BILL ANALYSIS Ó AB 664 Page A Date of Hearing: April 7, 2015 ASSEMBLY COMMITTEE ON HEALTH Rob Bonta, Chair AB 664 (Dodd) - As Introduced February 24, 2015 SUBJECT: Medi-Cal: universal assessment tool report. SUMMARY: Requires the Department of Health Care Services (DHCS), Department of Social Services (DSS), and the California Department of Aging (CDA) to evaluate and report to the Legislature on the outcomes of, and lessons learned from, the Medi-Cal universal assessment tool report (UAT) pilot. Specifically, this bill: 1)Requires, on or before January 1, 2017, that DHCS, DSS, and CDA, in consultation with the stakeholder workgroup established to develop the UAT, evaluate and report to the Legislature on the outcomes of, and lessons learned from, the UAT pilot. 2)Requires the UAT report to include: a) Findings from consumers assessed using the UAT, and from consumers choosing to be assessed using previous assessment tools. Specifies that interviews with consumers to evaluate various items including satisfaction or challenges with the administration of the UAT and concerns with how AB 664 Page B the UAT determines the services to be provided. b) Data regarding the amount and type of services identified by the previous assessment tools as compared to the amount and types of services determined through the UAT. c) Data regarding home and community based services (HCBS) utilization and costs before and after the use of the UAT and the percentage of consumers who experience hospitalization and skilled nursing facility (SNF) stays before and after the use of the UAT. EXISTING LAW: 1)Establishes the Medi-Cal program, under which qualified low-income individuals receive health care services, including HCBS. 2)Establishes, in eight counties throughout the state, the Coordinated Care Initiative (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. 3)Requires DHCS, DSS, and CDA, in consultation with a stakeholder workgroup, as specified, to develop a universal assessment process, including the development of a UAT for specified HCBS, in order to inform the universal assessment process and facilitate the development of plans of care based on the individual needs of the consumer. 4)Authorizes, no sooner than January 1, 2015, and upon AB 664 Page C completion of various conditions including federal approval, for managed health care plans, counties, and other HCBS providers to test the UAT for a specific and limited number of beneficiaries who receive or are potentially eligible to receive HCBS. 5)Authorizes the testing of the UAT in no fewer than two, but no more than four counties. Requires DHCS, DSS, and CDA, to, no later than March 1, 2014, report to the Legislature on the counties and beneficiary categories for which the universal assessment tool may be implemented. 6)Requires DHCS, DSS, and CDA to, no later than nine months following the implementation of the universal assessment process, report to the Legislature on the results of the initial use of the process, and authorizes the departments to propose additional beneficiary categories or counties for expanded use of the process. 7)Sets a July 1, 2017 sunset date for universal assessment provisions. FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee. COMMENTS: 1)PURPOSE OF THIS BILL. According to the author, California provides HCBS to low-income SPDs to help them remain in their own homes and communities. The author states that each of the three main HCBS programs; In-Home Supportive Services (IHSS); Community-Based Adult Services (CBAS); and, Multipurpose Senior Services Program (MSSP) perform their own eligibility determinations and service assessments, requiring those who receive services for more than one program to undergo multiple assessments that, in some cases, collect duplicative information. AB 664 Page D The author states that, in 2012, the Legislature recognized that separate eligibility determination and assessment processes create inefficiency in the administration of HCBS programs, and directed the state to develop a UAT to be pilot-tested in two to four counties with the goal of facilitating better care coordination, enhance consumer choices, reduce administrative inefficiencies, improve data analysis, and potentially create long-term fiscal savings. However, the author states that the law establishing the UAT pilot test does not require the administration to conduct a formal evaluation. Thus, the author concludes that this bill is necessary to require a formal evaluation of the UAT pilot program, and to require the administration to report to the Legislature on the pilot's outcomes and lessons learned. 2)BACKGROUND. a) HCBS programs. According to the Legislative Analyst's Office (LAO), approximately 1.9 million SPDs are enrolled in Medi-Cal, which provides LTSS to beneficiaries who meet certain eligibility requirements. LTSS are mainly comprised of HCBS provided in a client's home or community, or institutional care provided in a facility. Three of the main Medi-Cal HCBS programs are IHSS, CBAS, and MSSP. Each HCBS program has its own distinct eligibility criteria and processes for eligibility determinations and assessment processes to determine the amount and types of services provided to consumers. The table<1> below briefly describes each program, as well as the respective populations served and current assessment process. ------------------------------------------------------------ | HCBS Program |Population Served | Assessment Process | |------------------+------------------+----------------------| --------------------------- <1> Excerpt from Figure 2, Current Assessment Processes for Three Major HCBS Programs, "The Universal Assessment Tool: Improving Care for Recipients of Home- and Community-Based Services," Legislative Analyst's Office, January 2015 AB 664 Page E |IHSS |Individuals aged |In-home assessment | |Provides in-home |65 and older, |conducted by a county | |personal care and |blind, or |social worker using a | |domestic services |disabled. |statewide | |to individuals to | |standardized | |help them remain | |assessment to | |safely in their | |determine the number | |own homes and | |of service hours to | |communities. | |be provided to each | | | |consumer. | |------------------+------------------+----------------------| |CBAS |Adults with |Eligibility | |Outpatient |chronic medical, |determination | |facility-based |cognitive, or |conducted by a | |program that |mental health |Medi-Cal managed care | |provides services |conditions and/or |plan (or by a nurse | |to program |disabilities who |if CBAS is provide on | |participants by a |are at risk of |a fee-for-service | |multidisciplinary |needing |(FFS) basis), which | |staff including |institutional |is followed by a | |nurses, |care. |multidisciplinary | |therapists, | |team assessment and | |social workers, | |individual plan of | |and CBAS center | |care developed by the | |directors. | |CBAS | | | |multidisciplinary | | | |staff and approved by | | | |the managed care plan | | | |(or Medi-Cal field | | | |office for FFS | | | |applicants). | |------------------+------------------+----------------------| |MSSP |Adults age 65 and |An MSSP nurse and | |Provides social |older who are |social worker conduct | |and health case |eligible for SNF |an initial health and | |management |placement. |psychosocial | |services. | |assessment, | | | |respectively, to | | | |determine eligibility | AB 664 Page F | | |and needs for case | | | |management services. | ------------------------------------------------------------ According to the LAO, while the vast majority of HCBS recipients statewide receive only IHSS, approximately 28,000 of these recipients require services from more than one HCBS program. As demonstrated in the table above, each of the three HCBS program requires its own assessment to determine the amount and type of services a client is authorized to receive from a particular program, thus requiring individuals needing services from more than one program to undergo separate assessments for each. Additionally, each program collects much of the same information during its respective assessment. For example, IHSS, CBAS, and MSSP each collect biographical information, medical diagnoses, medications taken, determination of functional needs, and alternative resources of other HCBS received. IHSS and MSSP each collect information about cognitive impairment on their respective assessments. CBAS and MSSP separately collect information about bodily systems review and medication management. b) CCI and the UAT. 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 currently being implemented in seven California counties, and has the following three major components: i) Cal MediConnect Program: a three-year demonstration project for dual eligible to receive coordinated medical, behavioral, health, long-term institutional, and HCBS through a single managed care plan; ii) Mandatory enrollment of dual eligibles and Medi-Cal only SPDs into Medi-Cal managed care; and, iii) Managed Long-Term Supports and Services (MLTSS): AB 664 Page G Integration of nursing facility care, IHSS, CBAS, and MSSP as managed care benefits. MLTSS is intended to create fiscal incentives for delivering care to beneficiaries at lower cost in the home and community as compared to services provided in an institution such as a SNF. The CCI requires managed care plans to conduct a brief health risk assessment either in person, by telephone, or by mail for all new beneficiaries, and use historical health utilization data to identify SPDs enrolled in the plan who likely have a higher-risk of experiencing an adverse health outcome or decline in health or functional status. If a beneficiary is found to be at higher-risk, the managed care plan is required to develop a care plan that coordinates programs and services delivered by other entities, such as county welfare departments for IHSS. Under the CCI, HCBS administrators are required to share data with managed care plans, but there has been no systematic data sharing among HCBS programs and consequently no comprehensive HCBS assessment record on which assessors and care managers can rely to coordinate the provision of services to consumers. DSS shares IHSS data with managed care plans in CCI counties, and CBAS centers submit individual plans of care to managed care plans. According to the LAO, managed care plans have entered into agreements with MSSP providers to define roles and responsibilities and establish policies and procedures for sharing information and coordinating care. In light of the integration of LTSS as a managed care benefit, and the challenges presented by a disintegrated assessment process, universal assessment for HCBS through the use of a UAT is looked upon as having many potential benefits, including the creation of a single HCBS assessment record, improvement of care coordination, reduction in administrative inefficiencies, and improved data collection to better understand consumer needs. AB 664 Page H c) Status of UAT development. Pursuant to the CCI, DHCS, DSS, and CDA are required to work with stakeholders representing HCBS consumers, HCBS providers, managed care plans, counties, area agencies on aging, independent living centers, and legislative staff to develop a UAT. The workgroup is required to consider various factors in the development of the UAT, including the roles and responsibilities of health plans, counties, and HCBS providers administering the assessment; criteria for reassessment; how results from the new assessments can be used for oversight and quality monitoring of HCBS providers, and how the universal assessment process would incorporate person-centered principles and protections. Stakeholder engagement on the development of a universal assessment process began in 2013 and is ongoing. To date, no counties have been selected to pilot the UAT, and in order to accommodate time for additional stakeholder engagement, research, pre-pilot testing, pilot county selection, and other action items necessary prior to the launch of the UAT pilot, it is currently estimated that the pilot will begin July 2016. 3)SUPPORT. The American Federation of State, County, and Municipal Employees (AFSCME) states that, under the state's current assessment process, HCBS consumers undergo unnecessary and duplicative assessments, and that this bill will require a formal evaluation of the UAT pilot to ensure that the state's UAT properly shifts HCBS assessment to a person-centered approach integrating all aspects of an individual's care coordination. AFSMCE states the evaluation proposed in this bill is necessary, because if the UAT is successful, the Legislature should expand the program to all California counties. 4)PREVIOUS LEGISLATION. a) SB 1008 (Committee on Budget and Fiscal Review), Chapter AB 664 Page I 33, Statutes of 2012, established the main components of the CCI, including the provisions for the Cal MediConnect Program, mandatory Medi-Cal managed care for SPDs, and MLTSS. b) 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 the UAT as well as data-sharing agreements between managed care plans and HCBS administrators. 5) Policy Comment. Bill and current statute afford little time for UAT pilot evaluation. This bill would require a report to the Legislature on the UAT pilot on or before January 1, 2017. However, given that implementation of the UAT pilot may not commence until July 2016, there will be little time for evaluation prior to the reporting deadline. Also, given that existing law sets forth a July 1, 2017 sunset of existing universal assessment provisions, there is not much room to adjust the timeline for a UAT report. Successful implementation of the UAT pilot report required under this bill will require strict adherence to the proposed timelines for launching the UAT pilot itself. REGISTERED SUPPORT / OPPOSITION: Support American Federation of State, County, and Municipal Employees, AFL-CIO United Domestic Workers of America/AFSCME Local 3930 Opposition AB 664 Page J None on file. Analysis Prepared by:Kelly Green / HEALTH / (916) 319-2097