BILL ANALYSIS Ó
AB 187
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Date of Hearing: April 7, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 187
(Bonta) - As Amended March 4, 2015
SUBJECT: Medi-Cal: managed care: California Children's
Services program.
SUMMARY: Extends the sunset date on the prohibition on
incorporating California Children's Services (CCS) covered
services in a Medi-Cal managed care (MCMC) contract until the
Department of Health Care Services (DHCS) has completed
evaluations of CCS pilot programs.
EXISTING LAW:
1)Establishes the Medi-Cal Program, administered by DHCS, which
provides comprehensive health benefits to low-income children,
their parents or caretaker relatives, pregnant women, elderly,
blind or disabled persons, nursing home residents, and
refugees who meet specified eligibility criteria.
2)Establishes the CCS Program to provide specified medical care
and therapy services to children with eligible conditions.
3)Authorizes the state to contract for comprehensive managed
health care services for Medi-Cal beneficiaries and requires
mandatory enrollment of beneficiaries in specified eligibility
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categories.
4)Prohibits, until January 1, 2016, CCS covered services from
being incorporated into MCMC contracts, except in county
organized health systems (COHS) plans originally established.
5)Requires DHCS to seek proposals to establish models of
organized health care delivery for Medi-Cal eligible children
with CCS-eligible conditions and conduct an evaluation.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, CCS is a vital
program that our most medically vulnerable children rely on to
provide them with timely and adequate access to specialty
health care services. The author states that the most recent
CCS carve-out is expiring in January of 2016, and the
Legislature has a responsibility to ensure that future
administration of the CCS program maintains high standards of
care, continues to allow providers to make fiscally
disinterested decisions and strengthens care coordination for
families. This bill continues excluding the CCS program from
MCMC until DHCS has completed an evaluation of two CCS pilots
that were authorized in 2010. The author concludes that after
the evaluations are completed, stakeholders, the Legislature
and administration will have more information which will allow
an adequate evaluation of the future of CCS.
2)BACKGROUND. Originally established in 1927, the CCS Program
provides diagnostic and treatment services, medical case
management, and physical and occupational therapy services to
children under age 21 with CCS-eligible medical conditions.
Some examples of CCS-eligible conditions include chronic
medical conditions such as cystic fibrosis, hemophilia,
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cerebral palsy, heart disease, cancer, traumatic injuries, and
certain infectious diseases. CCS also provides medical
therapy services that are delivered at public schools.
The CCS program is administered as a partnership between county
health departments and DHCS. As of January, 2010, there were
178,530 children enrolled in CCS. According to DHCS, 90% of
CCS enrollees are also eligible for Medi-Cal and 10% were
CCS-only or were covered by other insurance. The Medi-Cal
Program reimburses providers for Medi-Cal eligible
beneficiaries.
CCS is a statewide program. In counties with populations
greater than 200,000 (independent counties), county staff
perform all case management activities for eligible children
residing within their county. This includes determining all
phases of program eligibility, evaluating needs for specific
services, determining the appropriate provider(s), and
authorizing for medically necessary care. For counties with
populations under 200,000 (dependent counties), the Children's
Medical Services Branch of DHCS provides medical case
management and eligibility and benefits determination through
its regional offices located in Sacramento, San Francisco, and
Los Angeles. CCS authorizes and pays for specific medical
services and equipment provided by CCS-approved specialists.
3)MCMC. MCMC contracts for health care services through
established networks of organized systems of care, which
emphasize primary and preventive care. Managed care plans are
a cost-effective use of health care resources that improve
health care access and assure quality of care. Approximately
8.8 million Medi-Cal beneficiaries in all 58 California
counties receive their health care through six different
models of managed care.
Mandatory enrollment of families and children into a MCMC full
risk plan was authorized as part of the state budget of 1992.
In implementing this mandatory enrollment, the former
Department of Health Services (now DHCS) released a strategic
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plan in 1993. With regard to CCS, the Strategic Plan stated
that the department desired Medi-Cal children participating in
managed care to continue to have direct access to the level of
highly specialized services provided under the CCS Program.
In order to assure that CCS-eligible children received the
benefit of fully-coordinated care, it would be the
responsibility of the managed care plan to identify children
with CCS-eligible conditions, arrange for referral to the
local CCS office and coordinate the provision of care. CCS
services would continue to be provided through the CCS program
while children would be mandatorily enrolled in a health plan
in the counties covered by the managed care expansion for
purposes of receiving primary care and other services
unrelated to the conditions being treated by the CCS Program.
4)CCS "CARVE OUT." Consistent with the Strategic Plan, SB 1371
(Bergeson), Chapter 917, Statutes of 1994, was enacted to
provide that CCS-covered services, for CCS-eligible children,
would not be incorporated into managed care, termed a "carve
out" and would be provided and paid for on a fee-for service
basis through the CCS Program for three years. Also in line
with the Strategic Plan, SB 1371 authorized pilot projects to
test alternative managed care models tailored to the special
health care needs of CCS program, including using different
payment and incentive models. No pilot projects were ever
approved.
The carve out has been extended repeatedly since then, usually
for three or four year periods. The first extension allowed
the COHS in the counties of San Mateo, Santa Barbara, Solano,
and Napa to include CCS services. Later extensions also
allowed Yolo and Marin counties to include CCS services
5)CCS REDESIGN STAKEHOLDER ADVISORY BOARD. DHCS has implemented
a stakeholder process to investigate potential improvements or
changes to the CCS program, in partnership with the University
of California, Los Angeles Center for Health Policy Research.
A CCS Redesign Stakeholder Advisory Board (RSAB) composed of
individuals from various organizations and backgrounds with
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expertise in both the CCS program and care for children and
youth with special health care needs, was assembled in
September of 2014 to lead this process. RSAB meets on a
bi-monthly bases and the last convening will be in July of
2015.
According to DHCS, the CCS RSAB goals are to:
a) Implement Patient and Family Centered Approach: provide
comprehensive treatment, and focus on the whole-child
rather than only their CCS eligible conditions.
b) Improve Care Coordination through an Organized Delivery
System: provide enhanced care coordination among primary,
specialty, inpatient, outpatient, mental health, and
behavioral health services through an organized delivery
system that improves the care experience of the patient and
family.
c) Maintain Quality: ensure providers and organized
delivery systems meet quality standards and outcome
measures specific to the CCS population.
d) Streamline Care Delivery: improve the efficiency and
effectiveness of the CCS health care delivery system.
e) Build on Lessons Learned: consider lessons learned from
current pilots and prior reform efforts, as well as
delivery system changes for other Medi-Cal populations.
f) Cost-Effective: ensure costs are no more than the
projected cost that would otherwise occur for CCS children,
including all state-funded delivery systems. Consider
simplification of the funding structure and value-based
payments, to support a coordinated service delivery
approach.
6)SECTION 1115 WAIVERS. Section 1115 of the Social Security Act
authorizes the federal Secretary of Health and Human Services
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to allow states to receive federal Medicaid matching funds
without complying with all of the federal Medicaid rules. On
November 1, 2010, California received federal approval for a
five year Section 1115 Medi-Cal Demonstration Project Waiver,
entitled "A Bridge to Reform." Authorization for the Bridge
to Reform Waiver expires on October 2, 2015. Traditionally
designed as research and demonstration programs to test
innovative program improvements and to facilitate coverage
expansions to populations not otherwise eligible, they are
also used to modify benefits structures and financing
mechanisms.
The 2010 Bridge to Reform Waiver included authorization for CCS
pilot programs aimed at improving health outcomes, improving
cost-effectiveness, creating clearer accountability, improving
satisfaction with care, and promoting timely access to care
and family-centered care.
Four potential models for CCS pilot projects emerged from the
CCS Technical Working Group and the Stakeholder Advisory
Committee:
a) Existing Medi-Cal Managed Care Organization Plans
(MCOs);
b) Specialty Health Care Plan;
c) Enhanced Primary Care Case Management, and
d) Provider-based Accountable Care Organization.
Five counties were awarded grants to carry out the four pilots
on October 12, 2011.
On March 27, 2015, DHCS submitted a request to renew the
state's section 1115 Medicaid Waiver for a new five-year term.
The new Waiver, "Medi-Cal 2020," seeks approximately $17
billion in federal investment to further the achievements
California has made in health care reform through a set of
payment and delivery system transformation strategies. The
Medi-Cal 2020 Waiver program includes extended authorization
for the CCS pilot programs authorized in 2010.
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7)CCS PILOTS. SB 208 (Steinberg), Chapter 714, Statutes of
2010, requires DHCS to seek proposals to test these models
either statewide or on a more limited geographic basis and not
limited to the provision of CCS services. SB 208 requires the
models to be established by January 1, 2012 and requires they
be selected from among the models developed by the Children
with Special Health Care Needs Technical Workgroup. There was
no specified number of pilots and no ending date.
Five CCS pilots were ultimately authorized under the 2010 1115
Waiver, focused on exploring new service delivery models that
would improve the CCS Program and meet both stakeholder and
the state's needs. The proposed pilots varied by types of
providers participating, enrollment criteria, and eligibility
criteria. Only two pilot projects were undertaken, the San
Mateo Health Plan MCO pilot and the Rady Children's Hospital
Provider Based MCO pilot.
a) Rady Children's Hospital San Diego. The County CCS
program determines if CCS children met the criteria to be
in the accountable care organization demonstration project
based on three qualifying health conditions. They estimated
625 members would be eligible. Beneficiaries are placed in
a delivery system designed to meet his/her needs.
b) Health Plan of San Mateo. All 2,000 CCS children in San
Mateo would be eligible for the MCO plan. They will
provide holistic care including primary care, specialty
care, social and psychological care, as well as whatever
services are necessary to address the child and family's
well-being. The pilot launched in April of 2013.
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These models were required to meet specified standards
including establishing a network that includes CCS-approved
providers and maintain the current system of regionalized
pediatric specialty and subspecialty services. SB 208 also
requires DHCS to conduct a simultaneous evaluation, to assess
the effectiveness of each model in improving the delivery of
health care services for these children and specifies the
measures for the evaluation. These measures included, at
minimum, the following:
a) The types of services and expenditures for services;
b) Improvement in the coordination of care for children;
c) Improvement in the quality of care;
d) Improvement in the value of care provided;
e) The rate of growth of expenditures; and,
f) Parent/Provider satisfaction.
8) SUPPORT. According to the Children's Specialty Care
Coalition, CCS carve-out has been extended repeatedly to
protect access to the specialty care for this vulnerable
population. Recently, DHCS, in its effort to strengthen the
program, assembled the CCS RSAB. The RSAB is composed of
stakeholders including the Children's Specialty Care Coalition
to assess the CCS program in its current state and develop a
framework for a new model of care going forward. The
development and implementation of any new model will take
time, and must be phased in slowly. The Children's Specialty
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Care Coalition believes that this bill is necessary to ensure
the care that children receive through CCS is not disrupted,
while efforts are underway by DHCS and RSAB to explore new
ways to enhance delivery of care.
9)RELATED LEGISLATION. SB 586 (Ed Hernandez), removes the CCS
carve-out sunset date and creates a new health plan, the Kids
Integrated Delivery System (KIDS) plan. The KIDS plan is
required to coordinate, integrate, and provide or arrange for
the full range of Medi-Cal and CCS services. This bill is
scheduled to be heard on April 22, 2014 in the Senate Health
Committee.
10) PREVIOUS
LEGISLATION.
a) AB 301 (Pan), Chapter 460, Statutes of 2011, extends the
sunset date from January 1, 2012, to January 1, 2016 on the
CCS carve-out.
b) SB 208 (Steinberg), Chapter 714, Statutes of 2010,
implements the new 2010 Medi-Cal Section 1115 Waiver, and
requires DHCS to establish a pilot project and seek
proposals to test four models exploring potential options
to redesign the CCS Program.
c) AB 2379 (Chan), Chapter 333, Statutes of 2007, extends
the sunset date from August 1, 2008, to January 1, 2012 on
the CCS carve-out.
d) SB 1103 (Committee on Budget and Fiscal Review),
Chapter 228, Statutes of 2004, extends the sunset on the
carve-out from August 1, 2005 to September 1, 2008.
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e) AB 3049 (Committee on Health), Chapter 536, Statutes of
2002, extends the sunset on the carve-out from August 1,
2003 to August 1, 2005 and added COHS in Yolo and Marin
counties to the list of exceptions to the carve-out.
f) AB 1107 (Cedillo), Chapter 146, Statutes of 1999,
extends the sunset on the carve-out until August 1, 2003.
g) AB 469 (Papan) of 1999 would have allowed Medi-Cal
beneficiaries in the CCS Program to disenroll from
mandatory managed care if certain conditions are met. AB
469 was vetoed by then Governor Davis.
h) SB 391 (Solis), Chapter 294, Statutes of 1997, extended
the CCS carve-out until August 1, 2000, except for
contracts entered into for COHS in the counties of San
Mateo, Santa Barbara, Solano, and Napa.
i) SB 1371 (Bergeson), Chapter 917, Statutes of 1994,
required that CCS-eligible services be carved out of any
MCMC contract until three years after the effective date of
the contract.
REGISTERED SUPPORT / OPPOSITION:
Support
American Academy of Pediatrics, California
Children's Specialty Care Coalition
AB 187
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Opposition
None on file.
Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097