BILL NUMBER: AB 1310	INTRODUCED
	BILL TEXT


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  21
  22  years of age who uses a medical technology
that compensates for the loss of a vital bodily  function.
  function, requires treatment for one or more active
complex medical conditions, or requires the administration of one or
more technically complex treatments. 
   (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  more than one agent,   one or
more agents,  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  nasogastric
or gastrostomy   nasogastric, gastrostomy, or
jejunostomy  tube.
   (E) Dependence on other medical technologies required
continuously,  which   that  , in the
opinion of the attending physician and the Medi-Cal consultant,
require the services of a  professional  
licensed registered  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  support, and dependence on one of the treatment
procedures specified in subparagraphs (A) to (F), inclusive, of
paragraph (2).  support. 
   (4) Dependence on skilled nursing care in the administration of
any three of the  following  six treatment 
procedures specified in subparagraphs (A) to (F), inclusive, of
paragraph (2).   procedures:  
   (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 one or more agents, 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 nasogastric,
gastrostomy, or jejunostomy tube.  
   (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.
 
   (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. 
   (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 
 , for a patient  lacking either cognitive or physical
ability  of the patient  to protect his or her
airway  ,  and dependence on one of the  following 
five treatment  procedures specified in subparagraphs (A) to
(E), inclusive, of paragraph (2).   procedures: 

   (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 one or more agents, 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 nasogastric,
gastrostomy, or jejunostomy tube.  
   (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.
 
   (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.  
   (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. 
   (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.