BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 187
---------------------------------------------------------------
|AUTHOR: |Bonta |
|---------------+-----------------------------------------------|
|VERSION: |May 28, 2015 |
---------------------------------------------------------------
---------------------------------------------------------------
|HEARING DATE: |July 8, 2015 | | |
---------------------------------------------------------------
---------------------------------------------------------------
|CONSULTANT: |Scott Bain |
---------------------------------------------------------------
SUBJECT : Medi-Cal: managed care: California Children's Services
program.
SUMMARY : Extends the sunset date on the California Children's Services
(CCS) "carve out" by an additional one year, under which
CCS-covered services are prohibited from being incorporated in a
Medi-Cal managed care plan.
Existing law:
1)Establishes the Medi-Cal Program, administered by DHCS, which
provides comprehensive health benefits to low-income children
up to 266% of the federal poverty level (FPL), parents and
adults up to 138% of the FPL, pregnant women, and elderly,
blind or disabled persons, 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 to
require mandatory enrollment of Medi-Cal beneficiaries in
specified eligibility categories into managed care plans.
4)Prohibits CCS covered services from being be incorporated into
any Medi-Cal managed care (MCMC) plan contract entered into
after August 1, 1994 until January 1, 2016, except for
contracts entered into for county organized health systems or
Regional Health Authority in the Counties of San Mateo, Santa
Barbara, Solano, Yolo, Marin, and Napa. This is known as the
CCS "carve out."
5)Requires the Director of DHCS to establish, by January 1,
2012, organized health care delivery models for CCS-eligible
AB 187 (Bonta) Page 2 of ?
children. Requires these models to be chosen from the
following:
a) An enhanced primary care case management program;
b) A provider-based accountable care organization;
c) A specialty health care plan; or,
d) A Medi-Cal managed care plan that includes payment
and coverage for CCS-eligible conditions.
This bill: Extends the sunset date on the CCS "carve out" by an
additional one year, until January 1, 2017. Under the CCS carve
out, CCS-covered services are prohibited from being incorporated
in a MCMC plan.
FISCAL
EFFECT : According to the Assembly Appropriations Committee,
there is no direct increase in state costs, as this continues
the current practice of "carving out" CCS services. This bill
prohibits the incorporation of CCS services into managed care
contracts for one year. It is unlikely to have a fiscal impact
as compared to the status quo, as a current stakeholder process
is underway to redesign the CCS delivery system and it is
unlikely that children would enroll in managed care before
January 1, 2017.
PRIOR
VOTES :
-----------------------------------------------------------------
|Assembly Floor: |78 - 0 |
|------------------------------------+----------------------------|
|Assembly Appropriations Committee: |17 - 0 |
|------------------------------------+----------------------------|
|Assembly Health Committee: |16 - 0 |
| | |
-----------------------------------------------------------------
COMMENTS :
1)Author's statement. 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 most recent CCS carve-out is
expiring in January of 2016, and this bill extends the CCS
carve-out from Medi-Cal Managed Care until 2017. DHCS is
currently convening workgroups with stakeholders to determine
AB 187 (Bonta) Page 3 of ?
the future of the CCS program, however, any large change in
the program will need adequate time for implementation. 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.
2)CCS. The CCS program provides diagnostic and treatment
services, medical case management, and physical and
occupational therapy health care services to children under 21
years of age with CCS-eligible conditions (e.g., severe
genetic diseases, chronic medical conditions, infectious
diseases producing major sequelae, and traumatic injuries)
from families unable to afford catastrophic health care costs.
A child eligible for CCS must be a resident of California,
have a CCS-eligible condition, and be in a family with an
adjusted gross income of $40,000 or less in the most recent
tax year. Children in families with higher incomes may still
be eligible for CCS if the estimated cost of care to the
family in one year is expected to exceed 20% of the family's
adjusted gross income.
The CCS program is administered as a partnership between county
health departments and DHCS. 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. CCS authorizes and pays for specific
medical services and equipment provided by CCS-approved
specialists. CCS rates for physician services provided under
CCS are reimbursed at rates which are 39.7% greater than
applicable Medi-Cal rate. CCS hospital inpatient rates are the
same as those in Medi-Cal.
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.
AB 187 (Bonta) Page 4 of ?
3)Medi-Cal managed care and the CCS carve out. Most Medi-Cal
beneficiaries, including children, are required to enroll in
Medi-Cal managed care plans. However, for children who are
enrolled in both Medi-Cal and CCS, CCS services were carved
out of Medi-Cal managed care pursuant to SB 1371 (Bergeson,
Chapter 917), Statutes of 1994. Under the carve out,
CCS-covered services for CCS-eligible children are not
incorporated into Medi-Cal managed care, and are instead
provided and paid for on a FFS basis through the CCS Program.
The initial carve out under SB 1371 was for three years. The
CCS 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. DHCS
indicates the division of payment and care between CCS and the
primary Medi-Cal managed care plan has posed challenges,
including delays in care for children, fragmentation and a
lack of coordination, and increased cost to the state.
4)Medi-Cal Waiver and CCS pilots. SB 208 (Steinberg, Chapter
714), Statutes of 2010, was one of two bills in 2010
implementing the 2010 Medi-Cal waiver renewal. One provision
of SB 208 was a requirement that the DHCS director establish,
by January 1, 2012, organized health care delivery models for
CCS-eligible children, from four specified models. Five
demonstration applicants (San Mateo Health Plan, Alameda
County, LA Care, Children's Hospital Orange County, and Rady
Children's Hospital in San Diego) were approved in 2011, but
only the San Mateo Health Plan pilot has been implemented. The
Rady Children's Hospital in San Diego is for a subset of
CCS-eligible children with specified conditions but it has not
been implemented.
5)DHCS CCS proposal. DHCS has implemented a stakeholder process
to investigate potential improvements or changes to the CCS
program in partnership with the UCLA Center for Health Policy
Research. A CCS Redesign Stakeholder Advisory Board (RSAB)
composed of individuals from various organizations and
backgrounds with expertise in both the CCS program and care
for children and youth with special health care needs, was
AB 187 (Bonta) Page 5 of ?
assembled in September of 2014 to lead this process.
In June 2015, DHCS released is proposal for the CCS program
based on a "whole-child model" that would be implemented in
specified counties no sooner than January 2017. The first
phase would incorporate CCS services into Medi-Cal managed
care plans into three COHS plans in 15 additional counties.
Those counties are Del Norte, Humboldt, Lake, Lassen,
Mendocino, Merced, Modoc, Monterey, Orange, Santa Cruz, San
Luis Obispo, Shasta, Siskiyou, Sonoma, and Trinity.
Under the whole-child model, health plans would be at full
financial risk. Medi-Cal managed care plans would be required
to demonstrate support from stakeholders and be subject to a
readiness review by DHCS. The readiness review would include
evidence of adequate network of CCS-paneled providers,
evidence of policies and procedures regarding access to
specialty care outside of designated catchment area, a CCSM
family advisory committee in each county, and an integrated
electronic health records system. Under the "whole-child
model," care coordination and service authorization will shift
from counties to health plans. Counties and health plans will
jointly develop Memorandums of Understanding (MOU) to document
transition plans for these activities. Counties (or the state,
for dependent counties) will continue to perform initial and
periodic financial, residential, and medical eligibility
determinations. Counties will maintain responsibility for
medical therapy programs, and MOUs will be required with
health plans and counties. To improve continuity of care and
access to specialty providers for youth aging out of CCS and
transitioning to Medi-Cal managed care, DHCS is requiring all
Medi-Cal managed care plans, on a phased-in basis, to contract
with CCS providers or providers who meet the CCS panel
requirements.
In addition to the COHS counties, the whole-child model could
also be implemented in up to four counties in the two-plan
Medi-Cal managed care model. The determination of these
counties will be based on an application of interest to DHCS
from at least one plan in the county, a demonstration of
support from stakeholders and a readiness review by DHCS.
Based on the application and subject to federal approval, DHCS
may propose that CCS be incorporated into only one Medi-Cal
managed care plan in a two plan model county. Implementation
in the two-plan model counties would begin no earlier than
AB 187 (Bonta) Page 6 of ?
July 2017.
Under the DHCS proposal, children enrolled in existing fully
integrated models (such as Kaiser) would provide whole-child
care. In the remaining 33 counties where the whole-child model
is not offered, DHCS is proposing to extend the carve-out for
three additional years, until January 1, 2019.
6)Related legislation. SB 586 (Hernandez), would require DHCS to
enter into contracts with one or more Kids Integrated Delivery
System (KIDS) networks authorized by this bill to provide the
full range of CCS and Medi-Cal services to children eligible
for the CCS and Medi-Cal. This bill allows an individual on
Medi-Cal who is up to 26 years of age who was previously
treated for a CCS-eligible condition in the twelve months
prior to his or her 21st birthday to remain in a KIDS
network that accepts individuals up to age 26 under its
contract with DHCS. SB 586 would also make permanent, the CCS
"carve out" of CCS services from Medi-Cal managed care, except
for existing counties and for the newly created KIDS
established by this bill. SB 586 is awaiting hearing in the
Assembly Health Committee.
7)Prior legislation. AB 301 (Pan, Chapter 460, Statutes of
2011), extended the CCS carve out sunset date from January 1,
2012, to January 1, 2016.
SB 208 (Steinberg, Chapter 714, Statutes of 2010), implemented
the new 2010 Medi-Cal Section 1115 Waiver, and required DHCS
to establish a pilot project and seek proposals to test four
models exploring potential options to redesign the CCS
Program.
AB 2379 (Chan, Chapter 333, Statutes of 2007), extended the
CCS carve out sunset date from August 1, 2008, to January 1,
2012.
SB 1103 (Committee on Budget and Fiscal Review), Chapter 228,
Statutes of 2004, extended the sunset on the carve-out from
August 1, 2005 to September 1, 2008.
AB 3049 (Committee on Health, Chapter 536, Statutes of 2002),
extended the CCS carve out 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.
AB 187 (Bonta) Page 7 of ?
AB 1107 (Cedillo, Chapter 146, Statutes of 1999), extended the
CCS carve out sunset date until August 1, 2003.
AB 469 (Papan, 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.
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.
SB 1371 (Bergeson, Chapter 917, Statutes of 1994), required
that CCS-eligible services be carved out of any Medi-Cal
managed care contract until three years after the effective
date of the contract.
8)Support. The Children's Specialty Care Coalition (CSCC)
writes in support that the CCS carve-out has been extended
repeatedly to protect access to the specialty care for this
vulnerable population. CSCC 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. The CSCC
writes that, while it appreciates the DHCS stakeholder
process, it has significant concerns with the DHCS proposal
regarding network adequacy, monitoring of CCS standards of
care, and the lack of experience that some of the plans have
in dealing with children with chronic and serious health
conditions. CSCC states the DHCS bill language has not been
released, and it believes that with nearly two months left in
the legislative session, the CCS transition must be done
thoroughly and correctly and passing legislation in haste
could have serious unintended consequences.
SUPPORT AND OPPOSITION :
Support: American Federation of State, County and Municipal
Employees
California Association of Health Plans
California Children's Hospital Association
Children's Specialty Care Coalition
Disability Rights California
March of Dimes California Chapter
AB 187 (Bonta) Page 8 of ?
UCSF Benioff Children's Hospital
University of California
Oppose: None received
-- END --