BILL ANALYSIS Ó
AB 461
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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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