BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 664    
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          |AUTHOR:        |Dodd                                           |
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          |VERSION:       |June 25, 2015                                  |
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          |HEARING DATE:  |July 8, 2015   |               |               |
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          |CONSULTANT:    |Scott Bain                                     |
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           SUBJECT  :  Medi-Cal: universal assessment tool report.

         SUMMARY  :1)  Extends by six months, from July 1, 2017 to December 31, 2017,  
          the duration of the existing provisions of law requiring the  
          Department of Health Care Services (DHCS), the Department of  
          Social Services (DSS) and the California Department of Aging  
          (CDA) to establish a stakeholder workgroup to develop a  
          universal assessment process, a universal assessment tool (UAT),  
          authorization for piloting of the UAT, and reporting  
          requirements on those provisions. Requires, on or before January  
          1, 2017, DHCS, DSS, and CDA to evaluate and report to the  
          Legislature on the outcomes of, and lessons learned from, the  
          UAT pilot authorized, and would require the report to include,  
          among other things, findings from consumers assessed using the  
          UAT and findings from consumers choosing to be assessed using  
          previous assessment tools.
          
          Existing law:
          1)States legislative intent that a universal assessment process  
            for long-term services and supports (LTSS) be developed and  
            tested.

          2)Requires, no later than January 1, 2013, DHCS, DSS, and CDA to  
            establish a stakeholder workgroup to develop the universal  
            assessment process, including a UAT, for home- and  
            community-based services (HCBS). 

          3)Requires the stakeholder workgroup to include, but not be  
            limited to, consumers of In-Home Supportive Services (IHSS),  
            and other HCBS and their authorized representatives, managed  
            care health plans, counties, Multipurpose Senior Services  
            Program (MSSP) providers, Community-Based Adult Services  
            (CBAS) providers, area agencies on aging, independent living  







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            centers, and legislative staff. 
           
          4)Requires the universal assessment process to be used for all  
            HCBS, including IHSS. Requires the workgroup, in developing  
            the process, to build upon the IHSS uniform assessment process  
            and hourly task guidelines, the MSSP assessment process, and  
            other appropriate home- and community-based assessment tools.

          5)Requires DHCS, DSS and CDA, in developing the universal  
            assessment process, to develop a UAT that will inform the  
            universal assessment process and facilitate the development of  
            plans of care based on the individual needs of the consumer.  
            Requires the workgroup to consider specified issues.

          6)Requires DHCS, DSS and CDA, no later than March 1, 2014, to  
            report to the Legislature on the stakeholder workgroup's  
            progress in developing the universal assessment process, and  
            to identify the counties and beneficiary categories for which  
            the universal assessment process may be implemented 

          7)Permits, no sooner than January 1, 2015, upon completion of  
            the design and development of a new UAT, managed care health  
            plans, counties, and other HCBS services providers to test the  
            use of the tool for a specific and limited number of  
            beneficiaries who receive or are potentially eligible to  
            receive HCBS in no fewer than two, and no more than four, of  
            the counties where the Coordinated Care Initiative is  
            implemented, if the following conditions have been met:

                  a)        DHCS has obtained any federal approvals  
                    through necessary federal waivers or amendments, or  
                    state plan amendments, whichever occurs later;
                  b)        The system used to calculate the results of  
                    the tool has been tested; and,
                  c)        Any entity responsible for using the tool has  
                    been trained in its usage.

          8)Requires counties in which the tool has been piloted, no  
            sooner than January 1, 2015, to also utilize the UAT if one is  
            available and upon completion of the stakeholder process,  
            system design and testing, and county training for the  
            provision of IHSS services, if beneficiaries consent to the  
            use of the universal assessment process. Requires managed care  
            health plans to cover IHSS services based on the results of  
            the universal assessment process.








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          9)Requires, to the extent the UAT or universal assessment  
            process results in changes to the authorization process and  
            provision of IHSS services, those changes to be automated in  
            the Case Management Information and Payroll System.

          10)Requires DHCS to develop materials to inform consumers of the  
            option to participate in the UAT testing phase.

          11)Requires DHCS, DSS and CDA to implement a rapid-cycle quality  
            improvement system to monitor the implementation of the  
            universal assessment process, identify significant changes in  
            assessment results, and make modifications to the universal  
            assessment process.

          12)Requires beneficiaries to have the option to request an  
            additional assessment using the previous assessment process  
            for those HCBS and to receive services according to the  
            results of the additional assessment until existing law  
            relating to the IHSS assessment process is amended.

          13)Requires, no later than nine months after the implementation  
            of the universal assessment process, DHCS, DSS, and CDA, in  
            consultation with stakeholders, to report to the Legislature  
            on the results of the initial use of the universal assessment  
            process, and permits these entities to identify proposed  
            additional beneficiary categories or counties for expanded use  
            of this process and any necessary changes to provide statutory  
            authority for the continued use of the universal assessment  
            process. Requires DHCS, DSS and CDA to report annually  
            thereafter to the Legislature on the status and results of the  
            universal assessment process.

          14)Sunsets the above-described provisions on July 1, 2017.
          
          This bill:
          1)Extends, from July 1, 2017 to December 31, 2017 the duration  
            of the existing provisions of law requiring DHCS, DSS and CDA  
            to establish a stakeholder workgroup, to develop a universal  
            assessment process, a UAT, authorization for piloting of the  
            UAT, and reporting requirements.

          2)Requires, on or before January 1, 2017, DHCS, DSS, and CDA, in  
            consultation with the existing workgroup, to evaluate and  
            report to the Legislature on the outcomes of, and lessons  








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            learned from, the UAT pilot. Requires the report, at a  
            minimum, to include all of the following:

                  a)        Findings from consumers assessed using the  
                    UAT. Requires interviews with consumers who chose to  
                    be assessed using the UAT to be conducted to evaluate  
                    all of the following:

                        i.             The level of satisfaction consumers  
                         experienced with the UAT as compared to the  
                         previous assessment approach;
                        ii.            The level of satisfaction consumers  
                         experienced with the assessor from either the  
                         county or the managed care plan; 
                        iii.           The ability of consumers to  
                         understand and respond to the assessor  
                         administering the UAT for the duration of the  
                         assessment; and,
                        iv.            Any challenges experienced by  
                         consumers during the administration of the UAT.

                  b)        Findings from consumers choosing to be  
                    assessed using previous assessment tools. Requires  
                    interviews with consumers who chose to be assessed  
                    using previous assessment tools shall be conducted to  
                    evaluate both of the following:

                        i.             Reasons why the consumer chose to  
                         be assessed using the previous assessment tools;  
                         and,
                        ii.            Concerns the consumer may have had  
                         with the UAT determining the services to be  
                         provided.

         3)Data on 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, in order to better  
           understand any discrepancies that may exist between the  
           assessment approaches.

         4)Data on HCBS utilization and costs of consumers before and  
           after the use of the UAT, in order to better understand how the  
           UAT may impact the HCBS system.

         5)Data on the percentage of consumers who experience  








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           hospitalizations and skilled nursing facility stays over a  
           specific time period before and after the use of the UAT, in  
           order to better understand how the UAT may impact acute care  
           utilization.

           FISCAL  
          EFFECT  :  According to the Assembly Appropriations Committee,  
          costs in the low hundreds of thousands of dollars to DHCS (50%  
          GF/50% federal).

           PRIOR  
          VOTES  :  
          
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          |Assembly Floor:                     |80 - 0                      |
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          |Assembly Appropriations Committee:  |17 - 0                      |
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          |Assembly Health Committee:          |17 - 0                      |
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          COMMENTS  :
          1)Author's statement.  According to the author, California  
            provides HCBS to low-income seniors and persons with  
            disabilities to help them remain in their own homes and  
            communities. Each of the three main HCBS programs rely on  
            workers to determine eligibility and conduct an assessment for  
            the type of services that are needed. Currently, those who  
            receive services for more than one program undergo multiple  
            assessments that, in some cases, collect duplicative  
            information. 

            In 2012, the Legislature recognized that separate eligibility  
            determination and assessment processes create several forms of  
            inefficiency in the administration of these programs.  The UAT  
            was identified as an alternative to the current assessment  
            system. A UAT is a single application and data system that  
            would streamline eligibility determinations and assessments.  
            It would shift the existing HCBS framework from a  
            "program-based" approach to a "person-centered" approach. 

            The goal of this new framework is to facilitate better care  
            coordination, enhance consumer choices, reduce administrative  
            inefficiencies, improve data analysis capabilities, and  








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            potentially create long-term fiscal savings. Without a formal  
            evaluation, the Legislature will not know if the UAT will work  
            as it was intended to. 

          2)Background on HCBS assessments. Medi-Cal provides services to  
            low-income SPDs to help these individuals remain in their own  
            homes and communities rather than being placed in  
            institutional care. Each of the state's three main HCBS  
            programs (IHSS, CBAS, and MSSP) rely on workers to determine  
            eligibility and conduct an assessment to determine the amount  
            and type of services that a consumer may need. Currently,  
            clients who receive services from more than one HCBS program  
            undergo multiple assessments that, in some cases, collect  
            duplicative information. These assessments are typically paper  
            forms-unique to each program-used by assessors. Assessors for  
            each HCBS program determine eligibility and conduct an  
            assessment to determine the amount and type of services that a  
            client may need from the particular program to remain safely  
            in his/her home and community. An assessment generally  
            includes questions that cover one or more of the following  
            three areas: (a) medical needs, (b) routine daily functional  
            needs, and/or (c) consumer characteristics.
          
          3)Budget action and status of universal assessment. As part of  
            the 2012-13 budget, the Legislature enacted the Coordinated  
            Care Initiative (CCI), with the intent to promote care  
            coordination among SPDs by integrating health care LTSS  
            benefits in up to eight pilot counties. The CCI legislation,  
            SB 1036 (Committee on Budget and Fiscal Review), Chapter 45,  
            Statutes of 2012 also established the universal assessment  
            requirements. The workgroup met for the first time in  
            September 2013 and plans to continue its work of developing  
            the UAT through 2015. The affected state departments have  
            received a draft assessment tool but it is not yet public.  
            Department staff indicate they are not likely to begin  
            piloting the UAT until July 2016.
          
          4)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  








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            bill is necessary, because if the UAT is successful, the  
            Legislature should expand the program to all California  
            counties.  
          


          5)Policy issues. 

               a)     Bill and current statute afford little time for UAT  
                 pilot implementation and evaluation. The most recent  
                 amendments to this bill extend the duration of the  
                 universal assessment provisions of law by an additional  
                 six months, to December 31, 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 statute sunset date.

               b)     Existing reporting requirements. Existing law  
                 requires a report by March 1, 2014 by DHCS, DSS and CDA  
                 on the stakeholder workgroup's progress in developing the  
                 universal assessment process, and which identifies the  
                 counties and beneficiary categories for which the  
                 universal assessment process may be implemented. A second  
                 report is required nine months after the implementation  
                 of the universal assessment process on the results of the  
                 initial use of the universal assessment process. Finally,  
                 existing law requires these departments to report  
                 annually thereafter to the Legislature after the second  
                 report on the status and results of the universal  
                 assessment process. In discussions with department staff,  
                 one of the issues raised is whether the information  
                 sought in the report required by this bill is in a  
                 separate report from those that are currently required. 

           SUPPORT AND OPPOSITION  :
          Support:  American Federation of State, County and Municipal  
                    Employees
                    California Alliance for Retired Americans
                    California Senior Legislature
                    LeadingAge California
          
          Oppose:   None received


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