California Legislature—2015–16 Regular Session

Assembly Bill No. 461

Introduced by Assembly Member Mullin

(Coauthor: Assembly Member Gordon)

(Coauthor: Senator Hill)

February 23, 2015

An act to amend Section 14132.275 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

AB 461, as introduced, Mullin. Coordinated Care Initiative.

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. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. Existing federal law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age.

Existing law requires the department to seek federal approval pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof, to establish a demonstration project that enables beneficiaries dually eligible for the Medi-Cal program and the Medicare Program to receive a continuum of services that maximizes access to, and coordination of, benefits between the programs. Existing law requires, with some exceptions, the department to enroll dual eligible beneficiaries into a managed care plan that is selected to participate in the demonstration project unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled in a specified managed care organization on or before June 1, 2013. Existing law excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is receiving services through a regional center or state developmental center.

This bill would authorize a beneficiary receiving services through a regional center who resides in the County of San Mateo to participate voluntarily in the demonstration project if certain requirements are met.

This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Mateo.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

Section 14132.275 of the Welfare and Institutions
Code, as amended by Section 51 of Chapter 31 of the Statutes of
2014, 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 and in Section 14132.277, 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), 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. begin insert However, a beneficiary
receiving services through a regional center who resides in the
County of San Mateo may voluntarily enroll in the demonstration
project, upon receipt of all legal notifications required pursuant
to this section and applicable federal requirements. end insert

(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 Dual 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. 2.  

The Legislature finds and declares that a special law
is necessary and that a general law cannot be made applicable
within the meaning of Section 16 of Article IV of the California
Constitution because of the unique circumstances regarding the
availability of resources for dual eligible beneficiaries in the
County of San Mateo.