BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 187|
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THIRD READING
Bill No: AB 187
Author: Bonta (D)
Amended: 5/28/15 in Assembly
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 7/8/15
AYES: Hernandez, Nguyen, Hall, Monning, Nielsen, Pan, Roth,
Wolk
NO VOTE RECORDED: Mitchell
SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/27/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
ASSEMBLY FLOOR: 78-0, 6/2/15 - See last page for vote
SUBJECT: Medi-Cal: managed care: California Childrens
Services program.
SOURCE: Author
DIGEST: This bill 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.
ANALYSIS:
Existing law:
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1)Establishes the Medi-Cal Program, administered by the
Department of Health Care Services (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
(COHS) 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
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.
Comments
1)Author's statement. According to the author, CCS is a vital
program that the state's most medically vulnerable children
rely on to provide them with timely and adequate access to
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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 has
convened workgroups with stakeholders to determine 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.
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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.
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 fee-for-service 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, L.A. 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
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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
assembled in September of 2014 to lead this process.
In June 2015, DHCS released its proposal for the CCS program
based on a "whole-child model." DHCS released its proposed CCS
legislative language on July 16, 2015, and released revised
language on August 27, 2015. To date, the DHCS language has
not been amended into a bill.
Under DHCS' proposed language, the CCS carve-in would be
implemented in specified counties no sooner than January 2017.
The first phase would allow DHCS to incorporate CCS services
into Medi-Cal managed care plans into three COHS plans in 14
additional counties upon DHCS review and certification of the
COHS meeting readiness criteria. Those counties are Del Norte,
Humboldt, Lake, Lassen, Mendocino, Merced, Modoc, Monterey,
Santa Cruz, San Luis Obispo, Shasta, Siskiyou, Sonoma, and
Trinity. DHCS would be authorized to incorporate CCS into
Orange County (also a COHS county) upon DHCS review and
certification of COHS readiness no sooner than July 1, 2017.
Under the whole-child model, health plans would be at full
financial risk for CCS. In addition, DHCS proposes to repeal
the requirement that there be a separate actuarially sound
rate for CCS-eligible children. Medi-Cal managed care plans
would be required to demonstrate support from stakeholders and
be subject to a readiness review by DHCS prior to
implementation. 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 CCS 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
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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 non-COHS counties. 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. 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,
or until completion and submission of a newly required
evaluation of the CCS carve in that is implemented in COHS
counties.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee, unknown impact
on overall Medi-Cal expenditures for services provided to
CCS-eligible Medi-Cal beneficiaries (General Fund and federal
funds). Historically, the state has assumed that shifting
Medi-Cal beneficiaries into managed care will reduce costs,
relative to the fee-for-service system, due to better
coordination of care and less utilization of high-cost services.
Whether the Department would actually begin shifting CCS
children to managed care after the expiration of the "carve out"
is highly uncertain, given the serious health issues experienced
by CCS-eligible children. In addition, the serious health issues
faced by CCS children make it difficult to determine whether
cost savings are likely to be achieved through integration with
managed care.
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SUPPORT: (Verified8/28/15)
Alameda County Department of Public Health
Alta California Regional Center
American Academy of Pediatrics
American Federation of State, County and Municipal Employees
California Academy of Physician Assistants
California Asian Americans Advancing Justice - Los Angeles
California Association of Health Plans
California Children's Hospital Association
California Chronic Care Coalition
California Downs Syndrome Advocacy Coalition
California Hepatitis C Task Force
California Medical Association
California Pharmacists Association
California Women, Infants and Children Association
Children Now Children's Defense Fund-California
Children's Specialty Care Coalition
Disability Rights California
Down Syndrome Association of Orange County
Down Syndrome Information Alliance
Epilepsy California
Exceptional Parents Unlimited
Family Soup
Hemophilia Council of California
International Foundation for Autoimmune Arthritis
Lucile Packard Children's Hospital at Stanford
March of Dimes
Maternal and Child Health Access
Miller Children's and Women's Hospital Long Beach
National Association of Hepatitis Task Forces
National Downs Syndrome Congress
National Downs Syndrome Society
National Health Law Program
SEIU California
Sickle Cell Disease Foundation of California
The Children's Partnership
The FAIR Foundation
The Los Angeles Trust for Children's Health
UCSF Benioff Children's Hospital at Oakland
United Ways of California
University of California
Valley Children's Healthcare
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OPPOSITION: (Verified8/28/15)
None received
ARGUMENTS IN 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.
ASSEMBLY FLOOR: 78-0, 6/2/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd,
Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia,
Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray,
Hadley, Harper, Roger Hernández, Holden, Irwin, Jones,
Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low,
Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin,
Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea,
Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago,
Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,
Wilk, Williams, Wood, Atkins
NO VOTE RECORDED: Chávez, Grove
Prepared by:Scott Bain / HEALTH /
8/31/15 8:32:45
**** END ****
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