BILL NUMBER: SB 94 ENROLLED
BILL TEXT
PASSED THE SENATE JUNE 17, 2013
PASSED THE ASSEMBLY JUNE 15, 2013
AMENDED IN ASSEMBLY JUNE 13, 2013
INTRODUCED BY Committee on Budget and Fiscal Review
JANUARY 10, 2013
An act to amend Section 6253.2 of the Government Code, to amend
Sections 10101.1, 12300.7, 12306, 12306.1, 12306.15, 14182.16,
14182.17, 14186, 14186.1, 14186.2, 14186.3, 14186.36, and 14186.4 of,
to amend and add Sections 14132.275, 14183.6, and 14301.1 of, and to
add Sections 14132.277, 14182.18, and 14186.11 to, the Welfare and
Institutions Code, to repeal Section 10 of Chapter 33 of the Statutes
of 2012, and to repeal Sections 15, 16, and 17 of Chapter 45 of the
Statutes of 2012, relating to Medi-Cal, and making an appropriation
therefor, to take effect immediately, bill related to the budget.
LEGISLATIVE COUNSEL'S DIGEST
SB 94, Committee on Budget and Fiscal Review. Medi-Cal: managed
care: long-term services and supports: in-home supportive services.
(1) 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
seek federal approval to establish a demonstration project as
described in law pursuant to a Medicare or a Medicaid demonstration
project or waiver, or a combination thereof. Existing law provides
that if the department has not received by February 1, 2013, federal
approval, or notification indicating pending approval, of a mutual
ratesetting process, shared federal savings, and a 6-month enrollment
period in the demonstration project, effective March 1, 2013,
Chapter 45 of the Statutes of 2012, and specified provisions of
Chapter 33 of the Statutes of 2012, are inoperative, as provided.
Chapter 33 of the Statutes of 2012, among other things, requires that
Medi-Cal beneficiaries who have dual eligibility in the Medi-Cal and
Medicare programs be assigned as mandatory enrollees into managed
care plans in counties participating in the demonstration project,
and requires that no sooner than March 1, 2013, all Medi-Cal
long-term services and supports, which includes Multipurpose Senior
Services Program (MSSP) services, be covered under managed care plan
contracts and only available through managed care plans to
beneficiaries residing in counties participating in the demonstration
project. Chapter 45 of the Statutes of 2012, among other things,
establishes the California In-Home Supportive Services Authority
(Statewide Authority), and provides that the In-Home Supportive
Services Program is a Medi-Cal benefit available through managed care
health care plans in specified counties, as specified. Existing law
provides that no sooner than March 1, 2013, the Statewide Authority
shall assume specified responsibilities in a county or city and
county upon notification by the Director of Health Care Services that
the enrollment of eligible Medi-Cal beneficiaries described in
specified provisions of law has been completed in that county or city
and county.
This bill would instead require enrollment of eligible Medi-Cal
beneficiaries into managed care pursuant to the demonstration project
or other specified provisions, including managed care for long-term
services and supports, as one of the conditions that would be
required to be completed before the Statewide Authority assumes the
specified responsibilities. The bill would modify the provisions
governing when MSSP becomes a Medi-Cal benefit only through managed
care health plans, as prescribed. The bill would delete the provision
authorizing the Director of Health Care Services to forgo the
provision of long-term services and supports only through managed
care, in its entirety or partially, if and to the extent the director
determines that the quality of care for managed care beneficiaries,
efficiency, or cost-effectiveness of the program would be
jeopardized. The bill would require the State Department of Health
Care Services to convene quarterly meetings with stakeholders to make
recommendations regarding the Coordinated Care Initiative, as
specified. The bill would require that in Coordinated Care Initiative
Counties for managed care health plans providing long-term services
and supports, the department shall include in its contract with those
plans risk corridors to provide protections against either
significant overpayment or significant underpayments. The bill would
also repeal the provisions conditioning the operation of Chapter 45
of the Statutes of 2012 and specified provisions of Chapter 33 of the
Statutes of 2012 on receipt of federal approval or notification of
pending approval by February 1, 2013. The bill would instead
condition implementation of the Coordinated Care Initiative, as
defined, on whether the Director of Finance estimates that the
Coordinated Care Initiative will generate net General Fund savings,
as specified. The bill would also make other related technical,
nonsubstantive changes.
(2) The bill would appropriate the amount of $500,000 from the
General Fund to the State Department of Health Care Services for the
Coordinated Care Initiative for purposes of notifying dual eligible
beneficiaries and providers regarding the provisions of this act, and
would provide that those funds be available for encumbrance and
expenditure until June 30, 2014.
(3) This bill would declare that it is to take effect immediately
as a bill providing for appropriations related to the Budget Bill.
Appropriation: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 6253.2 of the Government Code, as amended by
Section 2 of Chapter 439 of the Statutes of 2012, is amended to read:
6253.2. (a) Notwithstanding any other provision of this chapter
to the contrary, information regarding persons paid by the state to
provide in-home supportive services pursuant to Article 7 (commencing
with Section 12300) of Chapter 3 of Part 3 of Division 9 of the
Welfare and Institutions Code, or services provided pursuant to
Section 14132.95, 14132.952, or 14132.956 of the Welfare and
Institutions Code, is not subject to public disclosure pursuant to
this chapter, except as provided in subdivision (b).
(b) Copies of names, addresses, and telephone numbers of persons
described in subdivision (a) shall be made available, upon request,
to an exclusive bargaining agent and to any labor organization
seeking representation rights pursuant to Section 12301.6 or 12302.25
of the Welfare and Institutions Code or the In-Home Supportive
Services Employer-Employee Relations Act (Title 23 (commencing with
Section 110000)). This information shall not be used by the receiving
entity for any purpose other than the employee organizing,
representation, and assistance activities of the labor organization.
(c) This section applies solely to individuals who provide
services under the In-Home Supportive Services Program (Article 7
(commencing with Section 12300) of Chapter 3 of Part 3 of Division 9
of the Welfare and Institutions Code), the Personal Care Services
Program pursuant to Section 14132.95 of the Welfare and Institutions
Code, the In-Home Supportive Services Plus Option pursuant to Section
14132.952 of the Welfare and Institutions Code, or the Community
First Choice Option pursuant to Section 14132.956 of the Welfare and
Institutions Code.
(d) Nothing in this section is intended to alter or shall be
interpreted to alter the rights of parties under the In-Home
Supportive Services Employer-Employee Relations Act (Title 23
(commencing with Section 110000)) or any other labor relations law.
(e) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 2. Section 6253.2 of the Government Code, as amended by
Section 1 of Chapter 439 of the Statutes of 2012, is amended to read:
6253.2. (a) Notwithstanding any other provision of this chapter
to the contrary, information regarding persons paid by the state to
provide in-home supportive services pursuant to Article 7 (commencing
with Section 12300) of Chapter 3 of Part 3 of Division 9 of the
Welfare and Institutions Code or personal care services pursuant to
Section 14132.95 of the Welfare and Institutions Code, is not subject
to public disclosure pursuant to this chapter, except as provided in
subdivision (b).
(b) Copies of names, addresses, and telephone numbers of persons
described in subdivision (a) shall be made available, upon request,
to an exclusive bargaining agent and to any labor organization
seeking representation rights pursuant to subdivision (c) of Section
12301.6 or Section 12302.25 of the Welfare and Institutions Code or
Chapter 10 (commencing with Section 3500) of Division 4 of Title 1.
This information shall not be used by the receiving entity for any
purpose other than the employee organizing, representation, and
assistance activities of the labor organization.
(c) This section applies solely to individuals who provide
services under the In-Home Supportive Services Program (Article 7
(commencing with Section 12300) of Chapter 3 of Part 3 of Division 9
of the Welfare and Institutions Code) or the Personal Care Services
Program pursuant to Section 14132.95 of the Welfare and Institutions
Code.
(d) Nothing in this section is intended to alter or shall be
interpreted to alter the rights of parties under the
Meyers-Milias-Brown Act (Chapter 10 (commencing with Section 3500) of
Division 4) or any other labor relations law.
(e) This section shall be operative only if Section 1 of the act
that added this subdivision becomes inoperative pursuant to
subdivision (e) of that Section 1.
SEC. 3. Reserved]
SEC. 4. Reserved]
SEC. 5. Section 10101.1 of the Welfare and Institutions Code, as
amended by Section 23 of Chapter 439 of the Statutes of 2012, is
amended to read:
10101.1. (a) For the 1991-92 fiscal year and each fiscal year
thereafter, the state's share of the costs of the county services
block grant and the in-home supportive services administration
requirements shall be 70 percent of the actual nonfederal
expenditures or the amount appropriated by the Legislature for that
purpose, whichever is less.
(b) Federal funds received under Title 20 of the federal Social
Security Act (42 U.S.C. Sec. 1397 et seq.) and appropriated by the
Legislature for the county services block grant and the in-home
supportive services administration shall be considered part of the
state share of cost and not part of the federal expenditures for this
purpose.
(c) For the period during which Section 12306.15 is operative,
each county's share of the nonfederal costs of the county services
block grant and the in-home supportive services administration
requirements as specified in subdivision (a) shall remain, but the
County IHSS Maintenance of Effort pursuant to Section 12306.15 shall
be in lieu of that share.
(d) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 6. Section 10101.1 of the Welfare and Institutions Code, as
amended by Section 22 of Chapter 439 of the Statutes of 2012, is
amended to read:
10101.1. (a) For the 1991-92 fiscal year and each fiscal year
thereafter, the state's share of the costs of the county services
block grant and the in-home supportive services administration
requirements shall be 70 percent of the actual nonfederal
expenditures or the amount appropriated by the Legislature for that
purpose, whichever is less.
(b) Federal funds received under Title 20 of the federal Social
Security Act (42 U.S.C. Sec. 1397 et seq.) and appropriated by the
Legislature for the county services block grant and the in-home
supportive services administration shall be considered part of the
state share of cost and not part of the federal expenditures for this
purpose.
(c) This section shall be operative only if Section 5 of the act
that added this subdivision becomes inoperative pursuant to
subdivision (d) of that Section 5.
SEC. 7. Section 12300.7 of the Welfare and Institutions Code is
amended to read:
12300.7. (a) No sooner than March 1, 2013, the California In-Home
Supportive Services Authority shall assume the responsibilities set
forth in Title 23 (commencing with Section 110000) of the Government
Code in a county or city and county upon notification by the Director
of Health Care Services that the enrollment of eligible Medi-Cal
beneficiaries described in Section 14132.275 or 14182.16, or Article
5.7 (commencing with Section 14186) of Chapter 7 has been completed
in that county or city and county.
(b) A county or city and county, subject to subdivision (a) and
upon notification from the Director of Health Care Services, shall do
one or both of the following:
(1) Have the entity that performed functions set forth in the
county ordinance or contract in effect at the time of the
notification pursuant to subdivision (a) and established pursuant to
Section 12301.6 continue to perform those functions, excluding
subdivision (c) of that section.
(2) Assume the functions performed by the entity, at the time of
the notification pursuant to subdivision (a), pursuant to Section
12301.6, excluding subdivision (c) of that section.
(c) If a county or city and county assumes the functions described
in paragraph (2) of subdivision (b), it may establish or contract
with an entity for the performance of any or all of the functions
assumed.
SEC. 8. Section 12306 of the Welfare and Institutions Code, as
amended by Section 37 of Chapter 439 of the Statutes of 2012, is
amended to read:
12306. (a) The state and counties shall share the annual cost of
providing services under this article as specified in this section.
(b) Except as provided in subdivisions (c) and (d), the state
shall pay to each county, from the General Fund and any federal funds
received under Title XX of the federal Social Security Act available
for that purpose, 65 percent of the cost of providing services under
this article, and each county shall pay 35 percent of the cost of
providing those services.
(c) For services eligible for federal funding pursuant to Title
XIX of the federal Social Security Act under the Medi-Cal program
and, except as provided in subdivisions (b) and (d) the state shall
pay to each county, from the General Fund and any funds available for
that purpose 65 percent of the nonfederal cost of providing services
under this article, and each county shall pay 35 percent of the
nonfederal cost of providing those services.
(d) (1) For the period of July 1, 1992, to June 30, 1994,
inclusive, the state's share of the cost of providing services under
this article shall be limited to the amount appropriated for that
purpose in the annual Budget Act.
(2) The department shall restore the funding reductions required
by subdivision (c) of Section 12301, fully or in part, as soon as
administratively practicable, if the amount appropriated from the
General Fund for the 1992-93 fiscal year under this article is
projected to exceed the sum of the General Fund expenditures under
Section 14132.95 and the actual General Fund expenditures under this
article for the 1992-93 fiscal year. The entire amount of the excess
shall be applied to the restoration. Services shall not be restored
under this paragraph until the Department of Finance has determined
that the restoration of services would result in no additional costs
to the state or to the counties relative to the combined state
appropriation and county matching funds for in-home supportive
services under this article in the 1992-93 fiscal year.
(e) For the period during which Section 12306.15 is operative,
each county's share of the costs of providing services pursuant to
this article specified in subdivisions (b) and (c) shall remain, but
the County IHSS Maintenance of Effort pursuant to Section 12306.15
shall be in lieu of that share.
(f) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 9. Section 12306 of the Welfare and Institutions Code, as
amended by Section 36 of Chapter 439 of the Statutes of 2012, is
amended to read:
12306. (a) The state and counties shall share the annual cost of
providing services under this article as specified in this section.
(b) Except as provided in subdivisions (c) and (d), the state
shall pay to each county, from the General Fund and any federal funds
received under Title XX of the federal Social Security Act available
for that purpose, 65 percent of the cost of providing services under
this article, and each county shall pay 35 percent of the cost of
providing those services.
(c) For services eligible for federal funding pursuant to Title
XIX of the federal Social Security Act under the Medi-Cal program
and, except as provided in subdivisions (b) and (d) the state shall
pay to each county, from the General Fund and any funds available for
that purpose 65 percent of the nonfederal cost of providing services
under this article, and each county shall pay 35 percent of the
nonfederal cost of providing those services.
(d) (1) For the period of July 1, 1992, to June 30, 1994,
inclusive, the state's share of the cost of providing services under
this article shall be limited to the amount appropriated for that
purpose in the annual Budget Act.
(2) The department shall restore the funding reductions required
by subdivision (c) of Section 12301, fully or in part, as soon as
administratively practicable, if the amount appropriated from the
General Fund for the 1992-93 fiscal year under this article is
projected to exceed the sum of the General Fund expenditures under
Section 14132.95 and the actual General Fund expenditures under this
article for the 1992-93 fiscal year. The entire amount of the excess
shall be applied to the restoration. Services shall not be restored
under this paragraph until the Department of Finance has determined
that the restoration of services would result in no additional costs
to the state or to the counties relative to the combined state
appropriation and county matching funds for in-home supportive
services under this article in the 1992-93 fiscal year.
(e) This section shall be operative only if Section 8 of the act
that added this subdivision becomes inoperative pursuant to
subdivision (f) of that Section 8.
SEC. 10. Section 12306.1 of the Welfare and Institutions Code, as
amended by Section 7 of Chapter 4 of the Statutes of 2013, is amended
to read:
12306.1. (a) When any increase in provider wages or benefits is
negotiated or agreed to by a public authority or nonprofit consortium
under Section 12301.6, then the county shall use county-only funds
to fund both the county share and the state share, including
employment taxes, of any increase in the cost of the program, unless
otherwise provided for in the annual Budget Act or appropriated by
statute. No increase in wages or benefits negotiated or agreed to
pursuant to this section shall take effect unless and until, prior to
its implementation, the department has obtained the approval of the
State Department of Health Care Services for the increase pursuant to
a determination that it is consistent with federal law and to ensure
federal financial participation for the services under Title XIX of
the federal Social Security Act, and unless and until all of the
following conditions have been met:
(1) Each county has provided the department with documentation of
the approval of the county board of supervisors of the proposed
public authority or nonprofit consortium rate, including wages and
related expenditures. The documentation shall be received by the
department before the department and the State Department of Health
Care Services may approve the increase.
(2) Each county has met department guidelines and regulatory
requirements as a condition of receiving state participation in the
rate.
(b) Any rate approved pursuant to subdivision (a) shall take
effect commencing on the first day of the month subsequent to the
month in which final approval is received from the department. The
department may grant approval on a conditional basis, subject to the
availability of funding.
(c) The state shall pay 65 percent, and each county shall pay 35
percent, of the nonfederal share of wage and benefit increases
negotiated by a public authority or nonprofit consortium pursuant to
Section 12301.6 and associated employment taxes, only in accordance
with subdivisions (d) to (f), inclusive.
(d) (1) The state shall participate as provided in subdivision (c)
in wages up to seven dollars and fifty cents ($7.50) per hour and
individual health benefits up to sixty cents ($0.60) per hour for all
public authority or nonprofit consortium providers. This paragraph
shall be operative for the 2000-01 fiscal year and each year
thereafter unless otherwise provided in paragraphs (2), (3), (4), and
(5), and without regard to when the wage and benefit increase
becomes effective.
(2) The state shall participate as provided in subdivision (c) in
a total of wages and individual health benefits up to nine dollars
and ten cents ($9.10) per hour, if wages have reached at least seven
dollars and fifty cents ($7.50) per hour. Counties shall determine,
pursuant to the collective bargaining process provided for in
subdivision (c) of Section 12301.6, what portion of the nine dollars
and ten cents ($9.10) per hour shall be used to fund wage increases
above seven dollars and fifty cents ($7.50) per hour or individual
health benefit increases, or both. This paragraph shall be operative
for the 2001-02 fiscal year and each fiscal year thereafter, unless
otherwise provided in paragraphs (3), (4), and (5).
(3) The state shall participate as provided in subdivision (c) in
a total of wages and individual health benefits up to ten dollars and
ten cents ($10.10) per hour, if wages have reached at least seven
dollars and fifty cents ($7.50) per hour. Counties shall determine,
pursuant to the collective bargaining process provided for in
subdivision (c) of Section 12301.6, what portion of the ten dollars
and ten cents ($10.10) per hour shall be used to fund wage increases
above seven dollars and fifty cents ($7.50) per hour or individual
health benefit increases, or both. This paragraph shall be operative
commencing with the next state fiscal year for which the May Revision
forecast of General Fund revenue, excluding transfers, exceeds by at
least 5 percent, the most current estimate of revenue, excluding
transfers, for the year in which paragraph (2) became operative.
(4) The state shall participate as provided in subdivision (c) in
a total of wages and individual health benefits up to eleven dollars
and ten cents ($11.10) per hour, if wages have reached at least seven
dollars and fifty cents ($7.50) per hour. Counties shall determine,
pursuant to the collective bargaining process provided for in
subdivision (c) of Section 12301.6, what portion of the eleven
dollars and ten cents ($11.10) per hour shall be used to fund wage
increases or individual health benefits, or both. This paragraph
shall be operative commencing with the next state fiscal year for
which the May Revision forecast of General Fund revenue, excluding
transfers, exceeds by at least 5 percent, the most current estimate
of revenues, excluding transfers, for the year in which paragraph (3)
became operative.
(5) The state shall participate as provided in subdivision (c) in
a total cost of wages and individual health benefits up to twelve
dollars and ten cents ($12.10) per hour, if wages have reached at
least seven dollars and fifty cents ($7.50) per hour. Counties shall
determine, pursuant to the collective bargaining process provided for
in subdivision (c) of Section 12301.6, what portion of the twelve
dollars and ten cents ($12.10) per hour shall be used to fund wage
increases above seven dollars and fifty cents ($7.50) per hour or
individual health benefit increases, or both. This paragraph shall be
operative commencing with the next state fiscal year for which the
May Revision forecast of General Fund revenue, excluding transfers,
exceeds by at least 5 percent, the most current estimate of revenues,
excluding transfers, for the year in which paragraph (4) became
operative.
(e) (1) On or before May 14 immediately prior to the fiscal year
for which state participation is provided under paragraphs (2) to
(5), inclusive, of subdivision (d), the Director of Finance shall
certify to the Governor, the appropriate committees of the
Legislature, and the department that the condition for each
subdivision to become operative has been met.
(2) For purposes of certifications under paragraph (1), the
General Fund revenue forecast, excluding transfers, that is used for
the relevant fiscal year shall be calculated in a manner that is
consistent with the definition of General Fund revenues, excluding
transfers, that was used by the Department of Finance in the 2000-01
Governor's Budget revenue forecast as reflected on Schedule 8 of the
Governor's Budget.
(f) Any increase in overall state participation in wage and
benefit increases under paragraphs (2) to (5), inclusive, of
subdivision (d), shall be limited to a wage and benefit increase of
one dollar ($1) per hour with respect to any fiscal year. With
respect to actual changes in specific wages and health benefits
negotiated through the collective bargaining process, the state shall
participate in the costs, as approved in subdivision (c), up to the
maximum levels as provided under paragraphs (2) to (5), inclusive, of
subdivision (d).
(g) For the period during which Section 12306.15 is operative,
each county's share of the costs of negotiated wage and benefit
increases specified in subdivision (c) shall remain, but the County
IHSS Maintenance of Effort pursuant to Section 12306.15 shall be in
lieu of that share.
(h) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 11. Section 12306.1 of the Welfare and Institutions Code, as
amended by Section 8 of Chapter 4 of the Statutes of 2013, is amended
to read:
12306.1. (a) When any increase in provider wages or benefits is
negotiated or agreed to by a public authority or nonprofit consortium
under Section 12301.6, then the county shall use county-only funds
to fund both the county share and the state share, including
employment taxes, of any increase in the cost of the program, unless
otherwise provided for in the annual Budget Act or appropriated by
statute. No increase in wages or benefits negotiated or agreed to
pursuant to this section shall take effect unless and until, prior to
its implementation, the department has obtained the approval of the
State Department of Health Care Services for the increase pursuant to
a determination that it is consistent with federal law and to ensure
federal financial participation for the services under Title XIX of
the federal Social Security Act, and unless and until all of the
following conditions have been met:
(1) Each county has provided the department with documentation of
the approval of the county board of supervisors of the proposed
public authority or nonprofit consortium rate, including wages and
related expenditures. The documentation shall be received by the
department before the department and the State Department of Health
Care Services may approve the increase.
(2) Each county has met department guidelines and regulatory
requirements as a condition of receiving state participation in the
rate.
(b) Any rate approved pursuant to subdivision (a) shall take
effect commencing on the first day of the month subsequent to the
month in which final approval is received from the department. The
department may grant approval on a conditional basis, subject to the
availability of funding.
(c) The state shall pay 65 percent, and each county shall pay 35
percent, of the nonfederal share of wage and benefit increases
negotiated by a public authority or nonprofit consortium pursuant to
Section 12301.6 and associated employment taxes, only in accordance
with subdivisions (d) to (f), inclusive.
(d) (1) The state shall participate as provided in subdivision (c)
in wages up to seven dollars and fifty cents ($7.50) per hour and
individual health benefits up to sixty cents ($0.60) per hour for all
public authority or nonprofit consortium providers. This paragraph
shall be operative for the 2000-01 fiscal year and each year
thereafter unless otherwise provided in paragraphs (2), (3), (4), and
(5), and without regard to when the wage and benefit increase
becomes effective.
(2) The state shall participate as provided in subdivision (c) in
a total of wages and individual health benefits up to nine dollars
and ten cents ($9.10) per hour, if wages have reached at least seven
dollars and fifty cents ($7.50) per hour. Counties shall determine,
pursuant to the collective bargaining process provided for in
subdivision (c) of Section 12301.6, what portion of the nine dollars
and ten cents ($9.10) per hour shall be used to fund wage increases
above seven dollars and fifty cents ($7.50) per hour or individual
health benefit increases, or both. This paragraph shall be operative
for the 2001-02 fiscal year and each fiscal year thereafter, unless
otherwise provided in paragraphs (3), (4), and (5).
(3) The state shall participate as provided in subdivision (c) in
a total of wages and individual health benefits up to ten dollars and
ten cents ($10.10) per hour, if wages have reached at least seven
dollars and fifty cents ($7.50) per hour. Counties shall determine,
pursuant to the collective bargaining process provided for in
subdivision (c) of Section 12301.6, what portion of the ten dollars
and ten cents ($10.10) per hour shall be used to fund wage increases
above seven dollars and fifty cents ($7.50) per hour or individual
health benefit increases, or both. This paragraph shall be operative
commencing with the next state fiscal year for which the May Revision
forecast of General Fund revenue, excluding transfers, exceeds by at
least 5 percent, the most current estimate of revenue, excluding
transfers, for the year in which paragraph (2) became operative.
(4) The state shall participate as provided in subdivision (c) in
a total of wages and individual health benefits up to eleven dollars
and ten cents ($11.10) per hour, if wages have reached at least seven
dollars and fifty cents ($7.50) per hour. Counties shall determine,
pursuant to the collective bargaining process provided for in
subdivision (c) of Section 12301.6, what portion of the eleven
dollars and ten cents ($11.10) per hour shall be used to fund wage
increases or individual health benefits, or both. This paragraph
shall be operative commencing with the next state fiscal year for
which the May Revision forecast of General Fund revenue, excluding
transfers, exceeds by at least 5 percent, the most current estimate
of revenues, excluding transfers, for the year in which paragraph (3)
became operative.
(5) The state shall participate as provided in subdivision (c) in
a total cost of wages and individual health benefits up to twelve
dollars and ten cents ($12.10) per hour, if wages have reached at
least seven dollars and fifty cents ($7.50) per hour. Counties shall
determine, pursuant to the collective bargaining process provided for
in subdivision (c) of Section 12301.6, what portion of the twelve
dollars and ten cents ($12.10) per hour shall be used to fund wage
increases above seven dollars and fifty cents ($7.50) per hour or
individual health benefit increases, or both. This paragraph shall be
operative commencing with the next state fiscal year for which the
May Revision forecast of General Fund revenue, excluding transfers,
exceeds by at least 5 percent, the most current estimate of revenues,
excluding transfers, for the year in which paragraph (4) became
operative.
(e) (1) On or before May 14 immediately prior to the fiscal year
for which state participation is provided under paragraphs (2) to
(5), inclusive, of subdivision (d), the Director
of Finance shall certify to the Governor, the
appropriate committees of the Legislature, and the department that
the condition for each subdivision to become operative has been met.
(2) For purposes of certifications under paragraph (1), the
General Fund revenue forecast, excluding transfers, that is used for
the relevant fiscal year shall be calculated in a manner that is
consistent with the definition of General Fund revenues, excluding
transfers, that was used by the Department of Finance in the 2000-01
Governor's Budget revenue forecast as reflected on Schedule 8 of the
Governor's Budget.
(f) Any increase in overall state participation in wage and
benefit increases under paragraphs (2) to (5), inclusive, of
subdivision (d), shall be limited to a wage and benefit increase of
one dollar ($1) per hour with respect to any fiscal year. With
respect to actual changes in specific wages and health benefits
negotiated through the collective bargaining process, the state shall
participate in the costs, as approved in subdivision (c), up to the
maximum levels as provided under paragraphs (2) to (5), inclusive, of
subdivision (d).
(g) This section shall be operative only if Section 10 of the act
that added this subdivision becomes inoperative pursuant to
subdivision (h) of that Section 10.
SEC. 12. Section 12306.15 of the Welfare and Institutions Code is
amended to read:
12306.15. (a) Commencing July 1, 2012, all counties shall have a
County IHSS Maintenance of Effort (MOE). In lieu of paying the
nonfederal share of IHSS costs as specified in Sections 10101.1,
12306, and 12306.1, counties shall pay the County IHSS MOE.
(b) (1) The County IHSS MOE base year shall be the 2011-12 state
fiscal year. The County IHSS MOE base shall be defined as the amount
actually expended by each county on IHSS services and administration
in the County IHSS MOE base year, as reported by each county to the
department, except that for administration, the County IHSS MOE base
shall include no more or no less than the full match for the county's
allocation from the state.
(2) Administration expenditures shall include both county
administration and public authority administration. The County IHSS
MOE base shall be unique to each individual county.
(3) For a county that made 14 months of health benefit payments
for IHSS providers in the 2011-12 fiscal year, the Department of
Finance shall adjust that county's County IHSS MOE base calculation.
(4) The County IHSS MOE base for each county shall be no less than
each county's 2011-12 expenditures for the Personal Care Services
Program and IHSS used in the caseload growth calculation pursuant to
Section 17605.
(c) (1) On July 1, 2014, the County IHSS MOE base shall be
adjusted by an inflation factor of 3.5 percent.
(2) Beginning on July 1, 2015, and annually thereafter, the County
IHSS MOE from the previous year shall be adjusted by an inflation
factor of 3.5 percent.
(3) (A) Notwithstanding paragraphs (1) and (2), in fiscal years
when the combined total of 1991 realignment revenues received
pursuant to Sections 11001.5, 6051.2, and 6201.2 of the Revenue and
Taxation Code, for the prior fiscal year is less than the combined
total received for the next prior fiscal year, the inflation factor
shall be zero.
(B) The Department of Finance shall provide notification to the
appropriate legislative fiscal committees and the California State
Association of Counties by May 14 of each year whether the inflation
factor will apply for the following fiscal year, based on the
calculation in subparagraph (A).
(d) In addition to the adjustment in subdivision (c), the County
IHSS MOE shall be adjusted for the annualized cost of increases in
provider wages or health benefits that are locally negotiated,
mediated, or imposed before the Statewide Authority assumes the
responsibilities set forth in Section 110011 of the Government Code
for a given county as provided in Section 12300.7.
(1) (A) If the department approves the rates and other economic
terms for a locally negotiated, mediated, or imposed increase in the
provider wages, health benefits, or other economic terms pursuant to
Section 12306.1 and paragraph (3), the state shall pay 65 percent,
and the affected county shall pay 35 percent, of the nonfederal share
of the cost increase in accordance with subparagraph (B).
(B) With respect to any increase in provider wages or health
benefits approved after July 1, 2012, pursuant to subparagraph (A),
the state shall participate in that increase as provided in
subparagraph (A) up to the amount specified in subdivision (d) of
Section 12306.1.
(C) The county share of these expenditures shall be included in
the County IHSS MOE, in addition to the amount established under
subdivisions (b) and (c). For any increase in provider wages or
health benefits that becomes effective on a date other than July 1,
the Department of Finance shall adjust the county's County IHSS MOE
to reflect the annualized cost of the county's share of the
nonfederal cost of the wage or health benefit increase.
(2) (A) If the department does not approve the rates and other
economic terms for a locally negotiated, mediated, or imposed
increase in the provider wages, health benefits, or other economic
terms pursuant to Section 12306.1 or paragraph (3), the county shall
pay the entire nonfederal share of the cost increase.
(B) The county share of these expenditures shall be included in
the County IHSS MOE, in addition to the amount established under
subdivisions (b) and (c). For any increase in provider wages or
health benefits that becomes effective on a date other than July 1,
the Department of Finance shall adjust the county's County IHSS MOE
to reflect the annualized cost of the county's share of the
nonfederal cost of the wage or health benefit increase.
(3) In addition to the rate approval requirements in Section
12306.1, it shall be presumed by the department that locally
negotiated rates and other economic terms within the following limits
are approved:
(A) A net increase in the combined total of wages and health
benefits of up to 10 percent per year above the current combined
total of wages and health benefits paid in that county.
(B) A cumulative total of up to 20 percent in the sum of the
combined total of changes in wages or health benefits, or both, until
the Statewide Authority assumes the responsibilities set forth in
Section 110011 of the Government Code for a given county as provided
in Section 12300.7.
(e) The County IHSS MOE shall only be adjusted pursuant to
subdivisions (c) and (d).
(f) The Department of Finance shall consult with the California
State Association of Counties to implement the County IHSS MOE, which
shall include, but not be limited to, determining each county's
County IHSS MOE base pursuant to subdivision (b), developing the
computation for the annualized amount pursuant to subdivision (d),
and the process by which it will be determined that each county has
met its County IHSS MOE each year.
SEC. 13. Section 14132.275 of the Welfare and Institutions Code is
amended to read:
14132.275. (a) The department shall seek federal approval to
establish the demonstration project described in this section
pursuant to a Medicare or a Medicaid demonstration project or waiver,
or a combination thereof. Under a Medicare demonstration, the
department may contract with the federal Centers for Medicare and
Medicaid Services (CMS) and demonstration sites to operate the
Medicare and Medicaid benefits in a demonstration project that is
overseen by the state as a delegated Medicare benefit administrator,
and may enter into financing arrangements with CMS to share in any
Medicare program savings generated by the demonstration project.
(b) After federal approval is obtained, the department shall
establish the demonstration project that enables dual eligible
beneficiaries to receive a continuum of services that maximizes
access to, and coordination of, benefits between the Medi-Cal and
Medicare programs and access to the continuum of long-term services
and supports and behavioral health services, including mental health
and substance use disorder treatment services. The purpose of the
demonstration project is to integrate services authorized under the
federal Medicaid Program (Title XIX of the federal Social Security
Act (42 U.S.C. Sec. 1396 et seq.)) and the federal Medicare Program
(Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395
et seq.)). The demonstration project may also include additional
services as approved through a demonstration project or waiver, or a
combination thereof.
(c) For purposes of this section, the following definitions shall
apply:
(1) "Behavioral health" means Medi-Cal services provided pursuant
to Section 51341 of Title 22 of the California Code of Regulations
and Drug Medi-Cal substance abuse services provided pursuant to
Section 51341.1 of Title 22 of the California Code of Regulations,
and any mental health benefits available under the Medicare Program.
(2) "Capitated payment model" means an agreement entered into
between CMS, the state, and a managed care health plan, in which the
managed care health plan receives a capitation payment for the
comprehensive, coordinated provision of Medi-Cal services and
benefits under Medicare Part C (42 U.S.C. Sec. 1395w-21 et seq.) and
Medicare Part D (42 U.S.C. Sec. 1395w-101 et seq.), and CMS shares
the savings with the state from improved provision of Medi-Cal and
Medicare services that reduces the cost of those services. Medi-Cal
services include long-term services and supports as defined in
Section 14186.1, behavioral health services, and any additional
services offered by the demonstration site.
(3) "Demonstration site" means a managed care health plan that is
selected to participate in the demonstration project under the
capitated payment model.
(4) "Dual eligible beneficiary" means an individual 21 years of
age or older who is enrolled for benefits under Medicare Part A (42
U.S.C. Sec. 1395c et seq.) and Medicare Part B (42 U.S.C. Sec. 1395j
et seq.) and is eligible for medical assistance under the Medi-Cal
State Plan.
(d) No sooner than March 1, 2011, the department shall identify
health care models that may be included in the demonstration project,
shall develop a timeline and process for selecting, financing,
monitoring, and evaluating the demonstration sites, and shall provide
this timeline and process to the appropriate fiscal and policy
committees of the Legislature. The department may implement these
demonstration sites in phases.
(e) The department shall provide the fiscal and appropriate policy
committees of the Legislature with a copy of any report submitted to
CMS to meet the requirements under the demonstration project.
(f) Goals for the demonstration project shall include all of the
following:
(1) Coordinate Medi-Cal and Medicare benefits across health care
settings and improve the continuity of care across acute care,
long-term care, behavioral health, including mental health and
substance use disorder services, and home- and community-based
services settings using a person-centered approach.
(2) Coordinate access to acute and long-term care services for
dual eligible beneficiaries.
(3) Maximize the ability of dual eligible beneficiaries to remain
in their homes and communities with appropriate services and supports
in lieu of institutional care.
(4) Increase the availability of and access to home- and
community-based services.
(5) Coordinate access to necessary and appropriate behavioral
health services, including mental health and substance use disorder
services.
(6) Improve the quality of care for dual eligible beneficiaries.
(7) Promote a system that is both sustainable and person and
family centered by providing dual eligible beneficiaries with timely
access to appropriate, coordinated health care services and community
resources that enable them to attain or maintain personal health
goals.
(g) No sooner than March 1, 2013, demonstration sites shall be
established in up to eight counties, and shall include at least one
county that provides Medi-Cal services via a two-plan model pursuant
to Article 2.7 (commencing with Section 14087.3) and at least one
county that provides Medi-Cal services under a county organized
health system pursuant to Article 2.8 (commencing with Section
14087.5). The director shall consult with the Legislature, CMS, and
stakeholders when determining the implementation date for this
section. In determining the counties in which to establish a
demonstration site, the director shall consider the following:
(1) Local support for integrating medical care, long-term care,
and home- and community-based services networks.
(2) A local stakeholder process that includes health plans,
providers, mental health representatives, community programs,
consumers, designated representatives of in-home supportive services
personnel, and other interested stakeholders in the development,
implementation, and continued operation of the demonstration site.
(h) In developing the process for selecting, financing,
monitoring, and evaluating the health care models for the
demonstration project, the department shall enter into a memorandum
of understanding with CMS. Upon completion, the memorandum of
understanding shall be provided to the fiscal and appropriate policy
committees of the Legislature and posted on the department's Internet
Web site.
(i) The department shall negotiate the terms and conditions of the
memorandum of understanding, which shall address, but are not
limited to, the following:
(1) Reimbursement methods for a capitated payment model. Under the
capitated payment model, the demonstration sites shall meet all of
the following requirements:
(A) Have Medi-Cal managed care health plan and Medicare dual
eligible-special needs plan contract experience, or evidence of the
ability to meet these contracting requirements.
(B) Be in good financial standing and meet licensure requirements
under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter
2.2 (commencing with Section 1340) of Division 2 of the Health and
Safety Code), except for county organized health system plans that
are exempt from licensure pursuant to Section 14087.95.
(C) Meet quality measures, which may include Medi-Cal and Medicare
Healthcare Effectiveness Data and Information Set measures and other
quality measures determined or developed by the department or CMS.
(D) Demonstrate a local stakeholder process that includes dual
eligible beneficiaries, managed care health plans, providers, mental
health representatives, county health and human services agencies,
designated representatives of in-home supportive services personnel,
and other interested stakeholders that advise and consult with the
demonstration site in the development, implementation, and continued
operation of the demonstration project.
(E) Pay providers reimbursement rates sufficient to maintain an
adequate provider network and ensure access to care for
beneficiaries.
(F) Follow final policy guidance determined by CMS and the
department with regard to reimbursement rates for providers pursuant
to paragraphs (4) to (7), inclusive, of subdivision (o).
(G) To the extent permitted under the demonstration, pay
noncontracted hospitals prevailing Medicare fee-for-service rates for
traditionally Medicare covered benefits and prevailing Medi-Cal
fee-for-service rates for traditionally Medi-Cal covered benefits.
(2) Encounter data reporting requirements for both Medi-Cal and
Medicare services provided to beneficiaries enrolling in the
demonstration project.
(3) Quality assurance withholding from the demonstration site
payment, to be paid only if quality measures developed as part of the
memorandum of understanding and plan contracts are met.
(4) Provider network adequacy standards developed by the
department and CMS, in consultation with the Department of Managed
Health Care, the demonstration site, and stakeholders.
(5) Medicare and Medi-Cal appeals and hearing process.
(6) Unified marketing requirements and combined review process by
the department and CMS.
(7) Combined quality management and consolidated reporting process
by the department and CMS.
(8) Procedures related to combined federal and state contract
management to ensure access, quality, program integrity, and
financial solvency of the demonstration site.
(9) To the extent permissible under federal requirements,
implementation of the provisions of Sections 14182.16 and 14182.17
that are applicable to beneficiaries simultaneously eligible for
full-scope benefits under Medi-Cal and the Medicare Program.
(10) (A) In consultation with the hospital industry, CMS approval
to ensure that Medicare supplemental payments for direct graduate
medical education and Medicare add-on payments, including indirect
medical education and disproportionate share hospital adjustments
continue to be made available to hospitals for services provided
under the demonstration.
(B) The department shall seek CMS approval for CMS to continue
these payments either outside the capitation rates or, if contained
within the capitation rates, and to the extent permitted under the
demonstration project, shall require demonstration sites to provide
this reimbursement to hospitals.
(11) To the extent permitted under the demonstration project, the
default rate for noncontracting providers of physician services shall
be the prevailing Medicare fee schedule for services covered by the
Medicare program and the prevailing Medi-Cal fee schedule for
services covered by the Medi-Cal program.
(j) (1) The department shall comply with and enforce the terms and
conditions of the memorandum of understanding with CMS, as specified
in subdivision (i). To the extent that the terms and conditions do
not address the specific selection, financing, monitoring, and
evaluation criteria listed in subdivision (i), the department:
(A) Shall require the demonstration site to do all of the
following:
(i) Comply with additional site readiness criteria specified by
the department.
(ii) Comply with long-term services and supports requirements in
accordance with Article 5.7 (commencing with Section 14186).
(iii) To the extent permissible under federal requirements, comply
with the provisions of Sections 14182.16 and 14182.17 that are
applicable to beneficiaries simultaneously eligible for full-scope
benefits under both Medi-Cal and the Medicare Program.
(iv) Comply with all transition of care requirements for Medicare
Part D benefits as described in Chapters 6 and 14 of the Medicare
Managed Care Manual, published by CMS, including transition
timeframes, notices, and emergency supplies.
(B) May require the demonstration site to forgo charging premiums,
coinsurance, copayments, and deductibles for Medicare Part C and
Medicare Part D services.
(2) The department shall notify the Legislature within 30 days of
the implementation of each provision in paragraph (1).
(k) The director 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 provided under
this section. Contracts entered into or amended pursuant to 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 Title 2 of the Government Code.
(l) (1) (A) Except for the exemptions provided for in this
section, the department shall enroll dual eligible beneficiaries into
a demonstration site unless the beneficiary makes an affirmative
choice to opt out of enrollment or is already enrolled on or before
June 1, 2013, in a managed care organization licensed under the
Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code) that has previously contracted with the department as a
primary care case management plan pursuant to Article 2.9 (commencing
with Section 14088) to provide services to beneficiaries who are HIV
positive or who have been diagnosed with AIDS or in any entity with
a contract with the department pursuant to Chapter 8.75 (commencing
with Section 14591).
(B) Dual eligible beneficiaries who opt out of enrollment into a
demonstration site may choose to remain enrolled in fee-for-service
Medicare or a Medicare Advantage plan for their Medicare benefits,
but shall be mandatorily enrolled into a Medi-Cal managed care health
plan pursuant to Section 14182.16, except as exempted under
subdivision (c) of Section 14182.16.
(C) (i) Persons meeting requirements for the Program of
All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75
(commencing with Section 14591) or a managed care organization
licensed under the Knox-Keene Health Care Service Plan Act of 1975
(Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code) that has previously contracted with the
department as a primary care case management plan pursuant to Article
2.9 (commencing with Section 14088) of Chapter 7 to provide services
to beneficiaries who are HIV positive or who have been diagnosed
with AIDS may select either of these managed care health plans for
their Medicare and Medi-Cal benefits if one is available in that
county.
(ii) In areas where a PACE plan is available, the PACE plan shall
be presented as an enrollment option, included in all enrollment
materials, enrollment assistance programs, and outreach programs
related to the demonstration project, and made available to
beneficiaries whenever enrollment choices and options are presented.
Persons meeting the age qualifications for PACE and who choose PACE
shall remain in the fee-for-service Medi-Cal and Medicare programs,
and shall not be assigned to a managed care health plan for the
lesser of 60 days or until they are assessed for eligibility for PACE
and determined not to be eligible for a PACE plan. Persons enrolled
in a PACE plan shall receive all Medicare and Medi-Cal services from
the PACE program pursuant to the three-way agreement between the PACE
program, the department, and the Centers for Medicare and Medicaid
Services.
(2) To the extent that federal approval is obtained, the
department may require that any beneficiary, upon enrollment in a
demonstration site, remain enrolled in the Medicare portion of the
demonstration project on a mandatory basis for six months from the
date of initial enrollment. After the sixth month, a dual eligible
beneficiary may elect to enroll in a different demonstration site, a
different Medicare Advantage plan, fee-for-service Medicare, PACE, or
a managed care organization licensed under the Knox-Keene Health
Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code) that has
previously contracted with the department as a primary care case
management plan pursuant to Article 2.9 (commencing with Section
14088) to provide services to beneficiaries who are HIV positive or
who have been diagnosed with AIDS, for his or her Medicare benefits.
(A) During the six-month mandatory enrollment in a demonstration
site, a beneficiary may continue receiving services from an
out-of-network Medicare provider for primary and specialty care
services only if all of the following criteria are met:
(i) The dual eligible beneficiary demonstrates an existing
relationship with the provider prior to enrollment in a demonstration
site.
(ii) The provider is willing to accept payment from the
demonstration site based on the current Medicare fee schedule.
(iii) The demonstration site would not otherwise exclude the
provider from its provider network due to documented quality of care
concerns.
(B) The department shall develop a process to inform providers and
beneficiaries of the availability of continuity of services from an
existing provider and ensure that the beneficiary continues to
receive services without interruption.
(3) (A) Notwithstanding subparagraph (A) of paragraph (1) of
subdivision (l), a dual eligible beneficiary shall be excluded from
enrollment in the demonstration project if the beneficiary meets any
of the following:
(i) The beneficiary has a prior diagnosis of end-stage renal
disease. This clause shall not apply to beneficiaries diagnosed with
end-stage renal disease subsequent to enrollment in the demonstration
project. The director may, with stakeholder input and federal
approval, authorize beneficiaries with a prior diagnosis of end-stage
renal disease in specified counties to voluntarily enroll in the
demonstration project.
(ii) The beneficiary has other health coverage, as defined in
paragraph (5) of subdivision (b) of Section 14182.16.
(iii) The beneficiary is enrolled in a home- and community-based
waiver that is a Medi-Cal benefit under Section 1915(c) of the
federal Social Security Act (42 U.S.C. Sec. 1396n et seq.), except
for persons enrolled in Multipurpose Senior Services Program
services.
(iv) The beneficiary is receiving services through a regional
center or state developmental center.
(v) The beneficiary resides in a geographic area or ZIP Code not
included in managed care, as determined by the department and CMS.
(vi) The beneficiary resides in one of the Veterans' Homes of
California, as described in Chapter 1 (commencing with Section 1010)
of Division 5 of the Military and Veterans Code.
(B) (i) Beneficiaries who have been diagnosed with HIV/AIDS may
opt out of the demonstration project at the beginning of any month.
The State Department of Public Health may share relevant data
relating to a beneficiary's enrollment in the AIDS Drug Assistance
Program with the department, and the department may share relevant
data relating to HIV-positive beneficiaries with the State Department
of Public Health.
(ii) The information provided by the State Department of Public
Health pursuant to this subparagraph shall not be further disclosed
by the State Department of Health Care Services, and shall be subject
to the confidentiality protections of subdivisions (d) and (e) of
Section 121025 of the Health and Safety Code, except this information
may be further disclosed as follows:
(I) To the person to whom the information pertains or the
designated representative of that person.
(II) To the Office of AIDS within the State Department of Public
Health.
(C)
Beneficiaries who are Indians receiving Medi-Cal services in
accordance with Section 55110 of Title 22 of the California Code of
Regulations may opt out of the demonstration project at the beginning
of any month.
(D) The department, with stakeholder input, may exempt specific
categories of dual eligible beneficiaries from enrollment
requirements in this section based on extraordinary medical needs of
specific patient groups or to meet federal requirements.
(4) For the 2013 calendar year, the department shall offer federal
Medicare Improvements for Patients and Providers Act of 2008 (Public
Law 110-275) compliant contracts to existing Medicare Advantage
Special Needs Plans (D-SNP plans) to continue to provide Medicare
benefits to their enrollees in their service areas as approved on
January 1, 2012. In the 2013 calendar year, beneficiaries in Medicare
Advantage and D-SNP plans shall be exempt from the enrollment
provisions of subparagraph (A) of paragraph (1), but may voluntarily
choose to enroll in the demonstration project. Enrollment into the
demonstration project's managed care health plans shall be reassessed
in 2014 depending on federal reauthorization of the D-SNP model and
the department's assessment of the demonstration plans.
(5) For the 2013 calendar year, demonstration sites shall not
offer to enroll dual eligible beneficiaries eligible for the
demonstration project into the demonstration site's D-SNP.
(6) The department shall not terminate contracts in a
demonstration site with a managed care organization licensed under
the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code) that has previously contracted with the department as a
primary care case management plan pursuant to Article 2.9 (commencing
with Section 14088) to provide services to beneficiaries who are HIV
positive beneficiaries or who have been diagnosed with AIDS and with
any entity with a contract pursuant to Chapter 8.75 (commencing with
Section 14591), except as provided in the contract or pursuant to
state or federal law.
(m) Notwithstanding Section 10231.5 of the Government Code, the
department shall conduct an evaluation, in partnership with CMS, to
assess outcomes and the experience of dual eligibles in these
demonstration sites and shall provide a report to the Legislature
after the first full year of demonstration operation, and annually
thereafter. A report submitted to the Legislature pursuant to this
subdivision shall be submitted in compliance with Section 9795 of the
Government Code. The department shall consult with stakeholders
regarding the scope and structure of the evaluation.
(n) This section shall be implemented only if and to the extent
that federal financial participation or funding is available.
(o) It is the intent of the Legislature that:
(1) In order to maintain adequate provider networks, demonstration
sites shall reimburse providers at rates sufficient to ensure access
to care for beneficiaries.
(2) Savings under the demonstration project are intended to be
achieved through shifts in utilization, and not through reduced
reimbursement rates to providers.
(3) Reimbursement policies shall not prevent demonstration sites
and providers from entering into payment arrangements that allow for
the alignment of financial incentives and provide opportunities for
shared risk and shared savings in order to promote appropriate
utilization shifts, which encourage the use of home- and
community-based services and quality of care for dual eligible
beneficiaries enrolled in the demonstration sites.
(4) To the extent permitted under the demonstration project, and
to the extent that a public entity voluntarily provides an
intergovernmental transfer for this purpose, both of the following
shall apply:
(A) The department shall work with CMS in ensuring that the
capitation rates under the demonstration project are inclusive of
funding currently provided through certified public expenditures
supplemental payment programs that would otherwise be impacted by the
demonstration project.
(B) Demonstration sites shall pay to a public entity voluntarily
providing intergovernmental transfers that previously received
reimbursement under a certified public expenditures supplemental
payment program, rates that include the additional funding under the
capitation rates that are funded by the public entity's
intergovernmental transfer.
(5) The department shall work with CMS in developing other
reimbursement policies and shall inform demonstration sites,
providers, and the Legislature of the final policy guidance.
(6) The department shall seek approval from CMS to permit the
provider payment requirements contained in subparagraph (G) of
paragraph (1) and paragraphs (10) and (11) of subdivision (i), and
Section 14132.276.
(7) Demonstration sites that contract with hospitals for hospital
services on a fee-for-service basis that otherwise would have been
traditionally Medicare services will achieve savings through
utilization changes and not by paying hospitals at rates lower than
prevailing Medicare fee-for-service rates.
(p) 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 section. These activities may include providing consumer
assistance to beneficiaries affected by this section and conducting
financial audits, medical surveys, and a review of the adequacy of
provider networks of the managed care health plans participating in
this section. 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 under this section as the single state
Medicaid agency to the Department of Managed Health Care.
(q) (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 section.
(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 health plans to reflect
the short- and long-term results of the implementation of this
section. 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 managed care health plans.
(B) The department shall require 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 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 subparagraph is intended to limit 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.
(r) 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 this section
and any applicable federal waivers and state plan amendments 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 department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries. The department
shall notify the appropriate policy and fiscal committees of the
Legislature of its intent to issue instructions under this section at
least five days in advance of the issuance.
(s) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 14. Section 14132.275 is added to the Welfare and
Institutions Code, to read:
14132.275. (a) The department shall seek federal approval to
establish pilot projects described in this section pursuant to a
Medicare or a Medicaid demonstration project or waiver, or a
combination thereof. Under a Medicare demonstration, the department
may operate the Medicare component of a pilot project as a delegated
Medicare benefit administrator, and may enter into financing
arrangements with the federal Centers for Medicare and Medicaid
Services to share in any Medicare program savings generated by the
operation of any pilot project.
(b) After federal approval is obtained, the department shall
establish pilot projects that enable dual eligibles to receive a
continuum of services, and that maximize the coordination of benefits
between the Medi-Cal and Medicare programs and access to the
continuum of services needed. The purpose of the pilot projects is to
develop effective health care models that integrate services
authorized under the federal Medicaid Program (Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the
federal Medicare Program (Title XVIII of the federal Social Security
Act (42 U.S.C. Sec. 1395 et seq.)). These pilot projects may also
include additional services as approved through a demonstration
project or waiver, or a combination thereof.
(c) Not sooner than March 1, 2011, the department shall identify
health care models that may be included in a pilot project, shall
develop a timeline and process for selecting, financing, monitoring,
and evaluating these pilot projects, and shall provide this timeline
and process to the appropriate fiscal and policy committees of the
Legislature. The department may implement these pilot projects in
phases.
(d) Goals for the pilot projects shall include all of the
following:
(1) Coordinating Medi-Cal benefits, Medicare benefits, or both,
across health care settings and improving continuity of acute care,
long-term care, and home- and community-based services.
(2) Coordinating access to acute and long-term care services for
dual eligibles.
(3) Maximizing the ability of dual eligibles to remain in their
homes and communities with appropriate services and supports in lieu
of institutional care.
(4) Increasing the availability of and access to home- and
community-based alternatives.
(e) Pilot projects shall be established in up to four counties,
and shall include at least one county that provides Medi-Cal services
via a two-plan model pursuant to Article 2.7 (commencing with
Section 14087.3) and at least one county that provides Medi-Cal
services under a county organized health system pursuant to Article
2.8 (commencing with Section 14087.5). In determining the counties in
which to establish a pilot project, the director shall consider the
following:
(1) Local support for integrating medical care, long-term care,
and home- and community-based services networks.
(2) A local stakeholder process that includes health plans,
providers, community programs, consumers, and other interested
stakeholders in the development, implementation, and continued
operation of the pilot project.
(f) The director 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 provided under
this section. Contracts entered into or amended pursuant to 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 Title 2 of the Government Code.
(g) Services under Section 14132.95 or 14132.952, or Article 7
(commencing with Section 12300) of Chapter 3 that are provided under
the pilot projects established by this section shall be provided
through direct hiring of personnel, contract, or establishment of a
public authority or nonprofit consortium, in accordance with, and
subject to, Section 12302 or 12301.6, as applicable.
(h) Notwithstanding any other provision of state law, the
department may require that dual eligibles be assigned as mandatory
enrollees into managed care plans established or expanded as part of
a pilot project established under this section. Mandatory enrollment
in managed care for dual eligibles shall be applicable to the
beneficiary's Medi-Cal benefits only. Dual eligibles shall have the
option to enroll in a Medicare Advantage special needs plan (SNP)
offered by the managed care plan established or expanded as part of a
pilot project established pursuant to subdivision (e). To the extent
that mandatory enrollment is required, any requirement of the
department and the health plans, and any requirement of continuity of
care protections for enrollees, as specified in Section 14182, shall
be applicable to this section. Dual eligibles shall have the option
to forgo receiving Medicare benefits under a pilot project. Nothing
in this section shall be interpreted to reduce benefits otherwise
available under the Medi-Cal program or the Medicare Program.
(i) For purposes of this section, a "dual eligible" means an
individual who is simultaneously eligible for full-scope benefits
under Medi-Cal and the federal Medicare Program.
(j) Persons meeting requirements for the Program of All-Inclusive
Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with
Section 14591), may select a PACE plan if one is available in that
county.
(k) Notwithstanding Section 10231.5 of the Government Code, the
department shall conduct an evaluation to assess outcomes and the
experience of dual eligibles in these pilot projects and shall
provide a report to the Legislature after the first full year of
pilot operation, and annually thereafter. A report submitted to the
Legislature pursuant to this subdivision shall be submitted in
compliance with Section 9795 of the Government Code. The department
shall consult with stakeholders regarding the scope and structure of
the evaluation.
(l) This section shall be implemented only if and to the extent
that federal financial participation or funding is available to
establish these pilot projects.
(m) 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 this section
and any applicable federal waivers and state plan amendments 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 department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries. The department
shall notify the appropriate policy and fiscal committees of the
Legislature of its intent to issue instructions under this section at
least five days in advance of the issuance.
(n) This section shall be operative only if Section 13 of the act
that added this section becomes inoperative pursuant to subdivision
(s) of that Section 13.
SEC. 15. Section 14132.277 is added to the Welfare and
Institutions Code, to read:
14132.277. (a) For purposes of this section, the following
definitions shall apply:
(1) "Coordinated Care Initiative county" means the Counties of
Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego,
San Mateo, and Santa Clara, and any other county identified in
Appendix 3 of the memorandum of understanding between the state and
the Centers for Medicare and Medicaid Services Regarding A
Federal-State Partnership to Test a Capitated Financial Alignment
Model for Medicare-Medicaid Enrollees, inclusive of all amendments,
as authorized by Section 14132.275.
(2) "D-SNP plan" means a Medicare Advantage Special Needs Plan.
(3) "D-SNP contract" means a federal Medicare Improvements for
Patients and Provider Act of 2008 (Public Law 110-275) compliant
contract between the department and a D-SNP plan.
(b) For calendar year 2014, the department shall offer D-SNP
contracts to existing D-SNP plans to continue to provide benefits to
their enrollees in their service areas as approved on January 1,
2013. The director may include in any D-SNP contract provisions
requiring that the D-SNP plan do the following:
(1) Submit to the department a complete and accurate copy of the
bid submitted by the plan to the Centers for Medicare and Medicaid
Services for its D-SNP contract.
(2) Submit to the department copies of all utilization and quality
management reports submitted to the Centers for Medicare and
Medicaid Services.
(c) In Coordinated Care Initiative counties, Medicare Advantage
plans and D-SNP plans may continue to enroll beneficiaries in 2014.
In the 2014 calendar year, beneficiaries enrolled in a Medicare
Advantage or D-SNP plan operating in a Coordinated Care Initiative
county shall be exempt from the enrollment provisions of subparagraph
(A) of paragraph (1) of subdivision (l) of Section 14132.275. Those
beneficiaries may at any time voluntarily choose to disenroll from
their Medicare Advantage or D-SNP plan and enroll in a demonstration
site operating pursuant to subdivision (g) of Section 14132.275. If a
beneficiary chooses to do so, that beneficiary may subsequently
disenroll from the demonstration site and return to fee-for-service
Medicare or to a D-SNP plan or Medicare Advantage plan.
SEC. 16. Section 14182.16 of the Welfare and Institutions Code is
amended to read:
14182.16. (a) The department shall require Medi-Cal beneficiaries
who have dual eligibility in Medi-Cal and the Medicare Program to be
assigned as mandatory enrollees into new or existing Medi-Cal
managed care health plans for their Medi-Cal benefits in Coordinated
Care Initiative counties.
(b) For the purposes of this section and Section 14182.17, the
following definitions shall apply:
(1) "Coordinated Care Initiative counties" means the Counties of
Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego,
San Mateo, and Santa Clara.
(2) "Dual eligible beneficiary" means an individual 21 years of
age or older who is enrolled for benefits under Medicare Part A (42
U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j
et seq.), or both, and is eligible for medical assistance under the
Medi-Cal State Plan.
(3) "Full-benefit dual eligible beneficiary" means an individual
21 years of age or older who is eligible for benefits under Medicare
Part A (42 U.S.C. Sec. 1395c et seq.), Medicare Part B (42 U.S.C.
Sec. 1395j et seq.), and Medicare Part D (42 U.S.C. Sec. 1395w-101),
and is eligible for medical assistance under the Medi-Cal State Plan.
(4) "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 2.81
(commencing with Section 14087.96), or Article 2.91 (commencing with
Section 14089), of this chapter, or Chapter 8 (commencing with
Section 14200).
(5) "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.
(6) "Out-of-network Medi-Cal provider" means a health care
provider that does not have an existing contract with the beneficiary'
s managed care health plan or its subcontractors.
(7) "Partial-benefit dual eligible beneficiary" means an
individual 21 years of age or older who is enrolled for benefits
under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), but not
Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or who is eligible
for Medicare Part B (42 U.S.C. Sec. 1395j et seq.), but not Medicare
Part A (42 U.S.C. Sec. 1395c et seq.), and is eligible for medical
assistance under the Medi-Cal State Plan.
(c) (1) Notwithstanding subdivision (a), a dual eligible
beneficiary is exempt from mandatory enrollment in a managed care
health plan if the dual eligible beneficiary meets any of the
following:
(A) Except in counties with county organized health systems
operating pursuant to Article 2.8 (commencing with Section 14087.5),
the beneficiary has other health coverage.
(B) The beneficiary receives services through a foster care
program, including the program described in Article 5 (commencing
with Section 11400) of Chapter 2.
(C) The beneficiary is under 21 years of age.
(D) The beneficiary is not eligible for enrollment in managed care
health plans for medically necessary reasons determined by the
department.
(E) The beneficiary resides in one of the Veterans Homes of
California, as described in Chapter 1 (commencing with Section 1010)
of Division 5 of the Military and Veterans Code.
(F) The beneficiary is enrolled in any entity with a contract with
the department pursuant to Chapter 8.75 (commencing with Section
14591).
(G) The beneficiary is enrolled in a managed care organization
licensed under the Knox-Keene Health Care Service Plan Act of 1975
(Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code) that has previously contracted with the
department as a primary care case management plan pursuant to Article
2.9 (commencing with Section 14088) of Chapter 7.
(2) A beneficiary who has been diagnosed with HIV/AIDS is not
exempt from mandatory enrollment, but may opt out of managed care
enrollment at the beginning of any month.
(d) Implementation of this section shall incorporate the
provisions of Section 14182.17 that are applicable to beneficiaries
eligible for benefits under Medi-Cal and the Medicare Program.
(e) At the director's sole discretion, in consultation with
stakeholders, the department may determine and implement a phased-in
enrollment approach that may include Medi-Cal beneficiary enrollment
into managed care health plans immediately upon implementation of
this section in a specific county, over a 12-month period, or other
phased approach. The phased-in enrollment shall commence no sooner
than March 1, 2013, and not until all necessary federal approvals
have been obtained.
(f) To the extent that mandatory enrollment is required by the
department, an enrollee's access to fee-for-service Medi-Cal shall
not be terminated until the enrollee has selected or been assigned to
a managed care health plan.
(g) Except in a county where Medi-Cal services are provided by a
county organized health system, and notwithstanding any other law, in
any county in which fewer than two existing managed health care
plans contract with the department to provide Medi-Cal services under
this chapter that are available to dual eligible beneficiaries,
including long-term services and supports, the department may
contract with additional managed care health plans to provide
Medi-Cal services.
(h) For partial-benefit dual eligible beneficiaries, the
department shall inform these beneficiaries of their rights to
continuity of care from out-of-network Medi-Cal providers pursuant to
subparagraph (G) of paragraph (5) of subdivision (d) of Section
14182.17, and that the need for medical exemption criteria applied to
counties operating under Chapter 4.1 (commencing with Section 53800)
of Subdivision 1 of Division 3 of Title 22 of the California Code of
Regulations may not be necessary to continue receiving Medi-Cal
services from an out-of-network provider.
(i) The department may contract with existing managed care health
plans to provide or arrange for services under this section.
Notwithstanding any other law, the department may enter into the
contract without the need for a competitive bid process or other
contract proposal process, provided that the managed care health plan
provides written documentation that it meets all of the
qualifications and requirements of this section and Section 14182.17.
(j) The development of capitation rates for managed care health
plan contracts shall include the analysis of data specific to the
dual eligible population. For the purposes of developing capitation
rates for payments to managed care health plans, the department shall
require all managed care health plans, including existing managed
care health plans, to submit financial, encounter, and utilization
data in a form, at a time, and including substance as deemed
necessary by the department. Failure to submit the required data
shall result in the imposition of penalties pursuant to Section
14182.1.
(k) Persons meeting participation requirements for the Program of
All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75
(commencing with Section 14591) may select a PACE plan if one is
available in that county.
(l) Except for dual eligible beneficiaries participating in the
demonstration project pursuant to Section 14132.275, persons meeting
the participation requirements in effect on January 1, 2010, for a
Medi-Cal primary case management plan in operation on that date, may
select that primary care case management plan or a successor health
care plan that is licensed pursuant to the Knox-Keene Health Care
Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340)
of Division 2 of the Health and Safety Code) to provide services
within the same geographic area that the primary care case management
plan served on January 1, 2010.
(m) The department may implement an intergovernmental transfer
arrangement with a public entity that elects to transfer public funds
to the state to be used solely as the nonfederal share of Medi-Cal
payments to managed care health plans for the provision of services
to dual eligible beneficiaries pursuant to Section 14182.15.
(n)
To implement this section, the department may contract with public or
private entities. Contracts or amendments entered into under this
section may be on an exclusive or nonexclusive basis and 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.
(o) Any otherwise applicable provisions of this chapter, Chapter 8
(commencing with Section 14200), or Chapter 8.75 (commencing with
Section 14591) not in conflict with this section or with the Special
Terms and Conditions of the waiver shall apply to this section.
(p) The department shall, in coordination with and consistent with
an interagency agreement with the Department of Managed Health Care,
at a minimum, monitor on a quarterly basis the adequacy of provider
networks of the managed care health plans.
(q) The department shall suspend new enrollment of dual eligible
beneficiaries into a managed care health plan if it determines that
the managed care health plan does not have sufficient primary or
specialty care providers and long-term service and supports to meet
the needs of its enrollees.
(r) Managed care health plans shall pay providers in accordance
with Medicare and Medi-Cal coordination of benefits.
(s) This section shall be implemented only to the extent that all
federal approvals and waivers are obtained and only if and to the
extent that federal financial participation is available.
(t) 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 this section
and any applicable federal waivers and state plan amendments 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 department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries. The department
shall notify the appropriate policy and fiscal committees of the
Legislature of its intent to issue instructions under this section at
least five days in advance of the issuance.
(u) A managed care health plan that contracts with the department
for the provision of services under this section shall ensure that
beneficiaries have access to the same categories of licensed
providers that are available under fee-for-service Medicare. Nothing
in this section shall prevent a managed care health plan from
contracting with selected providers within a category of licensure.
(v) The department shall, commencing August 1, 2013, convene
stakeholders, at least quarterly, to review progress on the
Coordinated Care Initiative and make recommendations to the
department and the Legislature for the duration of the Coordinated
Care Initiative. The stakeholders shall include beneficiaries,
counties, and health plans, and representatives from primary care
providers, specialists, hospitals, nursing facilities, MSSP programs,
CBAS programs, other social service providers, the IHSS program,
behavioral health providers, and substance use disorders
stakeholders.
SEC. 17. Section 14182.17 of the Welfare and Institutions Code is
amended to read:
14182.17. (a) For the purposes of this section, the definitions
in subdivision (b) of Section 14182.16 shall apply.
(b) The department shall ensure and improve the care coordination
and integration of health care services for Medi-Cal beneficiaries
residing in Coordinated Care Initiative counties who are either of
the following:
(1) Dual eligible beneficiaries, as defined in subdivision (b) of
Section 14182.16, who receive Medi-Cal benefits and services through
the demonstration project established pursuant to Section 14132.275
or through mandatory enrollment in managed care health plans pursuant
to Section 14182.16.
(2) Medi-Cal beneficiaries who receive long-term services and
supports pursuant to Article 5.7 (commencing with Section 14186).
(c) The department shall develop an enrollment process to be used
in Coordinated Care Initiative counties to do the following:
(1) Except in a county that provides Medi-Cal services under a
county organized health system pursuant to Article 2.8 (commencing
with Section 14087.5), provide a choice of Medi-Cal managed care
plans to a dual eligible beneficiary who has opted for Medicare
fee-for-service, and establish an algorithm to assign beneficiaries
who do not make a choice.
(2) Ensure that only beneficiaries required to make a choice or
affirmatively opt out are sent enrollment materials.
(3) Establish enrollment timelines, developed in consultation with
health plans and stakeholders, and approved by CMS, for each
demonstration site. The timeline may provide for combining or phasing
in enrollment for Medicare and Medi-Cal benefits.
(d) Before the department contracts with managed care health plans
or Medi-Cal providers to furnish Medi-Cal benefits and services
pursuant to subdivision (b), the department shall do all of the
following:
(1) Ensure timely and appropriate communications with
beneficiaries as follows:
(A) At least 90 days prior to enrollment, inform dual eligible
beneficiaries through a notice written at not more than a sixth-grade
reading level that includes, at a minimum, how the Medi-Cal system
of care will change, when the changes will occur, and who they can
contact for assistance with choosing a managed care health plan or
with problems they encounter.
(B) Develop and implement an outreach and education program for
beneficiaries to inform them of their enrollment options and rights,
including specific steps to work with consumer and beneficiary
community groups.
(C) Develop, in consultation with consumers, beneficiaries, and
other stakeholders, an overall communications plan that includes all
aspects of developing beneficiary notices.
(D) Ensure that managed care health plans and their provider
networks are able to provide communication and services to dual
eligible beneficiaries in alternative formats that are culturally,
linguistically, and physically appropriate through means, including,
but not limited to, assistive listening systems, sign language
interpreters, captioning, written communication, plain language, and
written translations.
(E) Ensure that managed care health plans have prepared materials
to inform beneficiaries of procedures for obtaining Medi-Cal
benefits, including grievance and appeals procedures, that are
offered by the plan or are available through the Medi-Cal program.
(F) Ensure that managed care health plans have policies and
procedures in effect to address the effective transition of
beneficiaries from Medicare Part D plans not participating in the
demonstration project. These policies shall include, but not be
limited to, the transition of care requirements for Medicare Part D
benefits as described in Chapters 6 and 14 of the Medicare Managed
Care Manual, published by CMS, including a determination of which
beneficiaries require information about their transition supply, and,
within the first 90 days of coverage under a new plan, provide for a
temporary fill when the beneficiary requests a refill of a
nonformulary drug.
(G) Contingent upon available private or public funds other than
moneys from the General Fund, contract with community-based,
nonprofit consumer, or health insurance assistance organizations with
expertise and experience in assisting dual eligible beneficiaries in
understanding their health care coverage options.
(H) Develop, with stakeholder input, informing and enrollment
materials and an enrollment process in the demonstration site
counties. The department shall ensure all of the following prior to
implementing enrollment:
(i) Enrollment materials shall be made public at least 60 days
prior to the first mailing of notices to dual eligible beneficiaries,
and the department shall work with stakeholders to incorporate
public comment into the materials.
(ii) The materials shall be in a not more than sixth grade reading
level and shall be available in all the Medi-Cal threshold
languages, as well as in alternative formats that are culturally,
linguistically, and physically appropriate. For in-person enrollment
assistance, disability accommodation shall be provided, when
appropriate, through means including, but not limited to, assistive
listening systems, sign language interpreters, captioning, and
written communication.
(iii) The materials shall plainly state that the beneficiary may
choose fee-for-service Medicare or Medicare Advantage, but must
return the form to indicate this choice, and that if the beneficiary
does not return the form, the state shall assign the beneficiary to a
plan and all Medicare and Medi-Cal benefits shall only be available
through that plan.
(iv) The materials shall plainly state that the beneficiary shall
be enrolled in a Medi-Cal managed care health plan even if he or she
chooses to stay in fee-for-service Medicare.
(v) The materials shall plainly explain all of the following:
(I) The plan choices.
(II) Continuity of care provisions.
(III) How to determine which providers are enrolled in each plan.
(IV) How to obtain assistance with the choice forms.
(vi) The enrollment contractor recognizes, in compliance with
existing statutes and regulations, authorized representatives,
including, but not limited to, a caregiver, family member,
conservator, or a legal services advocate, who is recognized by any
of the services or programs that the person is already receiving or
participating in.
(I) Make available to the public and to all Medi-Cal providers
copies of all beneficiary notices in advance of the date the notices
are sent to beneficiaries. These copies shall be available on the
department's Internet Web site.
(2) Require that managed care health plans perform an assessment
process that, at a minimum, does all of the following:
(A) Assesses each new enrollee's risk level and needs by
performing a risk assessment process using means such as telephonic,
Web-based, or in-person communication, or review of utilization and
claims processing data, or by other means as determined by the
department, with a particular focus on identifying those enrollees
who may need long-term services and supports. The risk assessment
process shall be performed in accordance with all applicable federal
and state laws.
(B) Assesses the care needs of dual eligible beneficiaries and
coordinates their Medi-Cal benefits across all settings, including
coordination of necessary services within, and, when necessary,
outside of the managed care health plan's provider network.
(C) Uses a mechanism or algorithm developed by the managed care
health plan pursuant to paragraph (7) of subdivision (b) of Section
14182 for risk stratification of members.
(D) At the time of enrollment, applies the risk stratification
mechanism or algorithm approved by the department to determine the
health risk level of members.
(E) Reviews historical Medi-Cal fee-for-service utilization data
and Medicare data, to the extent either is accessible to and provided
by the department, for dual eligible beneficiaries upon enrollment
in a managed care health plan so that the managed care health plans
are better able to assist dual eligible beneficiaries and prioritize
assessment and care planning.
(F) Analyzes Medicare claims data for dual eligible beneficiaries
upon enrollment in a demonstration site pursuant to Section 14132.275
to provide an appropriate transition process for newly enrolled
beneficiaries who are prescribed Medicare Part D drugs that are not
on the demonstration site's formulary, as required under the
transition of care requirements for Medicare Part D benefits as
described in Chapters 6 and 14 of the Medicare Managed Care Manual,
published by CMS.
(G) Assesses each new enrollee's behavioral health needs and
historical utilization, including mental health and substance use
disorder treatment services.
(H) Follows timeframes for reassessment and, if necessary,
circumstances or conditions that require redetermination of risk
level, which shall be set by the department.
(3) Ensure that the managed care health plans arrange for primary
care by doing all of the following:
(A) Except for beneficiaries enrolled in the demonstration project
pursuant to Section 14132.275, forgo interference with a beneficiary'
s choice of primary care physician under Medicare, and not assign a
full-benefit dual eligible beneficiary to a primary care physician
unless it is determined through the risk stratification and
assessment process that assignment is necessary, in order to properly
coordinate the care of the beneficiary or upon the beneficiary's
request.
(B) Assign a primary care physician to a partial-benefit dual
eligible beneficiary receiving primary or specialty care through the
Medi-Cal managed care plan.
(C) Provide a mechanism for partial-benefit dual eligible
enrollees to request a specialist or clinic as a primary care
provider if these services are being provided through the Medi-Cal
managed care health plan. A specialist or clinic may serve as a
primary care provider if the specialist or clinic agrees to serve in
a primary care provider role and is qualified to treat the required
range of conditions of the enrollees.
(4) Ensure that the managed care health plans perform, at a
minimum, and in addition to, other statutory and contractual
requirements, care coordination, and care management activities as
follows:
(A) Reflect a member-centered, outcome-based approach to care
planning, consistent with the CMS model of care approach and with
federal Medicare requirements and guidance.
(B) Adhere to a beneficiary's determination about the appropriate
involvement of his or her medical providers and caregivers, according
to the federal Health Insurance Portability and Accountability Act
of 1996 (Public Law 104-191).
(C) Develop care management and care coordination for the
beneficiary across the medical and long-term services and supports
care system, including transitions among levels of care and between
service locations.
(D) Develop individual care plans for higher risk beneficiaries
based on the results of the risk assessment process with a particular
focus on long-term services and supports.
(E) Use nurses, social workers, the beneficiary's primary care
physician, if appropriate, and other medical professionals to provide
care management and enhanced care management, as applicable,
particularly for beneficiaries in need of or receiving long-term
services and supports.
(F) Consider behavioral health needs of beneficiaries and
coordinate those services with the county mental health department as
part of the beneficiary's care management plan when appropriate.
(G) Facilitate a beneficiary's ability to access appropriate
community resources and other agencies, including referrals as
necessary and appropriate for behavioral services, such as mental
health and substance use disorders treatment services.
(H) Monitor skilled nursing facility utilization and develop care
transition plans and programs that move beneficiaries back into the
community to the extent possible. Plans shall monitor and support
beneficiaries in the community to avoid further institutionalization.
(5) Ensure that the managed care health plans comply with, at a
minimum, and in addition to other statutory and contractual
requirements, network adequacy requirements as follows:
(A) Provide access to providers that comply with applicable state
and federal law, including, but not limited to, physical
accessibility and the provision of health plan information in
alternative formats.
(B) Meet provider network adequacy standards for long-term
services and supports that the department shall develop.
(C) Maintain an updated, accurate, and accessible listing of a
provider's ability to accept new patients, which shall be made
available to beneficiaries, at a minimum, by phone, written material,
and the Internet, and in accessible formats, upon request.
(D) Monitor an appropriate provider network that includes an
adequate number of accessible facilities within each service area.
(E) Contract with and assign patients to safety net and
traditional providers as defined in subdivisions (hh) and (jj),
respectively, of Section 53810 of Title 22 of the California Code of
Regulations, including small and private practice providers who have
traditionally treated dual eligible patients, based on available
medical history to ensure access to care and services. A managed care
health plan shall establish participation standards to ensure
participation and broad representation of traditional and safety net
providers within a service area.
(F) Maintain a liaison to coordinate with each regional center
operating within the plan's service area to assist dual eligible
beneficiaries with developmental disabilities in understanding and
accessing services and act as a central point of contact for
questions, access and care concerns, and problem resolution.
(G) Maintain a liaison and provide access to out-of-network
providers, for up to 12 months, for new members enrolled under
Sections 14132.275 and 14182.16 who have an ongoing relationship with
a provider, if the provider will accept the health plan's rate for
the service offered, or for nursing facilities and Community-Based
Adult Services, or the applicable Medi-Cal fee-for-service rate,
whichever is higher, and the managed care health plan determines that
the provider meets applicable professional standards and has no
disqualifying quality of care issues in accordance with guidance from
the department, including all-plan letters. A partial-benefit dual
eligible beneficiary enrolled in Medicare Part A who only receives
primary and specialty care services through a Medi-Cal managed care
health plan shall be able to receive these Medi-Cal services from an
out-of-network Medi-Cal provider for 12 months after enrollment. This
subparagraph shall not apply to out-of-network providers that
furnish ancillary services.
(H) Assign a primary care physician who is the primary clinician
for the beneficiary and who provides core clinical management
functions for partial-benefit dual eligible beneficiaries who are
receiving primary and specialty care through the Medi-Cal managed
care health plan.
(I) Employ care managers directly or contract with nonprofit or
proprietary organizations in sufficient numbers to provide
coordinated care services for long-term services and supports as
needed for all members.
(6) Ensure that the managed care health plans address medical and
social needs as follows:
(A) Offer services beyond those required by Medicare and Medi-Cal
at the managed care health plan's discretion.
(B) Refer beneficiaries to community resources or other agencies
for needed medical or social services or items outside the managed
care health plan's responsibilities.
(C) Facilitate communication among a beneficiary's health care and
personal care providers, including long-term services and supports
and behavioral health providers when appropriate.
(D) Engage in other activities or services needed to assist
beneficiaries in optimizing their health status, including assisting
with self-management skills or techniques, health education, and
other modalities to improve health status.
(E) Facilitate timely access to primary care, specialty care,
medications, and other health services needed by the beneficiary,
including referrals to address any physical or cognitive barriers to
access.
(F) Utilize the most recent common procedure terminology (CPT)
codes, modifiers, and correct coding initiative edits.
(7) (A) Ensure that the managed care health plans provide, at a
minimum, and in addition to other statutory and contractual
requirements, a grievance and appeal process that does both of the
following:
(i) Provides a clear, timely, and fair process for accepting and
acting upon complaints, grievances, and disenrollment requests,
including procedures for appealing decisions regarding coverage or
benefits, as specified by the department. Each managed care health
plan shall have a grievance process that complies with Section 14450,
and Sections 1368 and 1368.01 of the Health and Safety Code.
(ii) Complies with a Medicare and Medi-Cal grievance and appeal
process, as applicable. The appeals process shall not diminish the
grievance and appeals rights of IHSS recipients pursuant to Section
10950.
(B) In no circumstance shall the process for appeals be more
restrictive than what is required under the Medi-Cal program.
(e) The department shall do all of the following:
(1) Monitor the managed care health plans' performance and
accountability for provision of services, in addition to all other
statutory and contractual monitoring and oversight requirements, by
doing all of the following:
(A) Develop performance measures that are required as part of the
contract to provide quality indicators for the Medi-Cal population
enrolled in a managed care health plan and for the dual eligible
subset of enrollees. These performance measures may include measures
from the Healthcare Effectiveness Data and Information Set or
measures indicative of performance in serving special needs
populations, such as the National Committee for Quality Assurance
structure and process measures, or other performance measures
identified or developed by the department.
(B) Implement performance measures that are required as part of
the contract to provide quality assurance indicators for long-term
services and supports in quality assurance plans required under the
plans' contracts. These indicators shall include factors such as
affirmative member choice, increased independence, avoidance of
institutional care, and positive health outcomes. The department
shall develop these quality assurance indicators in consultation with
stakeholder groups.
(C) Effective January 10, 2014, and for each subsequent year of
the demonstration project authorized under Section 14132.275, provide
a report to the Legislature describing the degree to which Medi-Cal
managed care health plans in counties participating in the
demonstration project have fulfilled the quality requirements, as set
forth in the health plan contracts.
(D) Effective June 1, 2014, and for each subsequent year of the
demonstration project authorized by Section 14132.275, provide a
joint report, from the department and from the Department of Managed
Health Care, to the Legislature summarizing information from both of
the following:
(i) The independent audit report required to be submitted annually
to the Department of Managed Health Care by managed care health
plans participating in the demonstration project authorized by
Section 14132.275.
(ii) Any routine financial examinations of managed care health
plans operating in the demonstration project authorized by Section
14132.275 that have been conducted and completed for the previous
calendar year by the Department of Managed Health Care and the
department.
(2) Monitor on a quarterly basis the utilization of covered
services of beneficiaries enrolled in the demonstration project
pursuant to Section 14132.275 or receiving long-term services and
supports pursuant to Article 5.7 (commencing with Section 14186).
(3) Develop requirements for managed care health plans to solicit
stakeholder and member participation in advisory groups for the
planning and development activities relating to the provision of
services for dual eligible beneficiaries.
(4) Submit to the Legislature the following information:
(A) Provide, to the fiscal and appropriate policy committees of
the Legislature, a copy of any report submitted to CMS pursuant to
the approved federal waiver described in Section 14180.
(B) Together with the State Department of Social Services, the
California Department of Aging, and the Department of Managed Health
Care, in consultation with stakeholders, develop a programmatic
transition plan, and submit that plan to the Legislature within 90
days of the effective date of this section. The plan shall include,
but is not limited to, the following components:
(i) A description of how access and quality of service shall be
maintained during and immediately after implementation of these
provisions, in order to prevent unnecessary disruption of services to
beneficiaries.
(ii) Explanations of the operational steps, timelines, and key
milestones for determining when and how the components of paragraphs
(1) to (9), inclusive, shall be implemented.
(iii) The process for addressing consumer complaints, including
the roles and responsibilities of the departments and health plans
and how those roles and responsibilities shall be coordinated. The
process shall outline required response times and the method for
tracking the disposition of complaint cases. The process shall
include the use of an ombudsman, liaison, and 24-hour hotline
dedicated to assisting Medi-Cal beneficiaries navigate among the
departments and health plans to help ensure timely resolution of
complaints.
(iv) A description of how stakeholders were included in the
various phases of the planning process to formulate the transition
plan, and how their feedback shall be taken into consideration after
transition activities begin.
(C) The department, together with the State Department of Social
Services, the California Department of Aging, and the Department of
Managed Health Care, convene and consult with stakeholders at least
twice during the period following production of a draft of the
implementation plan and before submission of the plan to the
Legislature. Continued consultation with stakeholders shall occur on
an ongoing basis for the implementation of the provisions of this
section.
(D) No later than 90 days prior to the initial plan enrollment
date of the demonstration project pursuant to the provisions of
Sections 14132.275, 14182.16, and of Article 5.7 (commencing with
Section 14186), assess and report to the fiscal and appropriate
policy committees of the Legislature on the readiness of the managed
care health plans to address the unique needs of dual eligible
beneficiaries and Medi-Cal only seniors and persons
with disabilities pursuant
to the applicable readiness evaluation criteria and requirements set
forth in paragraphs (1) to (8), inclusive, of subdivision (b) of
Section 14087.48. The report shall also include an assessment of the
readiness of the managed care health plans in each county
participating in the demonstration project to have met the
requirements set forth in paragraphs (1) to (9), inclusive.
(E) The department shall submit two reports to the Legislature,
with the first report submitted five months prior to the commencement
date of enrollment and the second report submitted three months
prior to the commencement date of enrollment, that describe the
status of all of the following readiness criteria and activities that
the department shall complete:
(i) Enter into contracts, either directly or by funding other
agencies or community-based, nonprofit, consumer, or health insurance
assistance organizations with expertise and experience in providing
health plan counseling or other direct health consumer assistance to
dual eligible beneficiaries, in order to assist these beneficiaries
in understanding their options to participate in the demonstration
project specified in Section 14132.275 and to exercise their rights
and address barriers regarding access to benefits and services.
(ii) Develop a plan to ensure timely and appropriate
communications with beneficiaries as follows:
(I) Develop a plan to inform beneficiaries of their enrollment
options and rights, including specific steps to work with consumer
and beneficiary community groups described in clause (i), consistent
with the provisions of paragraph (1).
(II) Design, in consultation with consumers, beneficiaries, and
stakeholders, all enrollment-related notices, including, but not
limited to, summary of benefits, evidence of coverage, prescription
formulary, and provider directory notices, as well as all appeals and
grievance-related procedures and notices produced in coordination
with existing federal Centers for Medicare and Medicaid Services
(CMS) guidelines.
(III) Design a comprehensive plan for beneficiary and provider
outreach, including specific materials for persons in nursing and
group homes, family members, conservators, and authorized
representatives of beneficiaries, as appropriate, and providers of
services and supports.
(IV) Develop a description of the benefits package available to
beneficiaries in order to assist them in plan selection and how they
may select and access services in the demonstration project's
assessment and care planning process.
(V) Design uniform and plain language materials and a process to
inform seniors and persons with disabilities of copays and covered
services so that beneficiaries can make informed choices.
(VI) Develop a description of the process, except in those
demonstration counties that have a county operated health system, of
automatically assigning beneficiaries into managed care health plans
that shall include a requirement to consider Medicare service
utilization, provider data, and consideration of plan quality.
(iii) Finalize rates and comprehensive contracts between the
department and participating health plans to facilitate effective
outreach, enroll network providers, and establish benefit packages.
To the extent permitted by CMS, the plan rates and contract structure
shall be provided to the appropriate fiscal and policy committees of
the Legislature and posted on the department's Internet Web site so
that they are readily available to the public.
(iv) Ensure that contracts have been entered into between plans
and providers including, but not limited to, agreements with county
agencies as necessary.
(v) Develop network adequacy standards for medical care and
long-term supports and services that reflect the provisions of
paragraph (5).
(vi) Identify dedicated department or contractor staff with
adequate training and availability during business hours to address
and resolve issues between health plans and beneficiaries, and
establish a requirement that health plans have similar points of
contact and are required to respond to state inquiries when
continuity of care issues arise.
(vii) Develop a tracking mechanism for inquiries and complaints
for quality assessment purposes, and post publicly on the department'
s Internet Web site information on the types of issues that arise and
data on the resolution of complaints.
(viii) Prepare scripts and training for the department and plan
customer service representatives on all aspects of the program,
including training for enrollment brokers and community-based
organizations on rules of enrollment and counseling of beneficiaries.
(ix) Develop continuity of care procedures.
(x) Adopt quality measures to be used to evaluate the
demonstration projects. Quality measures shall be detailed enough to
enable measurement of the impact of automatic plan assignment on
quality of care.
(xi) Develop reporting requirements for the plans to report to the
department, including data on enrollments and disenrollments,
appeals and grievances, and information necessary to evaluate quality
measures and care coordination models. The department shall report
this information to the appropriate fiscal and policy committees of
the Legislature, and this information shall be posted on the
department's Internet Web site.
(f) This section shall be implemented only to the extent that all
federal approvals and waivers are obtained and only if and to the
extent that federal financial participation is available.
(g) To implement this section, the department may contract with
public or private entities. Contracts or amendments entered into
under this section may be on an exclusive or nonexclusive basis and a
noncompetitive bid basis and shall be exempt from 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.
(h) 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 this section
and any applicable federal waivers and state plan amendments 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 department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries. The department
shall notify the appropriate policy and fiscal committees of the
Legislature of its intent to issue instructions under this section at
least five days in advance of the issuance.
SEC. 18. Section 14182.18 is added to the Welfare and Institutions
Code, to read:
14182.18. (a) It is the intent of the Legislature that both the
managed care plans participating in and providing long-term services
and supports under Sections 14182.16 and 14186.2 and the state have
protections against either significant overpayment or significant
underpayments. Risk corridors are one method of risk sharing that may
limit the financial risk of misaligning the payments associated with
a contract to furnish long-term services and supports pursuant to a
contract under the Coordinated Care Initiative on an at-risk basis.
(b) In Coordinated Care Initiative counties, as defined in
paragraph (1) of subdivision (b) of Section 14182.16, for managed
care health plans providing long-term services and supports, the
department shall include in its contract with those plans risk
corridors designed with the following parameters:
(1) Risk corridors shall apply only to the costs of the
individuals and services identified below:
(A) Health care service costs for full benefit dual eligible
beneficiaries as defined in paragraph (3) of subdivision (b) of
Section 14182.16 for whom both of the following are true:
(i) The beneficiary is enrolled in the managed care health plan
and the plan's contract covers all Medi-Cal long-term services and
supports.
(ii) The beneficiary is not enrolled in the demonstration project.
(B) Long-term services and supports costs for partial benefit dual
eligible beneficiaries as defined in paragraph (7) of subdivision
(b) of Section 14182 and non-dual-eligible beneficiaries who are
enrolled in the managed care health plan and the plan's contract
covers all Medi-Cal long-term services and supports.
(2) Risk corridors applied to costs of beneficiary services
identified in subparagraph (A) of paragraph (1) shall only be in
place for a period of 24 months starting with the first month in
which both mandatory enrollment of full benefit dual eligible
beneficiaries pursuant to Section 14182.16 and mandatory coverage of
all Medi-Cal long-term services and supports pursuant to Section
14186.2 have occurred.
(3) Risk corridors applied to costs of beneficiary services
identified in subparagraph (B) of paragraph (1) shall only be in
place for a period of 24 months starting with the first month in
which mandatory coverage of all Medi-Cal long-term services and
supports pursuant to Section 14186.2 has occurred.
(4) The risk sharing of the costs of the individuals and services
under this subdivision shall be constructed by the department so that
it is symmetrical with respect to risk and profit, and so that all
of the following apply:
(A) The managed care health plan is fully responsible for all
costs in excess of the capitated rate of the plan up to 1 percent.
(B) The managed care health plan shall fully retain the revenues
paid through the capitated rate in excess of the costs incurred up to
1 percent.
(C) The managed care health plan and the department shall share
responsibility for costs in excess of the capitated rate of the plan
that are greater than 1 percent above the rate but less than 2.5
percent above the rate.
(D) The managed care health plan and the department shall share
the benefit of revenues in excess of the costs incurred that are
greater than 1 percent below the capitated rate of the plan but less
than 2.5 percent below the capitated rate of the plan.
(E) The department shall be fully responsible for all costs in
excess of the capitated rate of the plan that are more than 2.5
percent above the capitated rate of the plan.
(F) The department shall fully retain the revenues paid through
the capitated rate in excess of the costs incurred greater than 2.5
percent below the capitated rate of the plan.
(c) The department shall develop specific contractual language
implementing the requirements of this section and corresponding
details that shall be incorporated into the managed care health plan'
s contract.
(d) This section shall be implemented only to the extent that any
necessary federal approvals or waivers are obtained.
SEC. 19. Section 14183.6 of the Welfare and Institutions Code is
amended to read:
14183.6. (a) The department shall enter into an interagency
agreement with the Department of Managed Health Care to have the
Department of Managed Health Care, on behalf of the department,
conduct financial audits, medical surveys, and a review of the
provider networks of the managed care health plans participating in
the demonstration project and the Medi-Cal managed care expansion
into rural counties, and to provide consumer assistance to
beneficiaries affected by the provisions of Sections 14182.16 and
14182.17. The interagency agreement shall be updated, as necessary,
on an annual basis in order to maintain functional clarity regarding
the roles and responsibilities of these core activities. The
department shall not delegate its authority under this division as
the single state Medicaid agency to the Department of Managed Health
Care.
(b) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 20. Section 14183.6 is added to the Welfare and Institutions
Code, to read:
14183.6. (a) The department shall enter into an interagency
agreement with the Department of Managed Health Care to have the
Department of Managed Health Care, on behalf of the department,
conduct financial audits, medical surveys, and a review of the
provider networks of the managed care health plans participating in
the demonstration project and the Medi-Cal managed care expansion
into rural counties. The interagency agreement shall be updated, as
necessary, on an annual basis in order to maintain functional clarity
regarding the roles and responsibilities of these core activities.
The department shall not delegate its authority under this division
as the single state Medicaid agency to the Department of Managed
Health Care.
(b) This section shall be operative only if Section 19 of the act
that added this section becomes inoperative pursuant to subdivision
(b) of that Section 19.
SEC. 21. Section 14186 of the Welfare and Institutions Code is
amended to read:
14186. (a) It is the intent of the Legislature that long-term
services and supports (LTSS) be covered through managed care health
plans in Coordinated Care Initiative counties.
(b) It is further the intent of the Legislature that all of the
following occur:
(1) Persons receiving health care services through Medi-Cal
receive these services through a coordinated health care system that
reduces the unnecessary use of emergency and hospital services.
(2) Coordinated health care services, including medical, long-term
services and supports, and enhanced care management be covered
through Medi-Cal managed care health plans in order to eliminate
system inefficiencies and align incentives with positive health care
outcomes.
(3) Managed care health plans shall, in coordination with LTSS
care management providers, develop and expand care coordination
practices in consultation with counties, nursing facilities, area
agencies on aging, and other home- and community-based providers, and
share best practices. Unless the consumer objects, managed care
health plans may establish care coordination teams as needed. If the
consumer is an IHSS recipient, his or her participation and the
participation of his or her provider shall be subject to the consumer'
s consent. These care coordination teams shall include the consumer,
and his or her authorized representative, health plan, county social
services agency, Community-Based Adult Services (CBAS) case manager
for CBAS clients, Multipurpose Senior Services Program (MSSP) case
manager for MSSP clients, and, if an IHSS recipient, may include
others.
(4) To the extent possible, for Medi-Cal beneficiaries also
enrolled in the Medicare Program, that the department work with the
federal government to coordinate financing and incentives and permit
managed care health plans to coordinate health care provided under
both health care systems.
(5) The health care choices made by Medi-Cal beneficiaries be
considered with regard to all of the following:
(A) Receiving care in a home- and community-based setting to
maintain independence and quality of life.
(B) Selecting their health care providers in the managed care plan
network.
(C) Controlling care planning, decisionmaking, and coordination
with their health care providers.
(D) Gaining access to services that are culturally,
linguistically, and operationally sensitive to meet their needs or
limitations and that improve their health outcomes, enhance
independence, and promote living in home- and community-based
settings.
(E) Self-directing their care by being able to hire, fire, and
supervise their IHSS provider.
(F) Being assured by the department and coordinating departments
of their oversight of the quality of these coordinated health care
services.
(6) (A) Counties continue to perform functions necessary for the
administration of the IHSS program, including conducting assessments
and determining authorized hours for recipients, pursuant to Article
7 (commencing with Section 12300) of Chapter 3. County agency
assessments shall be shared with care coordination teams, when
applicable. The county agency thereafter may receive and consider
additional input from the care coordination team.
(B) Managed care health plans may authorize personal care services
and related domestic services in addition to the hours authorized
under Article 7 (commencing with Section 12300) of Chapter 3, which
managed care health plans shall be responsible for paying at no share
of cost to the county. The department, in consultation with the
State Department of Social Services, shall develop policies and
procedures for these additional benefits, which managed care health
plans may authorize. 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.
(7) (A) Effective January 1, 2015, or 19 months after commencement
of beneficiary enrollment into managed care pursuant to Sections
14182 and 14182.16, whichever is later, MSSP services shall
transition from a federal waiver pursuant to Section 1915(c) under
the federal Social Security Act (42 U.S.C. Sec. 1396n et seq.) to a
benefit administered and allocated by managed care health plans in
Coordinated Care Initiative counties.
(B) Notwithstanding Chapter 8 (commencing with Section 9560) of
Division 8.5, it is also the intent of the Legislature that the
provisions of this article shall apply to dual eligible and
Medi-Cal-only beneficiaries enrolled in MSSP. It is the further
intent of the Legislature that managed care health plans shall work
in collaboration with MSSP providers to begin development of an
integrated, person-centered care management and care coordination
model that works within the context of managed care, and explore
which portions of the MSSP program model may be adapted to managed
care while maintaining the integrity and efficacy of the MSSP model.
(8) In lieu of providing nursing facility services, managed care
health plans may authorize home- and community-based services plan
benefits, as defined in subdivision (d) of Section 14186.1, which
managed care health plans shall be responsible for paying at no share
of cost to the county.
SEC. 22. 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) "Coordinated Care Initiative counties" shall have the same
meaning as that term is defined in paragraph (1) of subdivision (b)
of Section 14182.16.
(b) "Home- and community-based services" means services provided
pursuant to paragraphs (1), (2), and (3) of subdivision (c).
(c) "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, or after 19 months,
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.
(d) "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.
(e) "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.
(f) "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.
(g) "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.
SEC. 23. Section 14186.11 is added to the Welfare and Institutions
Code, immediately following Section 14186.1, to read:
14186.11. Section 14186.17 shall apply to the provision of CBAS,
MSSP, skilled nursing facility, and IHSS services in Coordinated Care
Initiative counties as set forth in this article.
SEC. 24. Section 14186.2 of the Welfare and Institutions Code is
amended to read:
14186.2. (a) (1) Not sooner than March 1, 2013, all Medi-Cal
long-term services and supports (LTSS) described in subdivision (c)
of Section 14186.1 shall be services that are covered under managed
care health plan contracts and shall be available only through
managed care health plans to beneficiaries residing in Coordinated
Care Initiative counties, except for the exemptions provided for in
subdivision (c). The director shall consult with the Legislature,
CMS, and stakeholders when determining the implementation date for
this section. The department shall pay managed care health plans
using a capitation ratesetting methodology that pays for all Medi-Cal
benefits and services, including all LTSS, covered under the managed
care health plan contract. In order to receive any LTSS through
Medi-Cal, Medi-Cal beneficiaries shall mandatorily enroll in a
managed care health plan for the provision of Medi-Cal benefits.
(2) HCBS plan benefits may be covered services that are provided
under managed care health plan contracts for beneficiaries residing
in Coordinated Care Initiative counties, except for the exemptions
provided for in subdivision (c).
(3) Beneficiaries who are not mandatorily enrolled in a managed
care health plan pursuant to paragraph (15) of subdivision (b) of
Section 14182 shall not be required to receive LTSS through a managed
care health plan.
(4) The transition of the provision of LTSS through managed care
health plans shall occur after the department obtains any federal
approvals through necessary federal waivers or amendments, or state
plan amendments.
(5) Counties where LTSS are not covered through managed care
health plans shall not be subject to this article.
(6) Beneficiaries residing in counties not participating in the
dual eligible demonstration project pursuant to Section 14132.275
shall not be subject to this article.
(b) (1) The provisions of this article shall be applicable to a
Medi-Cal beneficiary enrolled in a managed care health plan in a
county where this article is effective.
(2) At the director's sole discretion, in consultation with
coordinating departments and stakeholders, the department may
determine and implement a phased-in enrollment approach that may
include the addition of Medi-Cal long-term services and supports in a
beneficiary's Medi-Cal managed care benefits immediately upon
implementation of this article in a specific county, over a 12-month
period, or other phased approach, but no sooner than March 1, 2013.
(c) (1) The provisions of this article shall not apply to any of
the following individuals:
(A) Medi-Cal beneficiaries who meet any of the following and
shall, therefore, continue to receive any medically necessary
Medi-Cal benefits, including LTSS, through fee-for-service Medi-Cal:
(i) Except in counties with county organized health systems
operating pursuant to Article 2.8 (commencing with Section 14087.5),
have other health coverage.
(ii) Receive services through any state foster care program
including the program described in Article 5 (commencing with Section
11400) Chapter 2, unless the beneficiary is already receiving
services through a managed care health plan.
(iii) Are not eligible for enrollment in managed care health plans
for medically necessary reasons determined by the department.
(iv) Reside in one of the Veterans' Homes of California, as
described in Chapter 1 (commencing with Section 1010) of Division 5
of the Military and Veterans Code.
(B) Persons enrolled in the Program of All-Inclusive Care for the
Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section
14591), or a managed care organization licensed under the Knox-Keene
Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code) that has
previously contracted with the department as a primary care case
management plan pursuant to Article 2.9 (commencing with Section
14088) of Chapter 7 to provide services to beneficiaries who are HIV
positive or who have been
diagnosed with AIDS.
(C) Persons who are under 21 years of age.
(D) Other specific categories of beneficiaries specified by the
department based on extraordinary medical needs of specific patient
groups or to meet federal requirements, in consultation with
stakeholders.
(2) Beneficiaries who have been diagnosed with HIV/AIDS are not
exempt from mandatory enrollment, but may opt out of managed care
enrollment at the beginning of any month.
(d) If the LTSS portion of the Coordinated Care Initiative pilot
is implemented, the provisions of Section 14186.35 shall apply.
SEC. 25. Section 14186.3 of the Welfare and Institutions Code is
amended to read:
14186.3. (a) (1) No sooner than July 1, 2012, Community-Based
Adult Services (CBAS) shall be a Medi-Cal benefit covered under every
managed care health plan contract and available only through managed
care health plans. Medi-Cal beneficiaries who are eligible for CBAS
shall enroll in a managed care health plan in order to receive those
services, except for beneficiaries exempt under subdivision (c) of
Section 14186.2 or in counties or geographic regions where Medi-Cal
benefits are not covered through managed care health plans.
Notwithstanding subdivision (a) of Section 14186.2 and pursuant to
the provisions of an approved federal waiver or plan amendment, the
provision of CBAS as a Medi-Cal benefit through a managed care health
plan shall not be limited to Coordinated Care Initiative counties.
(2) Managed care health plans shall determine a member's medical
need for CBAS using the assessment tool and eligibility criteria
established pursuant to the provisions of an approved federal waiver
or amendments and shall approve the number of days of attendance and
monitor treatment plans of their members. Managed care health plans
shall reauthorize CBAS in compliance with criteria established
pursuant to the provisions of the approved federal waiver or
amendment requirements.
(b) (1) Beginning in the 2012 calendar year, managed care health
plans shall collaborate with MSSP providers to begin development of
an integrated, person-centered care management and care coordination
model and explore how the MSSP program model may be adapted to
managed care while maintaining the efficacy of the MSSP model. The
California Department of Aging and the department shall work with the
MSSP site association and managed care health plans to develop a
template contract to be used by managed care health plans contracting
with MSSP sites in Coordinated Care Initiative counties.
(2) Notwithstanding the implementation date authorized in
paragraph (1) of subdivision (a) of Section 14186.2, beginning no
sooner than June 1, 2013, or on the date that any necessary federal
approvals or waivers are obtained, whichever is later, and effective
January 1, 2015, or 19 months after commencement of beneficiary
enrollment into managed care pursuant to Sections 14182 and 14182.16,
whichever is later:
(A) Multipurpose Senior Services Program (MSSP) services shall be
a Medi-Cal benefit available only through managed care health plans,
except for beneficiaries exempt under subdivision (c) of Section
14186.2 in Coordinated Care Initiative counties.
(B) Managed care health plans shall contract with all county and
nonprofit organizations that are designated providers of MSSP
services for the provision of MSSP case management and waiver
services. These contracts shall provide for all of the following:
(i) Managed care health plans shall allocate to the MSSP providers
the same level of funding they would have otherwise received under
their MSSP contract with the California Department of Aging.
(ii) MSSP providers shall continue to meet all existing federal
waiver standards and program requirements, which include maintaining
the contracted service levels.
(iii) Managed care plans and MSSP providers shall share
confidential beneficiary data with one another, as necessary to
implement the provisions of this section.
(C) The California Department of Aging shall continue to contract
with all designated MSSP sites, including those in the counties
participating in the demonstration project, and perform MSSP waiver
oversight and monitoring.
(D) The California Department of Aging and the department, in
consultation with MSSP providers, managed care health plans, and
stakeholders, shall develop service fee structures, services, and
person-centered care coordination models that shall be effective June
2013, for the provision of care coordination and home- and
community-based services to beneficiaries who are enrolled in managed
care health plans but not enrolled in MSSP, and who may have care
coordination and service needs that are similar to MSSP participants.
The service fees for MSSP providers and MSSP services for any
additional beneficiaries and additional services for existing MSSP
beneficiaries shall be based upon, and consistent with, the rates and
services delivered in MSSP.
(3) In the 2014 calendar year, the provisions of paragraph (2)
shall continue. In addition, managed care health plans shall work in
collaboration with MSSP providers to begin development of an
integrated, person-centered care management and care coordination
model that works within the context of managed care and explore which
portions of the MSSP program model may be adapted to managed care
while maintaining the integrity and efficacy of the MSSP model.
(4) (A) Effective January 1, 2015, or 19 months after the
commencement of beneficiary enrollment into managed care pursuant to
Sections 14182 and 14182.16, or on the date that any necessary
federal approvals or waivers are obtained, whichever is later, MSSP
services in Coordinated Care Initiative counties shall transition
from a federal waiver pursuant to Section 1915(c) under the federal
Social Security Act (42 U.S.C. Sec. 1396n et seq.) to a benefit
administered and allocated by managed care health plans.
(B) No later than January 1, 2014, the department, in consultation
with the California Department of Aging and the Department of
Managed Health Care, and with stakeholder input, shall submit a
transition plan to the Legislature to describe how subparagraph (A)
shall be implemented. The plan shall incorporate the principles of
the MSSP in the managed care benefit, and shall include provisions to
ensure seamless transitions and continuity of care. Managed care
health plans shall, in partnership with local MSSP providers, conduct
a local stakeholder process to develop recommendations that the
department shall consider when developing the transition plan.
(C) No later than 90 days prior to implementation of subparagraph
(A), the department, in consultation with the California Department
of Aging and the Department of Managed Health Care, and with
stakeholder input, shall submit a transition plan to the Legislature
that includes steps to address concerns, if any, raised by
stakeholders subsequent to the plan developed pursuant to
subparagraph (B).
(c) (1) Not sooner than March 1, 2013, or on the date that any
necessary federal approvals or waivers are obtained, whichever is
later, nursing facility services and subacute facility services shall
be Medi-Cal benefits available only through managed care health
plans.
(2) Managed care health plans shall authorize utilization of
nursing facility services or subacute facility services for their
members when medically necessary. The managed care health plan shall
maintain the standards for determining levels of care and
authorization of services for both Medicare and Medi-Cal services
that are consistent with policies established by the federal Centers
for Medicare and Medicaid Services and consistent with the criteria
for authorization of Medi-Cal services specified in Section 51003 of
Title 22 of the California Code of Regulations, which includes
utilization of the "Manual of Criteria for Medi-Cal Authorization,"
published by the department in January 1982, last revised April 11,
2011.
(3) The managed care health plan shall maintain continuity of care
for beneficiaries by recognizing any prior treatment authorization
made by the department for not less than six months following
enrollment of a beneficiary into the health plan.
(4) When a managed care health plan has authorized services in a
facility and there is a change in the beneficiary's condition under
which the facility determines that the facility may no longer meet
the needs of the beneficiary, the beneficiary's health has improved
sufficiently so the resident no longer needs the services provided by
the facility, or the health or safety of individuals in the facility
is endangered by the beneficiary, the managed care health plan shall
arrange and coordinate a discharge of the beneficiary and continue
to pay the facility the applicable rate until the beneficiary is
successfully discharged and transitioned into an appropriate setting.
(5) The managed care health plan shall pay providers, including
institutional providers, in accordance with the prompt payment
provisions contained in each health plan's contracts with the
department, including the ability to accept and pay electronic
claims.
SEC. 26. 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 (b) 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, 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) This section shall remain operative only until July 1, 2017.
SEC. 27. 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) 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.
(c) 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, and advocates.
(d) 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.
(e) 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.
(f) (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.
SEC. 28. Section 14301.1 of the Welfare and Institutions Code is
amended to read:
14301.1. (a) For rates established on or after August 1, 2007,
the department shall pay capitation rates to health plans
participating in the Medi-Cal managed care program using actuarial
methods and may establish health-plan- and county-specific rates.
Notwithstanding any other law, this section shall apply to any
managed care organization, licensed under the Knox-Keene Health Care
Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340)
of Division 2 of the Health and Safety Code), that has contracted
with the department as a primary care case management plan pursuant
to Article 2.9 (commencing with Section 14088) of Chapter 7 to
provide services to beneficiaries who are HIV positive or who have
been diagnosed with AIDS for rates established on or after July 1,
2012. The department shall utilize a county- and model-specific rate
methodology to develop Medi-Cal managed care capitation rates for
contracts entered into between the department and any entity pursuant
to Article 2.7 (commencing with Section 14087.3), Article 2.8
(commencing with Section 14087.5), and Article 2.91 (commencing with
Section 14089) of Chapter 7 that includes, but is not limited to, all
of the following:
(1) Health-plan-specific encounter and claims data.
(2) Supplemental utilization and cost data submitted by the health
plans.
(3) Fee-for-service data for the underlying county of operation or
other appropriate counties as deemed necessary by the department.
(4) Department of Managed Health Care financial statement data
specific to Medi-Cal operations.
(5) Other demographic factors, such as age, gender, or
diagnostic-based risk adjustments, as the department deems
appropriate.
(b) To the extent that the department is unable to obtain
sufficient actual plan data, it may substitute plan model, similar
plan, or county-specific fee-for-service data.
(c) The department shall develop rates that include administrative
costs, and may apply different administrative costs with respect to
separate aid code groups.
(d) The department shall develop rates that shall include, but are
not limited to, assumptions for underwriting, return on investment,
risk, contingencies, changes in policy, and a detailed review of
health plan financial statements to validate and reconcile costs for
use in developing rates.
(e) The department may develop rates that pay plans based on
performance incentives, including quality indicators, access to care,
and data submission.
(f) The department may develop and adopt condition-specific
payment rates for health conditions, including, but not limited to,
childbirth delivery.
(g) (1) Prior to finalizing Medi-Cal managed care capitation
rates, the department shall provide health plans with information on
how the rates were developed, including rate sheets for that specific
health plan, and provide the plans with the opportunity to provide
additional supplemental information.
(2) For contracts entered into between the department and any
entity pursuant to Article 2.8 (commencing with Section 14087.5) of
Chapter 7, the department, by June 30 of each year, or, if the budget
has not passed by that date, no later than five working days after
the budget is signed, shall provide preliminary rates for the
upcoming fiscal year.
(h) For the purposes of developing capitation rates through
implementation of this ratesetting methodology, Medi-Cal managed care
health plans shall provide the department with financial and
utilization data in a form and substance as deemed necessary by the
department to establish rates. This data shall be considered
proprietary and shall be exempt from disclosure as official
information pursuant to subdivision (k) of Section 6254 of the
Government Code as contained in the California Public Records Act
(Division 7 (commencing with Section 6250) of Title 1 of the
Government Code).
(i) Notwithstanding any other provision of law, on and after the
effective date of the act adding this subdivision, the department may
apply this section to the capitation rates it pays under any managed
care health plan contract.
(j) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may set and implement managed care capitation rates, and
interpret or make specific this section and any applicable federal
waivers and state plan amendments by means of plan letters, plan or
provider bulletins, or similar instructions, without taking
regulatory action.
(k) The department shall report, upon request, to the fiscal and
policy committees of the respective houses of the Legislature
regarding implementation of this section.
(l) Prior to October 1, 2011, the risk-adjusted countywide
capitation rate shall comprise no more than 20 percent of the total
capitation rate paid to each Medi-Cal managed care plan.
(m) (1) It is the intent of the Legislature to preserve the policy
goal to support and strengthen traditional safety net providers who
treat high volumes of uninsured and Medi-Cal patients when Medi-Cal
enrollees are defaulted into Medi-Cal managed care plans.
(2) As the department adds additional factors, such as managed
care plan costs, to the Medi-Cal managed care plan default assignment
algorithm, it shall consult with the Auto Assignment Performance
Incentive Program stakeholder workgroup to develop cost factor
disregards related to intergovernmental transfers and required
wraparound payments that support safety net providers.
(n) This section shall be inoperative if the Coordinated Care
Initiative becomes inoperative pursuant to Section 34 of the act that
added this subdivision.
SEC. 29. Section 14301.1 is added to the Welfare and
Institutions Code, to read:
14301.1. (a) For rates established on or after August 1, 2007,
the department shall pay capitation rates to health plans
participating in the Medi-Cal managed care program using actuarial
methods and may establish health-plan- and county-specific rates. The
department shall utilize a county- and model-specific rate
methodology to develop Medi-Cal managed care capitation rates for
contracts entered into between the department and any entity pursuant
to Article 2.7 (commencing with Section 14087.3), Article 2.8
(commencing with Section 14087.5), and Article 2.91 (commencing with
Section 14089) of Chapter 7 that includes, but is not limited to, all
of the following:
(1) Health-plan-specific encounter and claims data.
(2) Supplemental utilization and cost data submitted by the health
plans.
(3) Fee-for-service data for the underlying county of operation or
other appropriate counties as deemed necessary by the department.
(4) Department of Managed Health Care financial statement data
specific to Medi-Cal operations.
(5) Other demographic factors, such as age, gender, or
diagnostic-based risk adjustments, as the department deems
appropriate.
(b) To the extent that the department is unable to obtain
sufficient actual plan data, it may substitute plan model, similar
plan, or county-specific fee-for-service data.
(c) The department shall develop rates that include administrative
costs, and may apply different administrative costs with respect to
separate aid code groups.
(d) The department shall develop rates that shall include, but are
not limited to, assumptions for underwriting, return on investment,
risk, contingencies, changes in policy, and a detailed review of
health plan financial statements to validate and reconcile costs for
use in developing rates.
(e) The department may develop rates that pay plans based on
performance incentives, including quality indicators, access to care,
and data submission.
(f) The department may develop and adopt condition-specific
payment rates for health conditions, including, but not limited to,
childbirth delivery.
(g) (1) Prior to finalizing Medi-Cal managed care capitation
rates, the department shall provide health plans with information on
how the rates were developed, including rate sheets for that specific
health plan, and provide the plans with the opportunity to provide
additional supplemental information.
(2) For contracts entered into between the department and any
entity pursuant to Article 2.8 (commencing with Section 14087.5) of
Chapter 7, the department, by June 30 of each year, or, if the budget
has not passed by that date, no later than five working days after
the budget is signed, shall provide preliminary rates for the
upcoming fiscal year.
(h) For the purposes of developing capitation rates through
implementation of this ratesetting methodology, Medi-Cal managed care
health plans shall provide the department with financial and
utilization data in a form and substance as deemed necessary by the
department to establish rates. This data shall be considered
proprietary and shall be exempt from disclosure as official
information pursuant to subdivision (k) of Section 6254 of the
Government Code as contained in the California Public Records Act
(Division 7 (commencing with Section 6250) of Title 1 of the
Government Code).
(i) The department shall report, upon request, to the fiscal and
policy committees of the respective houses of the Legislature
regarding implementation of this section.
(j) Prior to October 1, 2011, the risk-adjusted countywide
capitation rate shall comprise no more than 20 percent of the total
capitation rate paid to each Medi-Cal managed care plan.
(k) (1) It is the intent of the Legislature to preserve the policy
goal to support and strengthen traditional safety net providers who
treat high volumes of uninsured and Medi-Cal patients when Medi-Cal
enrollees are defaulted into Medi-Cal managed care plans.
(2) As the department adds additional factors, such as managed
care plan costs, to the Medi-Cal managed care plan default assignment
algorithm, it shall consult with the Auto Assignment Performance
Incentive Program stakeholder workgroup to develop cost factor
disregards related to intergovernmental transfers and required
wraparound payments that support safety net providers.
(l) This section shall be operative only if Section 28 of the act
that added this section becomes inoperative pursuant to subdivision
(n) of that Section 28.
SEC. 30. Section 10 of Chapter 33 of the Statutes of 2012 is
repealed.
SEC. 31. Section 15 of Chapter 45 of the Statutes of 2012 is
repealed.
SEC. 32. Section 16 of Chapter 45 of the Statutes of 2012 is
repealed.
SEC. 33. Section 17 of Chapter 45 of the Statutes of 2012, as
amended by Section 45 of Chapter 439 of the Statutes of 2012, is
repealed.
SEC. 34. (a) At least 30 days prior to enrollment of beneficiaries
into the Coordinated Care Initiative, the Director of Finance shall
estimate the amount of net General Fund savings obtained from the
implementation of the Coordinated Care Initiative. This estimate
shall take into account any net savings to the General Fund achieved
through the tax imposed pursuant to Article 5 (commencing with
Section 6174) of Chapter 2 of Part 1 of Division 2 of the Revenue and
Taxation Code Article 5 (commencing with Section 6174).
(b) (1) By January 10 for each fiscal year after implementation of
the Coordinated Care Initiative, for as long as the Coordinated Care
Initiative remains operative, the Director of Finance shall estimate
the amount of net General Fund savings obtained from the
implementation of the Coordinated Care Initiative.
(2) Savings shall be determined under this subdivision by
comparing the estimated costs of the Coordinated Care Initiative, as
approved by the federal government, and the estimated costs of the
program if the Coordinated Care Initiative were not operative. The
determination shall also include any net savings to the General Fund
achieved through the tax imposed pursuant to Article 5 (commencing
with Section 6174) of Chapter 2 of Part 1 of Division 2 of the
Revenue and Taxation Code.
(3) The estimates prepared by the Director of Finance, in
consultation with the Director of Health Care Services, shall be
provided to the Legislature.
(c) (1) Notwithstanding any other law, if, at least 30 days prior
to enrollment of beneficiaries into the Coordinated Care Initiative,
the Director of Finance estimates pursuant to subdivision (a) that
the Coordinated Care Initiative will not generate net General Fund
savings, then the activities to implement the Coordinated Care
Initiative shall be suspended immediately and the Coordinated Care
Initiative shall become inoperative July 1, 2014.
(2) If the Coordinated Care Initiative becomes inoperative
pursuant to this subdivision, the Director of Health Care Services
shall provide any necessary notifications to any affected entities.
(3) For purposes of this subdivision and subdivision (d) only,
"Coordinated Care Initiative" means all of the following statutes and
any amendments to the following:
(A) Sections 14132.275, 14183.6, and 14301.1 of the Welfare and
Institutions Code, as amended by this act.
(B) Sections 14132.276, 14132.277, 14182.16, 14182.17, 14182.18,
and 14301.2 of the Welfare and Institutions Code.
(C) Article 5.7 (commencing with Section 14186) of Chapter 7 of
Part 3 of Division 9 of the Welfare and Institutions Code.
(D) Title 23 (commencing with Section 110000) of the Government
Code.
(E) Section 6531.5 of the Government Code.
(F) Section 6253.2 of the Government Code, as amended by this act.
(G) Sections 12300.5, 12300.6, 12300.7, 12302.6, 12306.15, 12330,
14186.35, and 14186.36 of the Welfare and Institutions Code.
(H) Sections 10101.1, 12306, and 12306.1 of the Welfare and
Institutions Code, as amended by this act.
(I) The amendments made to Sections 12302.21 and 12302.25 of the
Welfare and Institutions Code, as made by Chapter 439 of the Statutes
of 2012.
(d) (1) Notwithstanding any other law, and beginning in 2015, if
the Director of Finance estimates pursuant to subdivision (b) that
the Coordinated Care Initiative will not generate net General Fund
savings, the Coordinated Care Initiative shall become inoperative
January 1 of the following calendar year, except as follows:
(A) Section 12306.15 of the Welfare and Institutions Code shall
become inoperative as of July 1 of that same calendar year.
(B) For any agreement that has been negotiated and approved by the
Statewide Authority, the Statewide Authority shall continue to
retain its authority pursuant to Section 6531.5 and Title 23
(commencing with Section 110000) of the Government Code and Sections
12300.5, 12300.6, 12300.7, and 12302.6 of the Welfare and
Institutions Code, and shall remain the employer of record for all
individual providers covered by the agreement until the agreement
expires or is subject to renegotiation, whereby the authority of the
Statewide Authority shall terminate and the county shall be the
employer of record in accordance with Section 12302.25 of the Welfare
and Institutions Code and may establish an employer of record
pursuant to Section 12301.6 of the Welfare and Institutions Code.
(C) For an agreement that has been assumed by the Statewide
Authority that was negotiated and approved by a predecessor agency,
the Statewide Authority shall cease being the employer of record and
the county shall be reestablished as the employer of record for
purposes of bargaining and in accordance with Section 12302.25 of the
Welfare and Institutions Code, and may establish an employer of
record pursuant to Section 12301.6 of the Welfare and Institutions
Code.
(2) If the Coordinated Care Initiative becomes inoperative
pursuant to this subdivision, the Director of Health Care Services
shall provide any necessary notifications to any affected entities.
SEC. 35. For the purpose of the Coordinated Care Initiative, the
amount of five hundred thousand dollars ($500,000) is hereby
appropriated from the General Fund to the State Department of Health
Care Services for purposes of notifying dual eligible beneficiaries
and providers regarding the provisions of this act, and shall be
available for encumbrance and expenditure until June 30, 2014.
SEC. 36. This act is a bill providing for appropriations related
to the Budget Bill within the meaning of subdivision (e) of Section
12 of Article IV of the California Constitution, has been identified
as related to the budget in the Budget Bill, and shall take effect
immediately.