BILL ANALYSIS Ó AB 461 Page 1 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 AB 461 Page 2 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 AB 461 Page 3 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 AB 461 Page 4 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 AB 461 Page 5 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 AB 461 Page 6 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. AB 461 Page 7 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 AB 461 Page 8 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 AB 461 Page 9 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, AB 461 Page 10 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: AB 461 Page 11 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 AB 461 Page 12