BILL ANALYSIS Ó
AB 1518
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Date of Hearing: April 30, 2015
ASSEMBLY COMMITTEE ON AGING AND LONG-TERM CARE
Cheryl Brown, Chair
AB 1518
Committee on Aging and Long-Term Care - As Amended April 27,
2015
SUBJECT: Medi-Cal: nursing facilities.
SUMMARY: Expands opportunities to participate in the Nursing
Facility/Acute Hospital (NF/AH) waiver program, and stabilizes
service for younger, disabled Californians participating in the
Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
program. Specifically, this bill:
1)Increases the number of waiver participants in the NF/AH
waiver program by 5,000.
2)Adjusts the cost-cap associated with the NF/AH waiver to
coincide with skilled nursing facility care costs, and
increases those waiver limitations when skilled nursing
facility reimbursements are increased.
3)Provides for a smooth transition for participants of the EPSDT
at age 21 into equitable medically necessary, in-home nursing
provided through adult Medi-Cal, or a regional center.
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4)Conditions implementation upon obtaining the necessary
approvals and receipt of federal financial participation from
the Federal Centers for Medicare and Medicaid Services (CMS).
5)Directs implementation to commence within six months of the
department receiving authorization for the necessary
resources.
EXISTING LAW:
1)Medicaid 1915(c) waivers allow states to provide long term
care services in home and community based settings under the
Medicaid Program.
2)California's NF/AH waiver provides case
management/coordination, habilitation, home respite, waiver
personal care services, community transition, continuous
nursing and supportive services, environmental accessibility
adaptations, facility respite, family/caregiver training,
medical equipment operating expense, PERS-installation and
testing, PERS, private duty nursing including home health and
shared services, and, transitional case management for
medically fragile and technology dependent individuals.
3)For Medi-Cal eligible children under age 21, Early and
Periodic Screening, Diagnosis and Treatment (EPSDT) funds this
nursing. Home nursing hours are calculated based on the
appropriate institutional level of care equivalent.
FISCAL EFFECT: This measure has not been analyzed by a fiscal
committee.
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COMMENTS:
Author's Statement: California's NF/AH Waiver program does not
currently meet the needs of seniors and youth with disabilities
who wish to receive services at home, and avoid nursing homes
and other institutions. The author states that home-based
services are typically less expensive, more desirable to the
clients and their families, and consistent with state and
federal priorities; however, current state policies and limited
funding and flexibility prevent individuals from being moved
from institutions to home-based care. In addition, the author
asserts that upon turning 21, many individuals, who received
home care prior to their 21st birthday, are forced into
institutions because they become ineligible due to age
restrictions for specified services.
Background on NF/AH Waiver: "Medicaid waivers" allow states to
deliver and pay for health care services while the federal
government "waives" some of the usual Medicaid rules. For
instance, Medicaid 1915(c) waivers allow states to provide
long-term care services in home and community based settings,
instead of licensed health care facilities. California's NF/AH
waiver supports case management, habilitation, home respite,
personal care services, community transition assistance,
continuous nursing, and other supportive services, environmental
accessibility adaptations, caregiver training for family
members, private duty nursing such as home health care, and
special case management for medically fragile and
technology-dependent individuals.
Even as Medi-Cal long-term services and supports transition into
managed care through the Coordinated Care Initiative, the NF/AH
"waiver" provides comprehensive home and community-based
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alternative to nursing facility care for people who require
services beyond those offered by such long-term care mainstays
as In-Home Supportive Services (IHSS). While the NF/AH waiver
has great potential to assist the state with meeting the
directive of the Olmstead decision (which guarantees access to
the least restrictive, most "integrated," or home-like settings
for care, if not cost-prohibitive), California significantly
limits the NF/AH waiver utilization, thus creating barriers to
less-costly community living for eligible individuals. The
current NF/AH waiver has an enrollment cap of 3,792 persons in
2015 and 3,964 in 2016, yet there are approximately 70,000
people on Medi-Cal in nursing homes on any given day, 25% of
whom express an interest in leaving the facility and living in
the community. Since waivers are applied for, and initiated by
states, with CMS granting approval, AB 1518 directs the
California Department of Health Care Services (DHCS) to seek
permission to serve more than the 3,792 clients this year, and
3,964 next year.
Cost-Cap Inadequate: Besides the limitation upon the number of
participants, federal requirements for home and community-based
waivers include cost-neutrality provisions. Federal
cost-neutrality means that providing home and community-based
waiver services to an individual, or a group of individuals,
cannot cost the Medi-Cal program more than serving that
individual, or that group of individuals, in an institutional
setting. Currently, California applies a more rigorous standard
that limits waiver participation and favors institution
placements. Despite a federal option to utilize an "aggregate"
cost-cap, California has opted instead to utilize an
"individual" cost-cap, which does not permit the State to offset
the waiver costs of higher need individuals with the lower costs
individuals with less intensive needs. Interestingly, the
waiver which supports developmentally disabled Californians home
and community-based services utilizes an aggregate cost-cap with
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great success.
Background on EPSDT: The Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) benefit provides comprehensive
and preventive health care services for children under age 21
who are enrolled in Medi-Cal. EPSDT is key to ensuring that
children and adolescents receive appropriate preventive, dental,
mental health, developmental, and specialty services. Children
with the most significant medical needs can live at home with
the support of home nursing. For Medi-Cal eligible children
under age 21, EPSDT funds those services. Home nursing hours
are calculated based on the appropriate institutional level of
care equivalent.
At age 21, Medi-Cal recipients should transition from EPSDT to
home nursing funded by the NF/AH Waiver, the Developmental
Disabilities (DD) Waiver, or regional center services. Unless
needs have changed, this transition should be seamless and
services should not decrease. However, some individuals have
experienced a reduction in service because of the different way
the NF/AH program operates, including lower caps on hours and
more restrictive eligibility criteria.
Recent Amendments: AB 1518 requires DHCS, in determining the
need for additional waiver spots, to consider the needs
identified by programs that assist people to leave nursing
homes. Recent amendments recommended by the Assembly Committee
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on Health specifies which local and/or state programs must be
considered by DHCS when considering the number of Waiver slots;
clarifies which entity has the authority to decide if an
individual is at imminent risk, and what factors must be
considered by that entity in making that determination, and;
specifies the time range by which the provisions must be
implemented upon approval of the waiver by Centers for Medicare
and Medicaid Services.
Dual Referral: AB 1518 was previously heard in the Assembly
Health Committee where it passed 19-0 on April 21, 2015.
REGISTERED SUPPORT / OPPOSITION:
Support
American Federation of State, County and Municipal Employees
(AFSCME), AFL-CIO
California Advocates for Nursing Home Reform (CANHR)
California Association of Public Authorities (CAPA)
California Commission on Aging
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Congress of California Seniors
Disability Rights California
United Domestic Workers of America (UDW)/AFSCME Local 3930
Three individuals.
Opposition
None on file.
Analysis Prepared by:Robert MacLaughlin / AGING & L.T.C. / (916)
319-3990