BILL ANALYSIS Ó
AB 664
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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
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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
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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.
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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
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|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 |
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| | |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):
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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.
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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
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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
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None on file.
Analysis Prepared by:Kelly Green / HEALTH / (916) 319-2097