BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1261
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|AUTHOR: |Burke |
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|VERSION: |February 27, 2015 |
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|HEARING DATE: |June 17, 2015 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Community-based adult services: adult day health care
centers.
SUMMARY : Requires Community-Based Adult Services to be a Medi-Cal
benefit, and to be included as a covered service in contracts
with all Medi-Cal managed health care plans, with standards,
eligibility criteria, and provisions that are at least equal to
those contained in the Special Terms and Conditions of the
state's "Bridge to Reform" Section 1115 Medicaid Demonstration
Waiver.
Existing law:
1.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which health
care services are provided to qualified, low-income persons.
2.Excludes, to the extent permitted by federal law, adult day
health care (ADHC) from coverage under the Medi-Cal program.
3.Authorizes DHCS to implement a one-year moratorium on the
certification and enrollment into the Medi-Cal program of new
ADHC centers on a statewide basis, or within a geographic
area, with specified exemptions from the moratorium. Permits
the director of DHCS to extend this moratorium, if necessary,
to coincide with the implementation date of the ADHC centers
waiver.
4.Requires DHCS, to the extent that federal financial
participation is available, and pursuant to a demonstration
project or waiver of federal law, to establish specified
Medi-Cal pilot projects in up to eight counties, and requires
long-term services and supports (LTSS) to be available to
beneficiaries residing in counties participating in those
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pilot projects. Includes Community Based Adult Services (CBAS)
within the definition of LTSS. This demonstration project is
known as the Coordinated Care Initiative (CCI).
5.Requires, as part of the CCI, all Medi-Cal LTSS to be services
covered under Medi-Cal managed care health plan contracts and
available only through plans to beneficiaries residing in
counties participating in the demonstration, with specified
exemptions.
This bill:
1)Requires, notwithstanding the operational period of CBAS as
specified in the Special Terms and Conditions (STCs) of
California's Bridge to Reform Section 1115 Medicaid Waiver,
and notwithstanding the duration of the CBAS settlement
agreement, CBAS to be a Medi-Cal benefit, and to be included
as a covered service in contracts with all managed health care
plans, with standards, eligibility criteria, and provisions
that are at least equal to those contained in the STCs of the
demonstration waiver on the date this bill is signed into law.
Prohibits any modifications to the CBAS program that differ
from the STCs of the demonstration to be permitted only if
they offer more protections or permit greater access to CBAS.
2)Defines "CBAS" as an outpatient, facility-based program,
provided pursuant to a participant's individualized plan of
care, as developed by the center's multidisciplinary team,
that delivers nutrition services, professional nursing care,
therapeutic activities, facilitated participation in group or
individual activities, social services, personal care
services, and, when specified in the individual plan of care,
physical therapy, occupational therapy, speech therapy,
behavioral health services, registered dietician services, and
transportation.
3)Defines the eligibility criteria for CBAS services for
Medi-Cal beneficiaries, as one of five of the following:
a) Meet "Nursing Facility Level of Care A" (NF-A) criteria
as set forth in regulation, or above NF-A Level of Care;
b) Have a diagnosed organic, acquired or traumatic brain
injury, and the enrollee must need assistance or
supervision with either:
AB 1261 (Burke) Page 3 of ?
i. Two of the following: bathing, dressing,
self-feeding, toileting, ambulation, transferring,
medication management, or hygiene; or,
ii. One need from the above list and one of the
following: money management, accessing community and
health resources, meal preparation, or transportation.
c) Have a moderate to severe cognitive disorder such as
dementia, including dementia characterized by the
descriptors of, or equivalent to, Stages 5, 6, or 7 of the
Alzheimer's type;
d) Have a mild cognitive disorder such as dementia,
including dementia of the Alzheimer's Type, and needs
assistance or supervision with two of the following:
bathing, dressing, self-feeding, toileting, ambulation,
transferring, medication management, or hygiene; or,
e) Have a developmental disability.
4)Requires CBAS providers to be licensed as ADHCs and certified
by the California Department of Aging (CDA) as CBAS providers,
and to meet the standards specified in existing law and
regulation.
5)Requires CBAS providers to meet all applicable licensing and
Medi-Cal standards, and to provide services in accordance with
existing regulations.
6)Requires CBAS providers to comply with the provisions of
California's 2010 Bridge to Reform Section 1115 Medicaid
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Waiver and any successor demonstration.
7)Requires, in counties where DHCS has implemented Medi-Cal
managed care, CBAS to be available as a Medi-Cal managed care
benefit, except for individuals who are not qualified for, or
who are exempt from, enrollment in Medi-Cal managed care. For
these individuals, CBAS is required to be provided as a
fee-for-service benefit.
8)Requires CBAS to be provided as a fee-for-service (FFS)
Medi-Cal benefit to all eligible Medi-Cal beneficiaries who
qualify for CBAS in counties that have not implemented
Medi-Cal managed care.
9)Requires Medi-Cal managed care plans to reimburse contracted
providers at rates that are not less than Medi-Cal FFS rates,
as published and revised by the DHCS, including retroactive
payment of any rate increment based on DHCS retroactive rate
adjustments, for equivalent services on the date the services
were provided.
10)Implements this bill only to the extent that federal
financial participation is available.
11)Makes legislative findings regarding Californians support for
living in their home or a community-based setting free from
unnecessary institutionalization, the aging American
population, the history and services provided by ADHC centers,
the cost of ADHC services as compared to nursing home costs,
the creation of CBAS, the need to continue CBAS and to codify
CBAS so that disabled and frail Californians who rely on adult
day health programs are able to remain independent and free of
institutionalization as long as possible.
FISCAL
EFFECT : According to the Assembly Appropriations Committee:
1)Assuming federal approval is granted, annual costs to the DHCS
for continuation of CBAS as a Medi-Cal benefit of
approximately $300 million annually, and growing in future
years (50% General Fund (GF)/50% federal funds). Since CBAS
is already provided pursuant to the terms and conditions of a
federal waiver until October 31, 2015, to 2016 costs for eight
additional months of service are expected to be approximately
$200 million (50 percent GF/50% federal funds).
AB 1261 (Burke) Page 5 of ?
2)Minor administrative costs (50% GF/50% federal funds) to DHCS
to secure federal approval.
3)Costs to the Department of Public Health (DPH) associated with
the licensure of ADHCs, and CDA associated with certifying
facilities, will continue to be incurred. If not for the
continuation of CBAS through this bill or another mechanism,
there would likely be a reduction in the number of ADHC
providers, reducing licensure workload for DPH and
certification workload for CDA.
PRIOR
VOTES :
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|Assembly Floor: |79 - 0 |
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|Assembly Appropriations Committee: |17 - 0 |
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|Assembly Health Committee: |16 - 0 |
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COMMENTS :
1)Author's statement. According to the author, over 30,000
frail Californians and their families depend upon the adult
day health care services provided through the CBAS program.
While the current federal waiver ensures that the program will
continue for the next few years, the waiver did not include
language to ensure that providers will be reimbursed at levels
that are not less than current Medi-Cal FFS rates, and state
law has not been updated to reflect the program requirements
under the waiver and guarantee legislative oversight. This
bill preserves access to the adult day health care services
and gives providers a reliable rate structure to ensure
program sustainability.
2)Background on ADHC and CBAS. All state Medicaid programs have
the option to provide and receive federal financial
participation for optional services, in addition to those
services required by federal law. ADHC was an optional
community-based day program in FFS Medi-Cal for low-income
elders and younger disabled adults who are at risk for being
placed in a nursing home. ADHC services included physical
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therapy, occupational therapy, speech therapy and recipient
transportation to and from the ADHC facility. Eligibility was
based on an individual's functional limitations, severity of
chronic or post-acute health conditions, and risk for nursing
home placement. ADHC services were provided at licensed ADHC
centers, and included medical services, nursing care, meals,
social and therapeutic activities, and transportation. ADHC
centers could be both for-profit and not-for-profit.
Governors Schwarzenegger and Brown both proposed the
elimination of ADHC as an optional Medi-Cal benefit. In March
2011, AB 97 (Committee on Budget, Chapter 3, Statutes of
2011), eliminated ADHC as a benefit in Medi-Cal, subject to
approval by the federal Center for Medicare and Medicaid
Services (CMS), in order to achieve GF savings and because of
concerns over fraud in the program. In June 2011, the
Legislature passed AB 96 (Committee on Budget), which
authorized the creation of the Keeping Adults Free from
Institutions (KAFI) program to replace ADHC. In July of 2011,
Governor Brown vetoed AB 96, and instead proposed that his
Administration would develop an alternate plan to transition
ADHC participants to other services. In August 2011, DHCS
presented its plan for transitioning ADHC participants to
other services, which included the enrollment of ADHC
participants in Medi-Cal managed care. From mid-August through
October of 2011, DHCS began implementing the managed care
portion of its transition plan.
In June 2011, seven plaintiffs filed a class action lawsuit in
the U.S. District Court on behalf of ADHC participants. The
lawsuit, Esther Darling, et al. v. Toby Douglas, et al., was
brought against DHCS to block the elimination of ADHC as an
optional Medi-Cal benefit, as the plaintiffs argued the
changes would place them at risk of unnecessary
institutionalization, violated their due process rights, and
that the restrictive eligibility criteria in a previous ADHC
bill violated Medicaid requirements.
In November 2011, DHCS announced that it had reached a
settlement with plaintiffs to resolve the lawsuit. Under the
terms of the settlement, ADHC will be eliminated and replaced
by a new program called CBAS, which would be included under
the state's Medicaid Demonstration Waiver, known as
California's Bridge to Reform. CBAS was defined in the
settlement as an outpatient facility-based program that
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delivers skilled nursing care, social services, therapies,
personal care, family/caregiver training and support, meals
and transportation to eligible beneficiaries. In January 2012,
the Court granted final approval of the settlement, which
lasts for 30 months or until August 2014. Medi-Cal managed
care plans began covering CBAS in mid- to late 2012.
The Governor's May 2015-16 Budget estimated CBAS expenditures
in 2015-16 of $194.4 million GF. Expenditures in CBAS have
declined significantly from the prior ADHC program, which had
expenditures of $212 million GF in 2009-10. CBAS providers are
subject to the 10 percent Medi-Cal rate reduction, which was
implemented for CBAS providers in December 2011, retroactive
to June 2011. According to data from the Department of Aging,
the number of ADHC centers and ADHC/CBAS program Medi-Cal
participants have declined since 2009-10. In 2009-10, there
were 313 centers and 37,277 Medi-Cal participants. In March
2015, the number of ADHC centers was estimated to be 241, with
31,182 Medi-Cal participants. CBAS was added to the state's
current Section 1115 waiver in 2014, which expires on October
31, 2015, and the state is proposing to continue the program
after that date.
3)Prior legislation. AB 1552 (Lowenthal, 2014), was similar to
this bill except it did not contain a FFS rate floor requiring
Medi-Cal managed care plans to pay CBAS providers at least at
Medi-Cal FFS rates. AB was vetoed by the Governor Brown. In
his veto message, Governor Brown stated this benefit is
authorized under an approved waiver by the federal government,
and the terms of the waiver may change, pending federal
review. Governor Brown indicated codifying this benefit is
premature.
SB 1008 (Committee on Budget and Fiscal Review, Chapter 33,
Statutes of 2012) and SB 1036 (Committee on Budget and Fiscal
Review), Chapter 45, Statutes of 2012 authorize the CCI as an
eight-county pilot project to integrate Medi-Cal and Medicare
benefits under managed care for dual eligibles, and to
integrate LTSS under managed care for dual eligibles and
Medi-Cal-only seniors and persons with disabilities (SPDs).
AB 96 (Committee on Budget, 2011) would have established the
KAFI program, and required DHCS to submit an application to
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CMS to implement the program. AB 96 was vetoed by Governor
Brown.
AB 97 (Committee on Budget, Chapter 3, Statutes of 2011),
health budget trailer bill, among other provisions, eliminated
ADHC as a Medi-Cal benefit.
SB 208 (Steinberg, Chapter 714, Statutes of 2010), contains
the provisions implementing Medicaid Demonstration.
AB 518 (Yamada, 2013), was similar to this measure except it
also included a requirement that DHCS certify and enroll as
new CBAS providers only those providers that are exempt from
taxation under Section 501(c)(3) of the federal Internal
Revenue Code, commencing July 1, 2015. AB 518 was heard on
June 12, 2013 in Senate Health Committee, but no vote was
taken on the measure.
4)Support. The California Association for Adult Day Services
(CAADS) writes in support of this bill to extend the CBAS
program beyond the expiration of its current waiver coverage,
thus ensuring continuity of care to this vulnerable
population. CAADS states CBAS serves over 28,000 low-income
California seniors and persons with disabilities, chronic
conditions and complex care needs such as Alzheimer's disease
or other dementia, diabetes, high blood pressure, mental
health diagnoses, traumatic brain injury, people who have had
a stroke or breathing problems or who cannot take medications
properly. This bill will ensure that these vulnerable Medi-Cal
eligible participants continue to have access to high-quality
clinical, therapeutic, and support services that enable them
to live in their own homes with dignity and independence
despite having multiple chronic health conditions that put
them at risk of high-cost institutional placement. CAADS
concludes that, as California implements health care reform
and moves to managed, outcome-driven care, it is essential
that integrated community-based programs such as CBAS are key
partners in the changing systems, and that they expand to meet
the growing needs of California's aging population and the
goals of offering alternatives to institutional care.
SUPPORT AND OPPOSITION :
Support: California Association for Adult Day Services
(sponsor)
AARP
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Acacia Adult Day Services
Adult Day Health Care of Mad River
Alzheimer's Association California Council
Ararat Adult Day Health Care Center
Avenidas
Bay Area Community Services
California Association of Public Authorities for IHSS
California PACE Association
California State Council on Developmental Disabilities
Casa Pacifica Adult Day Health Care Center
Congress of California Seniors
Disability Rights California
Eskaton Adult Day Health Center
Friends of Adult Day Health Care Centers
Get Together Adult Day Health Care Center
Guardian Adult Health Centers of California
J GELT Corporation
Justice in Aging
LeadingAge California
Meals-on-Wheels Greater San Diego, Inc.
New Life Adult Day Health Care
Partners in Care Foundation
Rehabilitation Services of Northern California:
Bedford Center
San Fernando Valley Adult Day Health Care, LLC.
San Francisco Department of Aging and Adult Services
San Ysidro Health Center
Sunny Cal Adult Day Health Care Center, Inc.
Sunny Day Adult Community Based Adult Services
Tender Heart Adult Day Health Care Center
United Domestic Workers/AFSCME Local 3930
United Way of Santa Barbara County
Numerous individuals
Oppose: None received
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