California Legislature—2013–14 Regular Session

Assembly Bill No. 1310

Introduced by Assembly Member Brown

February 22, 2013

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

LEGISLATIVE COUNSEL’S DIGEST

AB 1310, as introduced, Brown. Medi-Cal: pediatric subacute care.

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. For the purposes of the subacute care program, existing law defines pediatric subacute services as 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. Existing law also provides that, for the purposes of the subacute care program, medical necessity for pediatric subacute care services, as defined, shall be substantiated in one of 5 ways.

This bill would expand the definition of pediatric subacute services to include the health care services needed by a person between 21 and 22 years of age who uses a medical technology that compensates for the loss of a vital bodily function and to include the health care services needed by a person under 22 years of age who requires treatment for one or more active complex medical conditions or requires the administration of one or more technically complex treatments.

This bill would also provide that one of the ways that medical necessity for pediatric subacute care services shall be substantiated is by dependence on complex wound care management or the presence of a medical condition and necessity of care such that his or her health care needs may be satisfied by placement in a facility providing pediatric subacute care services, but, in the absence of access to a pediatric subacute care service, the only alternative in patient care sufficient to meet the patient’s medical needs is an acute care hospital bed. The bill would also provide that medical necessity may be shown solely by dependence on total parenteral nutrition or other intravenous nutritional support, without a showing of dependence on additional treatments, and by dependence on tracheostomy care, as specified, in conjunction with dependence on tube feeding by means of a jejunostomy tube.

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 14132.25 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 begin delete 21 end delete begin insert 22 end insert years
of age who uses a medical technology that compensates for the
loss of a vital bodily begin delete function. end delete begin insert function, requires treatment for one
or more active complex medical conditions, or requires the
administration of one or more technically complex treatments. end insert

(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 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.

(B) Dependence on continuous intravenous therapy, including
administration of a therapeutic agent necessary for hydration or
of intravenous pharmaceuticals, or intravenous pharmaceutical
administration of begin delete more than one agent, end delete begin insert one or more agents, end insert via a
peripheral or central line, without continuous infusion.

(C) Dependence on peritoneal dialysis treatments requiring at
least four exchanges every 24 hours.

(D) Dependence on tube feeding by means of a begin delete nasogastric or
gastrostomy end delete begin insert nasogastric, gastrostomy, or jejunostomy end insert tube.

(E) Dependence on other medical technologies required
continuously, begin delete which end delete begin insert that end insert , in the opinion of the attending physician
and the Medi-Cal consultant, require the services of a begin delete professional end delete
begin insert licensed registered end insert nurse.

(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 begin delete support, and dependence on one of the treatment
procedures specified in subparagraphs (A) to (F), inclusive, of
paragraph (2). end delete begin insert support. end insert

(4) Dependence on skilled nursing care in the administration of
any three of the begin insert following end insert six treatment begin delete procedures specified in
subparagraphs (A) to (F), inclusive, of paragraph (2). end delete begin insert procedures: end insert

begin insert

(A) Dependence on intermittent suctioning at least every eight
hours and room air mist and oxygen as needed.

end insert begin insert

(B) Dependence on continuous intravenous therapy, including
administration of a therapeutic agent necessary for hydration or
of intravenous pharmaceuticals, or intravenous pharmaceutical
administration of one or more agents, via a peripheral or central
line, without continuous infusion.

end insert begin insert

(C) Dependence on peritoneal dialysis treatments requiring at
least four exchanges every 24 hours.

end insert begin insert

(D) Dependence on tube feeding by means of a nasogastric,
gastrostomy, or jejunostomy tube.

end insert begin insert

(E) Dependence on other medical technologies required
continuously that in the opinion of the attending physician and the
Medi-Cal consultant, require the services of a licensed registered
nurse.

end insert begin insert

(F) Dependence on biphasic positive airway pressure at least
six hours a day, including assessment or intervention every three
hours for a patient lacking either cognitive or physical ability of
the patient to protect his or her airway.

end insert

(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 begin delete and end delete begin insert , for a
patient end insert lacking either cognitive or physical ability begin delete of the patient end delete
to protect his or her airway begin insert , end insert and dependence on one of the begin insert following end insert
five treatment begin delete procedures specified in subparagraphs (A) to (E),
inclusive, of paragraph (2). end delete begin insert procedures: end insert

begin insert

(A) Dependence on intermittent suctioning at least every eight
hours and room air mist and oxygen as needed.

end insert begin insert

(B) Dependence on continuous intravenous therapy, including
administration of a therapeutic agent necessary for hydration or
of intravenous pharmaceuticals, or intravenous pharmaceutical
administration of one or more agents, via a peripheral or central
line, without continuous infusion.

end insert begin insert

(C) Dependence on peritoneal dialysis treatments requiring at
least four exchanges every 24 hours.

end insert begin insert

(D) Dependence on tube feeding by means of a nasogastric,
gastrostomy, or jejunostomy tube.

end insert begin insert

(E) Dependence on other medical technologies required
continuously that in the opinion of the attending physician and the
Medi-Cal consultant, require the services of a licensed registered
nurse.

end insert begin insert

(6) Dependence on complex wound care management, including
daily assessment or intervention by a licensed registered nurse
and daily dressing changes, wound packing, debridement, negative
pressure wound therapy, or a special mattress.

end insert begin insert

(7) The patient has a medical condition and requires an intensity
of medical or skilled nursing care such that his or her health care
needs may be satisfied by placement in a facility providing
pediatric subacute care services, but, in the absence of a facility
providing pediatric subacute care services, the only other inpatient
care appropriate to meet the patient’s health care needs under the
Medi-Cal program is in an acute care licensed hospital bed.

end insert

(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.