BILL ANALYSIS                                                                                                                                                                                                    



          SENATE COMMITTEE ON HUMAN SERVICES
                               Senator McGuire, Chair
                                2015 - 2016  Regular 

          Bill No:              AB 97
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          |Author:   |Weber                                                 |
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          |Version:  |March 26, 2015         |Hearing    |June 23, 2015    |
          |          |                       |Date:      |                 |
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          |Urgency:  |No                     |Fiscal:    |Yes              |
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          |Consultant|Sara Rogers                                           |
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               Subject:  In-home supportive services:  provider wages

            SUMMARY
          
          This bill requires the Case Management Information and  
          Payrolling System (CMIPS II) for In-Home Supportive Services  
          (IHSS) to be reprogrammed to enable IHSS recipients in  
          Coordinated Care Initiative (CCI) counties to receive additional  
          services authorized and paid for by managed care health plans.


            ABSTRACT
          
          Existing law:

          1)Establishes in state law a program of public Medi-Cal benefits  
            to provide health care for people who lack sufficient annual  
            income to meet the costs of health care, and whose other  
            assets are so limited that their application toward the costs  
            of such care would jeopardize the person or family's future  
            minimum self-maintenance and security. (WIC 14000 et seq.)

          2)Establishes the IHSS program to provide in-home domestic  
            supportive and personal care services for aged, blind or  
            disabled individuals living at or below the poverty level for  
            the purpose of enabling consumers to avoid  
            institutionalization and remain safely in their homes. (WIC  
            12300 et seq.)










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          3)Requires the California Department of Social Services (CDSS)  
            to be responsible for procuring and implementing a new Case  
            Management Information and Payroll System (CMIPS II) for IHSS  
            and establishes minimum functionalities that are required to  
            be provided by the system. (WIC 12317)


          4)Establishes the CCI, subject to federal approval, which  
            establishes in eight counties an integrated health and  
            long-term managed care plan for individuals and seniors and  
            persons with disabilities who receive both Medi-Cal and  
            Medicare benefits, and includes IHSS under managed care health  
            plan contracts, available only through managed care health  
            plans for beneficiaries residing in counties participating in  
            the CCI demonstration project, with specified exceptions. (WIC  
            14182.16) (WIC 14186.35)


          5)Declares legislative intent that managed care health plans may  
            authorize and pay for personal-care services and related  
            domestic services in addition to the IHSS hours already  
            authorized for a recipient in a CCI demonstration county, at  
            no cost to the county.  Requires the Department of Health Care  
            Services, in consultation with the CDSS to develop policies  
            and procedures for these additional benefits authorized and  
            paid for by health plans. (WIC 14186 (b)(6)(B))


          This bill:

          1)Requires CMIPS II to be programmed to do all of the following  
            in order to enable managed care health plans to pay a provider  
            for the additional personal care and related domestic services  
            that the plan authorizes beyond the IHSS hours authorized by a  
            CCI county:


             a)   Receive payments from managed care health plans for the  
               additional hours of service;


             b)   Issue a single payroll check to providers that covers  
               both the IHSS hours and the hours authorized by the managed  
               care health plan; and









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             c)   Differentiate between IHSS hours and the hours  
               authorized by the managed care health plan for purposes of  
               federal reimbursement and to enable managed care health  
               plans to track the recipient impact of the additional  
               benefits.


            FISCAL IMPACT
          
          According to the Assembly Appropriations Committee, this bill  
          will incur the following costs:


                 One-time costs to CDSS of $6 million ($3 million GF) to  
               design, develop, and implement the CMIPS II system changes.


                 One-time costs to CDSS of approximately $550,000 (GF)  
               for two years for 4.5 positions for implementation.


                 On-going annual operating costs to CDSS of $1 million  
               ($500,000 GF) to operate the new payroll system.


          A subsequent analysis of the Assembly Budget Committee of a  
          similar proposal estimated that the budget year General Fund  
          cost for the project would be approximately $2 million GF ($7  
          million total funds).


            BACKGROUND AND DISCUSSION
          
          Purpose of the bill:

          According to the author, the CCI permits a managed care health  
          plan to authorize additional hours of IHSS services if the  
          services are necessary to allow the consumer to continue living  
          in his or her own home, instead of residing in a more costly  
          institution. The author cites existing law which states the  
          Department of Health Care Services (DHCS), "in consultation with  
          the State Department of Social Services, shall develop policies  









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          and procedures for these additional benefits, which managed care  
          health plans may authorize." However, the author states that the  
          state has not created a mechanism to pay an individual provider  
          to work these additional service hours authorized by the managed  
          care health plans. The author states that in order to maintain  
          the continuity of care for the medically fragile CCI population,  
          the consumer should have the option to have his or her existing  
          IHSS provider work these additional service hours, instead of  
          assigning an unknown provider, without the consumer's approval,  
          to enter his or her home. 
          
          In Home Supportive Services Program (IHSS)

          The IHSS program was established in 1973 as an innovative  
          alternative to institutional care, and evolved in the context of  
          a growing "independent living" civil rights movement led by  
          persons with disabilities.<1> The program has experienced  
          continuous growth following the U.S. Supreme Court decision  
          Olmstead v. L.C. in 1999 which established the rights of people  
          with disabilities to receive services in the most integrated  
          setting possible to "provide individuals with disabilities  
          opportunities to live their lives like individuals without  
          disabilities"<2> under the American with Disabilities Act.


          The IHSS program is operated as benefit under the Medi-Cal  
          program, providing in-home services to more than 467,000  
          qualified low-income individuals who are aged, blind, or  
          disabled. County welfare agencies administer the program under  
          CDSS oversight and county social workers determine eligibility  
          and assess eligible consumers to determine the allowable  
          services and number of allotted hours following a standardized  
          in home assessment. 


          ---------------------------
          <1> http://www.cicaihss.org/ihss-public-authority-history


          <2> Statement of the Department of Justice on Enforcement of the  
          Integration Mandate of Title II of the Americans with  
          Disabilities Act and Olmstead v. L.C. June 22 2011.  
          http://www.ada.gov/olmstead/q&a_olmstead










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          Coordinated Care Initiative (CCI)
          
          Pursuant to federal law under the Patient Protection and  
          Affordable Care Act (P.L. 111-148) and the Health Care and  
          Education Reconciliation Act of 2010 (P.L. 111-152),  
          California's Budget Act of 2012<3> enacted the CCI, with the  
          intention of better coordinating the medical, mental and  
          long-term care provided to Medi-Cal recipients while achieving  
          fiscal savings for the General Fund. Specifically, according to  
          a Senate Budget Subcommittee 3 agenda, the CCI broadly  
          encompasses three components:<4> 


                 Long-Term Supports and Services (LTSS) as a Medi-Cal  
               Managed Care Benefit: CCI incorporated LTSS into Medi-Cal  
               managed care, including nursing facility care, IHSS, the  
               Multipurpose Senior Services Program, and Community-Based  
               Adult Services. A Senate Budget Committee agenda states  
               this change is estimated to impact about 600,000  
               Medi-Cal-only enrollees and up to 456,000 persons eligible  
               for both Medicare and Medi-Cal who are in Cal MediConnect.


                 Cal MediConnect Program: A three-year demonstration  
               project for persons eligible for both Medicare and Medi-Cal  
               (dual eligibles) to receive coordinated medical, behavioral  
               health, long-term institutional, and home-and  
               community-based services through a single organized  
               delivery system (health plan). The Senate Budget Committee  
               states that no more than 456,000 beneficiaries would be  
               eligible for the duals demonstration in the participating  
               counties. This demonstration project is a joint project  
             --------------------------


          <3> SB 1008 (Committee on Budget and Fiscal Review, Chapter 33,  
          Statutes of 2012), and SB 1036 (Committee on Budget and Fiscal  
          Review, Chapter 45, Statutes of 2012), and amended by SB 94  
          (Committee on Budget and Fiscal Review, Chapter 37, Statutes of  
          2013)


          <4>  
           http://sbud.senate.ca.gov/sites/sbud.senate.ca.gov/files/SUB3/042 
          42014Sub3_DPH_DHCS_HHSA.pdf  








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               with the federal Centers for Medicare and Medicaid Services  
               (CMS).


                 Mandatory Enrollment of Dual Eligibles and Others into  
               Medi-Cal Managed Care. Most Medi-Cal beneficiaries,  
               including dual eligibles, partial dual eligibles, and  
               previously excluded Seniors and Persons with Disabilities  
               (SPDs) who are Medi-Cal only, are required to join a  
               Medi-Cal managed care health plan to receive their Medi-Cal  
               benefits.


          Under Cal MediConnect, Medi-Cal managed care health plans are  
          responsible for providing and coordinating Medicare and Medi-Cal  
          benefits, including LTSS. Health plans will receive a blended  
          rate from the state and the federal government for these  
          services, including IHSS. However, existing CCI statutes clearly  
          specify that counties retain responsibility for assessing and  
          reassessing IHSS recipients and determining a recipient's  
          authorized number of hours, in addition the county operated  
          CMIPS will remain responsible for processing payroll.  


          Existing CCI statutes expresses legislative intent that a  
          mechanism be developed to allow managed care health plans to  
          authorize and pay for hours of personal care and domestic and  
          related services for IHSS recipients beyond the hours of IHSS  
          services they receive pursuant to county authorization referred  
          to as "Care Plan Option (CPO) services." Furthermore, existing  
          law calls for the DHCS, in consultation with the CDSS, to  
          develop policies and procedures for the additional benefits that  
          the managed care health plans can authorize and these CPO  
          services are prohibited from being used to replace any care and  
          service hours authorized under IHSS. 


          In its Duals Plan Letter 13-006, DHCS directs Medi-Cal managed  
          care plans to establish the following:


             a)   Policies and procedures that guide how LTSS recipients  
               will be assessed for CPO service hours;
             b)   Policies and procedures for identifying enrollees that  









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               may need CPO services and for referring them to  
               community-based organizations and other available entities  
               that provide these services;
             c)   A training curriculum and program for Cal MediConnect  
               plan staff related to the Americans with Disabilities Act,  
               the Olmstead decision, CPO services issues, and community  
               and county home- and community-based services that may be  
               available; and
             d)   A grievance system under which enrollees may submit  
               their grievances to their Cal MediConnect plan.

          The new Case Management Information and Payrolling System: CMIPS  
          II

          The new Case Management Information and Payrolling System, was  
          designed, and is now operated by, the Office of Systems  
          Integration (OSI) on behalf of CDSS to track IHSS case  
          management information and process payroll for IHSS providers.  
          CMIPS II now serves all 58 counties and was implemented after a  
          multi-year effort to update the original 30-year-old CMIPS  
          system and according to OSI "provides modern web-based case  
          management functionality and sophisticated processing of  
          payroll" and that it "includes over 50 interfaces for timely  
          verifications and interactions." Additionally, CDSS states that  
          CMIPS II offers "increased accountability to program  
          administrators including counties, the state and the federal  
          government." 


            COMMENTS


          The potential for managed care health plans to authorize  
          additional services was highlighted as a significant advantage  
          of the CCI, which anticipated moving significant numbers of  
          Medi-Cal recipients into managed care despite vocal concerns  
          raised by advocacy groups about the ability of managed care  
          plans to provide adequate care to IHSS recipients with complex  
          health needs. As of May 2015, nearly 123,000 individuals were  
          enrolled into Cal MediConnect, however among IHSS consumers, 64  
          percent of potential enrollees have opted out, and an additional  
          17 percent have disenrolled, numbers that are significantly  
          higher than those of the non-IHSS population. These opt-out  
          rates have raised concerns about the ability of the state to  









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          achieve the requisite savings upon which CCI was conditioned.


          The Administration testified at numerous budget committee  
          hearings regarding the importance of the Care Plan Option  
          services in keeping recipients out of institutions, however the  
          additional services have not been implemented because the  
          current CMIPS payroll system lacks the functionality to allow  
          for medical managed care plans to pay IHSS workers for the  
          additional hours. Furthermore, staff notes that during the  
          development and implementation of CMIPS II, the new system was  
          touted as offering substantially more flexibility for  
          reprogramming associated with changing state and federal laws.


          However, at recent budget hearings, the Administration testified  
          against adding this functionality to the current CMIPS system,  
          citing cost and other priorities. Supporters of this bill state  
          that this bill may assist the administration in fulfilling one  
          of the highlighted promises of CCI, and thus attract IHSS  
          consumers to opt-in to Cal MediConnect.
          
            PRIOR VOTES
          
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          |Assembly Floor:                                            |79 - |
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          |Assembly Appropriations Committee:                         |17 - |
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          |Assembly Human Services Committee:                         |7 -  |
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            POSITIONS
                                          
          Support:
               United Domestic Workers of America/AFSCME Local 3930  
               (Co-Sponsor)
               AFSCME
               California Association of Public Authorities
               Health Plan of San Mateo
               Inland Empire Health Plan









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               Local Health Plans of California
               Molina Health Care of  
          California
                    

          Oppose:   
               None received.
                                      -- END --