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