and Community Based
Services (HCBS). Adds AAAs and ILCs to the list of stakeholders
that are to be notified and consulted by the Department of
Health Care Services (DHCS) and the Department of Social
Services (DSS) prior to taking actions by means of the
all-county letters, plan or provider bulletins, or similar
instructions in lieu of taking regulatory action when
implementing the LTSS Demonstration Project.
EXISTING LAW :
1)Establishes the Medicaid Program (Medi-Cal in California) as a
joint federal-state program to provide health care services to
low-income families with children, seniors, and persons with
disabilities (SPDs).
2)Establishes Medicare as a federal health insurance program to
provide coverage to eligible individuals who are disabled or
over age 65.
3)Establishes, in the federal Affordable Care Act, in the
federal Centers on Medicare and Medicaid Services (CMS), the
Federal Coordinated Health Care Office (Medicare-Medicaid
Coordination Office) and the Center for Medicare and Medicaid
Innovation to test innovative payment and delivery models to
lower costs and improve quality for enrollees who are dually
eligible for Medi-Cal and Medicare (dual eligibles).
4)Establishes the Coordinated Care Initiative (CCI) that
requires DHCS to seek federal approval to establish
demonstration sites in up to eight counties to provide
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coordinated Medi-Cal and Medicare benefits to dual eligibles
and authorizes DHCS to require SPDs who are eligible for
Medi-Cal only (not Medicare) to mandatorily enroll in Medi-Cal
managed care (MCMC) plans (MCPs). Requires consultation with
stakeholders in implementing these provisions.
5)Requires county agencies to conduct IHSS assessments and
authorization processes and provides for the development and
utilizations of a universal assessment tool no sooner than
January 1, 2015, as specified.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author this bill is
needed to define "stakeholders" to ensure that specific
groups, such as AAA's and ILC's are consulted in order to
establish proper LTSSs and managed care services for dual
eligibles in the implementation of the CCI in the eight
designated pilot project counties. According to the author,
the passage of the CCI marked an important step toward
transforming California's Medi-Cal care delivery system to
better serve the state's low-income SPDs. The author states
that building upon many years of stakeholder discussions, CCI
begins the process of integrating delivery of medical,
behavioral, and LTSS and provides a road map to integrate
Medicare and Medi-Cal for people in both programs. The author
points out that SB 1008 (Committee on Budget and Fiscal
Review), Chapter 33, Statutes of 2012 requires DHCS to consult
with stakeholders while preparing for various aspects of the
CCI implementation and oversight. However, stakeholders are
undefined under the CCI. The author concludes that AAAs and
ILCs are uniquely positioned with long-standing working
relationships and expertise in serving the CCI population.
The author states that including AAA's and ILC's in CCI
implementation will contribute to better planning, organizing,
monitoring, and assessing of services to California's SPDs and
their families.
2)BACKGROUND . In November of 2010, California obtained federal
approval for a Section 1115(b) Medicaid Demonstration Waiver
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from CMS entitled "A Bridge to Reform Waiver." Among other
provisions, this waiver authorized mandatory enrollment into
MCPs of over 600,000 low-income SPDs who are eligible for
Medi-Cal only (not Medicare) in 16 counties. Enrollment was
phased in over a one-year period in the affected counties;
beginning on June 1, 2011. Services covered were preventative
and acute medical services including out-patient, primary
care, specialty care, care coordination, in-patient services,
durable medical equipment, drugs, and medical transportation.
LTSS were carved out of managed care and are largely provided
through fee-for-service (FFS). In the proposed 2012-13
Budget, the Brown Administration requested authority from the
Legislature to allow a statewide CCI and proposed to include
LTSS for dual eligibles and SPDs into a coordinated delivery
system that would be delivered using managed care models. The
LTSSs proposed to be integrated included IHSS, Community-Based
Adult Services (CBAS), Multipurpose Senior Services (MSSP),
and skilled-nursing facility (SNF) services. The Legislature
enacted a modified version of the Governor's proposal in SB
1008, and SB 1036 (Committee on Budget and Fiscal Review),
Chapter 45, Statutes of 2012.
The two major parts of the CCI are the "Duals Demonstration" and
"Managed Medi-Cal LTSS." The Duals Demonstration is a
voluntary three-year demonstration for dual eligible
beneficiaries to receive coordinated medical, behavioral
health, long-term institutional, and HCBS services through a
single organized delivery system. The demonstration is
limited to eight counties, beginning no sooner than March
2103. The eight counties selected are Alameda, Los Angeles,
Orange, Riverside, San Bernardino, San Diego, San Mateo, and
Santa Clara. The CCI will use a capitated payment model to
provide Medicare and Medi-Cal benefits through existing MCPs.
The Managed Medi-Cal LTSS requires Medi-Cal-only SPDs (who are
currently mandated to enroll in a MCP for health care
services) and dual eligibles to receive their Medi-Cal LTSS
and behavioral and health care services through the same
plans.
SB 1008 required the Administration to consult with stakeholders
while preparing for various aspects of CCI implementation and
oversight. SB 1036 primarily made changes to IHSS, including
changes to counties' share of cost for IHSS and a shift to
statewide collective bargaining for IHSS provider wages and
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benefits-beginning with the eight demonstration counties. SB
1036 also required a stakeholder workgroup to develop a
universal assessment tool for HCBS. DHCS has convened six
stakeholder workgroups to solicit input and develop standards
related to the duals demonstration. These include: a) LTSS
and IHSS integration; b) behavioral health integration; c)
beneficiary notices and protections; d) quality and
evaluation; e) provider outreach; and, f) fiscal and
rate-setting.
3)Cal MediConnect . Federal approval for the dual eligible
portion of the CCI was received on March 27, 2013 in the form
of a Memorandum of Understanding (MOU), referred to as the Cal
MediConnect program. This component is the framework for the
demonstration allowing the combination of all Medicare and
Medi-Cal benefits into one plan. The MOU contains several
changes from the state's original proposal. Enrollment will
begin no earlier than October 2013. Beneficiaries would begin
receiving notices about their choices and upcoming changes no
earlier than July 2013. Beneficiaries who enroll in a Cal
MediConnect health plan can opt out at any time. California
originally proposed an initial six-month period, during which
eligible beneficiaries would have been required to remain in
the same health plan. The MOU allows for 456,000 total
beneficiaries to be eligible for enrollment into the Cal
MediConnect program. This is almost half the size called for
in the Governor's 2012-13 Budget Proposal of January 2012.
The number of enrollees in Los Angeles County will be capped
at 200,000 and enrollment will occur over a 15 month period.
There are also specified exempt populations, such as persons
with developmental disabilities receiving services through a
regional center, persons enrolled in specified waiver
programs, and except in San Mateo and Orange counties, persons
with end stage renal disease. In San Mateo enrollment will be
completed by January 1, 2014 and in the other six counties,
enrollment will be over a 12 month period.
4)POPULATION CHARACTERISTICS . About 1.9 million SPDs are
enrolled in Medi-Cal. The majority of SPDs are also eligible
for Medicare, the federal program that provides medical
services to qualifying persons over age 65 and certain persons
with disabilities. The SPDs who are eligible for both
Medi-Cal and Medicare are known as dual eligibles and receive
services paid by both programs. Most of the 1.2 million dual
eligibles in California currently receive both their medical
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and LTSS benefits under FFS. Although more than half of the
700,000 Medi-Cal-only SPDs have been mandatorily enrolled in
MCMC for their medical benefits, they also continue to receive
most LTSS benefits under FFS. Generally, SPDs are more
expensive to serve than other Medi-Cal beneficiaries because
of the higher prevalence of complex medical conditions and
greater functional needs within this population. According to
the Legislative Analyst's Office (LAO), CCI Update, February
2013, in 2011-12, SPDs represented 25% of enrollment but 60%
of General Fund expenditures in the Medi-Cal program. The LAO
stated that the high cost of SPDs may be exacerbated by the
fragmentation of care under the current framework, in which
Medi-Cal FFS, MCMC, and Medicare function in silos. Over 35%
are receiving LTSS and 5% are residents of a LTC facility.
Forty-four percent have three of more chronic conditions. The
top three are diabetes (41.6%), arthritis (31.8%), and heart
disease (29.1%).
5)LTSS . LTSS are a wide variety of services and supports that
help eligible beneficiaries meet their daily needs for
assistance and improve the quality of their lives. Examples
include assistance with bathing, dressing, and other basic
activities of daily life and self-care, as well as support for
everyday tasks such as laundry, shopping, and transportation.
LTSS are provided over an extended period, predominantly in
homes and communities, but also in facility-based settings
such as nursing facilities. Medi-Cal covered LTSS includes:
a) IHSS that provides in-home care for people who cannot
safely remain in their own homes without assistance. To
qualify for IHSS, an enrollee must be aged, blind, or
disabled and, in most cases, have income below the level to
qualify for the Supplemental Security Income/State
Supplementary Program;
b) CBAS is an outpatient, facility-based service program
that delivers skilled nursing care, social services,
therapies, personal care, family and caregiver training,
and support, meals, and transportation;
c) MSSP, a California specific program under a Section
1915(c) HCBS waiver to Medi-Cal eligible individuals who
are 65 years or older with disabilities as an alternative
to nursing facility placement: and,
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d) SNF services and subacute care services.
6)UNIFORM ASSESSMENT TOOL . According to a background paper
prepared for the Senate Human Services Committee Informational
Hearing, March 27, 2012, IHSS Integration into Medi-Cal
Managed Care: Policy Considerations, in 1988 DSS implemented a
Uniform Assessment Tool on a statewide basis in order to
assure that IHSS was delivered in all counties in a uniform
manner. This functional index tool applied only to IHSS, and
is not integrated with other LTSS including CBAS, MSSP, and
other waiver programs. It is based on a "Functional Index
Rank" for each of the activities of daily living. Counties
use statewide hourly task guidelines, established by DSS when
conducting assessments in order to consistently assess and
authorize services hours. According to regulations, the time
authorized must be based on the recipient's individual level
of need necessary to ensure his/her health, safety, and
independence based on the scope of tasks identified for
service. Additionally, current law requires recipients to
obtain a certification from a licensed health care
professional declaring that the applicant or recipient is
unable to perform some activities of daily living
independently, and that without services to assist him or her
with activities of daily living, the applicant or recipient is
at risk of placement in out-of-home care.
SB 1036 requires DSS, DHCS, and the California Department of
Aging (CDA) to establish a stakeholder workgroup to develop
the universal assessment process no later than June 1, 2013
and to develop a universal assessment tool for IHSS, CBAS, and
MSSP. The work group is required to build on the IHSS
assessment process, the MSSP assessment process, and other
appropriate HCBS assessment tools to develop a single
assessment tool that can be used to determine a person's level
of need for all three HCBS programs. SB 1036 stipulates that
a universal assessment tool will be used no sooner than
January 1, 2015.
The MOU with CMS requires the state to design, develop and
test a universal assessment process, including a universal
assessment tool, in 2015 for LTSS. It also requires the
process to be developed with stakeholder input, and initially
tested by a specified group of beneficiaries and in a limited
number of counties. The MOU requires the development, testing
and implementation to be consistent with the requirements set
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by SB 1036.
In the meantime, the MOU specifies that participating plans
will provide enrollees with an in-depth assessment process to
identify primary, acute, LTSS, and behavioral health and
functional needs. This assessment will incorporate standard
assessment questions specified by the State. It further
states that for all enrollees, the assessment process will, at
a minimum, identify, among other things, referrals to
appropriate LTSS and HCBS, such as behavioral health, IHSS,
CBAS, MSSP, personal care services, and nutrition programs.
County social workers will continue to assess IHSS applicants
for their level of need for services hours.
7)AAA . AAAs are established by federal law through the Older
Americans Act to lead in the planning, development and
monitoring of local systems of care for older adults. CDA
divides the state in 33 Planning and Service Areas (PSAs).
Within each PSA is an AAA responsible for planning and
administering services to seniors. The network of AAAs is
comprised of public agencies and nonprofit organizations whose
work focuses upon improving access to LTSS. AAAs directly
manage a wide array of federal and state-funded services that
help older adults find employment; support older and disabled
individuals to live as independently as possible in the
community; promote healthy aging and community involvement;
and, assist family members in their vital care giving role.
8)ILC . ILCs are non-profit organizations that assist people
with disabilities with a variety of daily living tasks. ILCs
also work with local and regional governments to improve
infrastructure, raise awareness about disability issues, and
advocate for legislation that promotes equal opportunities and
prohibits segregation and discrimination of people with
disabilities.
9)SUPPORT . The California Association of Area Agencies on Aging
(C4A), the statewide organization representing California's 33
area agencies on aging states in support that this bill is a
modest but important step to ensure the integration of AAAs
and independent centers in the dual demonstration pilots and
establish a linkage to their system planning and coordination
expertise. C4A contends that by not specifying these entities
as "stakeholders," the CCI statutes created a systemic barrier
for the coordination of LTSS; a primary goal of the CCI.
According to C4A, this sets up the risk to overlook the
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important role of the broader LTSS network led by area
agencies and the centers. These respective systems comprise
most LTSS that the managed care plans will rely on to keep
beneficiaries independent and living at home. Supporters,
including the California Commission on Aging and the
Alzheimer's Association, also state that inclusion of the AAA
and the ILC will enhance and strengthen CCI planning and
development efforts and provide a more accurate model for
comprehensive coordination of care across all sectors;
primary, acute, behavioral health and LTSS.
10)DOUBLE REFERRAL . This bill is double-referred, should it
pass out of this Committee, it will be referred to the
Committee on Aging and Long-Term Care.
11)RELATED LEGISLATION .
a) AB 209 (Pan) enacts the Medi-Cal Managed Care Quality
and Transparency Act of 2013 and requires the DHCS to
develop and implement a plan to monitor, evaluate, and
improve the quality and accessibility of health care and
dental services provided through MCMC. AB 209 is pending
in the Assembly Health Committee.
b) AB 518 (Yamada) establishes CBAS as a benefit in the
Medi-Cal program. Specifies the criteria for eligibility,
requires that CBAS be provided at licensed Adult Day Health
Centers certified by the DHCS as CBAS providers as
specified. Requires CBAS providers to meet specified
standards and, beginning July 1, 2015, have a non-profit
status. Provides for CBAS through MCMC or FFS, as
specified. Requires submission of a quality assurance
proposal to the legislature and specifies legislative
findings, declarations and intent.
12)PREVIOUS LEGISLATION .
a) SB 1008 and SB 1036 authorize the CCI as an eight-county
pilot project to: i) integrate Medi-Cal and Medicare
benefits under managed care for dual eligibles; and, ii)
integrate LTSS under managed care for dual eligibles and
Medi-Cal-only SPDs.
b) SB 208 (Steinberg), Chapter 714, Statutes of 2010,
contained the provisions implementing Section 1115(b)
Medicaid Demonstration Waiver from CMS entitled "A Bridge
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to Reform Waiver." Among the provisions, this waiver
authorized mandatory enrollment into MCPs of over 600,000
low-income SPDs who are eligible for Medi-Cal only (not
Medicare) in 16 counties
REGISTERED SUPPORT / OPPOSITION :
Support
Alzheimer's Association
California Association of Area Agencies on Aging
California Association of Public Authorities
California Commission on Aging
PSA 2 Area Agency on Aging
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097