BILL ANALYSIS                                                                                                                                                                                                    Ó



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          Date of Hearing:  April 14, 2015


                            ASSEMBLY COMMITTEE ON HEALTH


                                  Rob Bonta, Chair


          AB 461  
          (Mullin) - As Introduced February 23, 2015


          SUBJECT:  Coordinated Care Initiative.


          SUMMARY:  Authorizes a beneficiary receiving services through a  
          regional center who resides in the County of San Mateo to  
          voluntarily enroll in the Cal MediConnect demonstration project  
          under the Coordinated Care Initiative (CCI), upon receipt of all  
          legal notifications required under state and federal law, and  
          makes findings and declarations that a special law is necessary  
          because of the unique circumstances regarding the availability  
          of resources for dual eligible beneficiaries in the County of  
          San Mateo.  

          EXISTING LAW: 





          1)Establishes, under federal law, the 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 the age of 65.

          2)Establishes the Medi-Cal program, under which qualified  
            low-income individuals receive health care services, including  








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            home and community-based services (HCBS). 

          3)Establishes, in eight counties throughout the state, the CCI  
            which is designed to integrate, as managed care plan benefits,  
            medical care and long-term services and supports (LTSS) for  
            individuals dually eligible for Medicare and Medi-Cal (dual  
            eligibles) and seniors and persons with disabilities (SPDs)  
            enrolled in Medi-Cal only.

          4)Requires, under the CCI, the Department of Health Care  
            Services (DHCS) to seek federal approval to establish a  
            demonstration project that integrates services between  
            Medicare and Medi-Cal, and enables dual eligibles to receive a  
            continuum of services that maximizes access to, and  
            coordination of, benefits between the programs.  This  
            demonstration project is referred to as the Cal Medi-Connect  
            program.

          5)Establishes goals for the demonstration project, including  
            coordination of access to acute and long-term services for  
            dual eligibles, maximizing the ability of dual eligibles to  
            remain in their homes and communities, improve the quality of  
            care for dual eligibles, and promoting a system that is  
            sustainable and person- and family-centered by providing dual  
            eligibles with timely access to appropriate, coordinated  
            health care services and community resources.

          6)Requires DHCS, no sooner than March 1, 2013, to establish  
            demonstration sites in up to eight counties, and to enter into  
            a memorandum of understanding (MOU) with the federal Centers  
            for Medicare and Medicaid Services (CMS) which addresses  
            specified requirements for demonstration sites, including  
            having Medi-Cal managed care health plan and Medicare dual  
            eligible-special needs plan (D-SNP) contract experience, or  
            evidence of the ability to meet these contracting  
            requirements.

          7)Requires DHCS to enroll dual eligible beneficiaries into a  
            demonstration site, unless the beneficiary makes an  








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            affirmative choice to opt out of enrollment.  This process is  
            referred to as passive enrollment.  Provides that dual  
            eligible beneficiaries who opt out of enrollment may choose to  
            remain enrolled in Medicare fee-for-service (FFS) or a  
            Medicare Advantage plan for their Medicare benefits, but shall  
            be mandatorily enrolled into a Medi-Cal managed care health  
            plan for Medi-Cal benefits.

          8)Exempts specified beneficiary populations from enrollment in  
            the demonstration project, including beneficiaries with a  
            prior diagnosis of end-stage renal disease; beneficiaries  
            already enrolled in a Medi-Cal home and community-based waiver  
            program; and, beneficiaries who receive services through a  
            regional center or state developmental center.
          


          FISCAL EFFECT:  This bill has not yet been analyzed by a fiscal  
          committee.





          COMMENTS:  





          1)PURPOSE OF THIS BILL.  According to the author, in San Mateo  
            County, Health Plan of San Mateo (HPSM) serves about 12,000  
            dual eligible beneficiaries through its D-SNP, the vast  
            majority of whom transitioned into the CCI this year.  The  
            author states that approximately 600 dually eligible  
            developmentally disabled individuals remain in the D-SNP;  
            however, HPSM may close its D-SNP due to the costly nature of  
            running a program for such a small population, leaving this  
            population without a health plan that would integrate and  








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            maximize Medi-Cal and Medicare benefits.  The author concludes  
            that by allowing this population to voluntarily enroll in the  
            CCI, HPSM will be able to continue to provide them with the  
            option of managed care.
          
          2)BACKGROUND.



             a)   CCI.  The 2012 state budget authorized the CCI with the  
               goal of promoting the coordination of health, behavioral  
               health and social services for certain Medi-Cal  
               beneficiaries.  The CCI is a program intended to integrate  
               and coordinate the delivery of health benefits, including  
               behavioral health benefits and LTSS to dual eligibles and  
               SPDs living in seven California counties: Los Angeles,  
               Orange, Riverside, San Bernardino, San Diego, San Mateo and  
               Santa Clara.  (While current statute allows for CCI  
               implementation in eight counties, Alameda County, which had  
               been selected as a CCI demonstration site, will no longer  
               move forward with CCI implementation.)  The goals of the  
               CCI are to improve quality of care for beneficiaries;  
               maximize the ability of beneficiaries to remain safely in  
               their homes and communities; coordinate Medi-Cal and  
               Medicare benefits and improve continuity of care across  
               settings, and promote a person- and family-centered system  
               by which beneficiaries attain or maintain personal health  
               goals through timely access to coordinated health care  
               services and community resources.

             There are three major components to the CCI:

               i)     Cal MediConnect Program: A three-year demonstration  
                 project designed to coordinate medical, behavioral  
                 health, long-term institutional, and HCBS services by  
                 combining Medicare and Medi-Cal benefits into one  
                 integrated health plan.

               ii)    Mandatory enrollment of dual eligibles and  








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                 Medi-Cal-only SPDs into Medi-Cal managed care.



               iii)   Managed Long-Term Supports and Services (MLTSS):  
                 Integration of nursing facility care, In-Home Supportive  
                 Services, Community-Based Adult Services, and  
                 Multipurpose Senior Services Program as managed care  
                 benefits. 



             b)   Cal Medi-Connect.  The state received federal approval  
               of the Cal MediConnect program through an MOU entered into  
               between DHCS and CMS in March 2013.  Cal MediConnect plans  
               meeting all required selection criteria entered into  
               three-way contracts with DHCS and CMS, which outline the  
               plan's responsibilities under the Cal MediConnect program.   
               Cal MediConnect plans are paid a monthly capitated rate for  
               each individual enrollee, and are responsible for providing  
               a package of Medicare and Medi-Cal services in exchange for  
               that rate.  Cal MediConnect plans provide Medicare and  
               Medi-Cal services using a network of contracted providers  
               from which enrollees may receive services.

             A dual eligible may opt out of enrollment in CalMediConnect.   
               However, through passive enrollment, if a dual eligible  
               does not opt out, and does not affirmatively choose a  
               particular Cal MediConnect plan, the dual eligible will be  
               enrolled into a plan by DHCS.  Additionally, a dual  
               eligible who has enrolled in Cal MediConnect may change  
               plans or disenroll at any time. 

             If a dual eligible opts out or disenrolls from Cal  
               MediConnect, he or she will receive Medicare benefits  
               through Medicare FFS or a Medicare Advantage plan, and will  
               not be passively enrolled again for the remainder of the  
               life of the demonstration.  A dual eligible who opts out of  
               Cal MediConnect must still enroll in a Medi-Cal managed  








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               care plan for Medi-Cal benefits. 

             Dual eligibles who enroll in a Cal MediConnect plan are  
               eventually required to receive all covered services from  
               physicians and other providers who are a part of the plan's  
               network.  However, pursuant to existing law, as well as the  
               MOU entered into between DHCS and CMS, Cal MediConnect  
               enrollees are entitled to specified rights regarding  
               continuity of care that allow them to temporarily continue  
               to see existing providers outside of the Cal MediConnect  
               network.

             Certain dual eligible beneficiaries are not permitted to  
               participate in Cal MediConnect.  These include  
               beneficiaries with End Stage Renal Disease, beneficiaries  
               already enrolled in an Medi-Cal HCBS waiver program,  
               beneficiaries residing in certain geographic areas and zip  
               codes not included in managed care, and individuals with  
               developmental disabilities receiving services through a  
               regional center.

             c)   HPSM.  In certain counties, Medi-Cal managed care is  
               operated by a single County Organized Health System (COHS).  
                In COHS counties, a single plan serves all Medi-Cal  
               beneficiaries who are enrolled in managed care. 



             San Mateo County is a COHS county, and HPSM is the single  
               plan to serve all Medi-Cal beneficiaries enrolled in  
               managed care.  As such, HPSM operates the only Cal  
               MediConnect plan called CareAdvantage.  Passive enrollment  
               into CareAdvantage commenced in April 2014, and as of March  
               2015, 10,100 dual eligibles were actively enrolled in Cal  
               MediConnect.  San Mateo County has an enrollment rate of  
               84%, with 13% of dual eligibles opting out of Cal  
               MediConnect, and 4% disenrolling from Cal MediConnect.  The  
               enrollment rate is significantly higher than any other CCI  
               county.








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             d)   SNPs and the CCI.  Medicare SNPs are a type of Medicare  
               Advantage Plan which limit membership to people with  
               specific diseases or characteristics, and tailor their  
               benefits, provider choices, and drug formularies to best  
               meet the specific needs of the groups they serve.  D-SNPs  
               serve dual eligibles, and similar to Cal MediConnect plans,  
               D-SNPs combine Medicare and Medicaid benefits into one  
               plan.



             In CCI counties, D-SNPs that are operated by a plan that also  
               operates a CalMediConnect plan will be phased out.  In  
               January 2015, beneficiaries enrolled in a D-SNP operated by  
               a Cal MediConnect plan were transitioned into Cal  
               MediConnect.  Additionally, beneficiaries who are eligible  
               for Cal MediConnect will not be able to enroll in a D-SNP  
               after January 2015.  

             Like other beneficiaries eligible for Cal MediConnect, D-SNP  
               enrollees receive 90-, 60-, and 30-day Cal MediConnect  
               notices as well as guide book and choice book to provide  
               them with information about Cal MediConnect plans in their  
               respective county.

             Under this bill, the developmentally disabled persons  
               receiving care from a regional center who are currently  
               enrolled in HPSM's D-SNP are required to receive notices of  
               their option to enroll in HPSM's Cal MediConnect plan.   
               Additionally, according to HPSM, its Cal MediConnect plan  
               and its D-SNP use the same provider network providing for  
               continuity of care as the beneficiaries transition into the  
               Cal MediConnect plan.  According to HPSM, it will work with  
               DHCS and CMS on notice requirements and timeframes for  
               voluntary enrollment, and its CareAdvantage D-SNP will  
               remain available throughout 2016.

          3)SUPPORT.  HPSM supports this bill stating that it serves dual  








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            eligibles, 600 of which are developmentally disabled and  
            receive care through its SNP.  HPSM states that the SNP is  
            costly and inefficient to operate for only 600 members, and it  
            intends to close the SNP in the next year or two, potentially  
            leaving the 600 developmentally disabled members without a  
            consolidated health plan to maximize Medi-Cal and Medicare  
            benefits.  HPSM states that this bill will correct this  
            problem by allowing this special needs population to  
            voluntarily enroll in Cal MediConnect.  According to HPSM,  
            this bill also enjoys the support of the local San Mateo  
            County disability rights community.

          Golden Gate Regional Center (GGRC), the regional center serving  
            San Mateo County, supports this bill stating that the persons  
            with developmental disabilities who are enrolled in HPSM's  
            Medicare SNP should have the option to continue with HPSM  
            through the CCI.  GGRC states that the inability of these  
            individuals to continue with HPSM through the CCI would be  
            extremely disruptive to their care, and without the option for  
            voluntary CCI enrollment created under this bill, the  
            alternative for these beneficiaries will be a fragmented  
            system between Medicare FFS and Medi-Cal through HPSM.

          4)STATEMENT OF CONCERN.  The California Advocates for Nursing  
            Home Reform (CANHR) states that, while HPSM is seen as a model  
            managed care plan with regard to the CCI, plans in other  
            counties are struggling to provide coordinated care and have a  
            large number of problems that seriously harm enrollees.  As  
            such, CANHR states that the CCI is currently in jeopardy of  
            being terminated because of failure to meet projected savings,  
            and if the transition of regional center clients in San Mateo  
            is successful, other counties and plans may push to expand  
            voluntary enrollment of this population in other counties as a  
            way to meet savings goals and keep the CCI afloat.  Further,  
            CANHR states that if the CCI fails, this new vulnerable  
            population will have their continuity of care interrupted  
            along with thousands of other beneficiaries enrolled,  
            surrogate decision-makers will face challenges.  CANHR  
            concludes that regional center clients have surrogate  








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            decision-makers, many of whom will run into roadblocks when  
            they want to assist beneficiaries to disenroll from a plan or  
            change doctors within the plan.



          5)RELATED LEGISLATION.  SB 492 (Liu) establishes the CCI  
            Consumer Bill of Rights, which sets fort rights regarding  
            self-direction, quality, flexibility, accessibility of  
            services, and others.  SB 492 is pending hearing in Senate  
            Health Committee.

          6)PREVIOUS LEGISLATION.  





             a)   SB 857 (Committee on Budget and Fiscal Review), Chapter  
               31, Statutes of 2014, institutes various requirements  
               regarding contracts and enrollment limitations on D-SNP  
               plans in the context of the CCI.

             b)   SB 1008 (Committee on Budget and Fiscal Review), Chapter  
               33, Statutes of 2012, establishes the main components of  
               the CCI, including the provisions for the Cal MediConnect  
               Program, mandatory Medi-Cal managed care for SPDs, and  
               MLTSS.

             c)   SB 1036 (Committee on Budget and Fiscal Review), Chapter  
               45, Statutes of 2012, legislation authorizing other  
               components of the CCI, includes provisions that require the  
               development and pilot implementation of a universal  
               assessment tool as well as data-sharing agreements between  
               managed care plans and HCBS administrators.



             d)   SB 208 (Steinberg), Chapter 714, Statutes of 2010,  








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               authorized a pilot project in up to four counties, to  
               integrate the full range of Medicare and Medi-Cal services,  
               including LTSS and behavioral health services for dual  
               eligible individuals.



          7)POLICY COMMENT.  Under this bill, developmentally disabled  
            persons being served by a regional center will be able to  
            voluntarily enroll in Cal MediConnect.  According to the  
            author, voluntary enrollment under this bill is not intended  
            to be passive enrollment.  However, the passive enrollment  
            process could be interpreted by some as voluntary given that a  
            beneficiary may opt-out or disenroll.  Further, according to  
            some fact sheets published by DHCS, enrollment in Cal  
            Medi-Connect is referred to as "optional."  As such, to ensure  
            that the author's intent is met, the committee may wish to  
            amend the bill to clarify that the enrollment under this bill  
            shall not be conducted pursuant to passive enrollment, but  
            rather via a process by which the targeted population may  
            opt-in. 
          














          REGISTERED SUPPORT / OPPOSITION:










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          Support


          Association of Regional Center Agencies
          California Association of Public Authorities for IHSS
          County of San Mateo Board of Supervisors
          Golden Gate Regional Center
          Health Plan of San Mateo
          Local Health Plans of California 
          


          Opposition





          None on file.


          


          Analysis Prepared by:Kelly Green / HEALTH / (916) 319-2097



















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