BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 492
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|AUTHOR: |Liu |
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|VERSION: |April 20, 2015 |
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|HEARING DATE: |April 29, 2015 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Coordinated Care Initiative: Consumer Bill of Rights.
SUMMARY : Enacts the "Coordinated Care Initiative Consumer Bill of Rights"
which requires a consumer under the Coordinated Care Initiative
to specified rights, including the right to self-direction,
choice, coordination, integration of services, flexibility,
quality, cultural competence, accessibility, personal assistants
and caregivers, independence and grievance and appeals, and
timeliness. Requires this bill to be implemented only to the
extent permitted by applicable federal Medicare law, Medi-Cal law
and the "Memorandum of Understanding between the Centers for
Medicare and Medicaid Services and the State of California.
Existing law:
1.Establishes, under federal law, the Medicare program, which is
a public health insurance program for persons 65 years of age
and older and specified persons with disabilities who are under
the age of 65.
2.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services,
including home and community-based services (HCBS).
3.Requires DHCS to seek federal approval to establish the
demonstration project under a Medicare or a Medicaid
demonstration project or waiver. Authorizes DHCS under a
Medicare demonstration, to contract with the federal Centers
for Medicare and Medicaid Services (CMS) and demonstration
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sites to operate the Medicare and Medicaid benefits in a
demonstration project that is overseen by the state as a
delegated Medicare benefit administrator, and to enter into
financing arrangements with CMS to share in any Medicare
program savings generated by the demonstration project.
4.Requires DHCS, after federal approval is obtained, to establish
the demonstration project that enables dual eligible
beneficiaries to receive a continuum of services that maximizes
access to, and coordination of, benefits between the Medi-Cal
and Medicare programs and access to the continuum of long-term
services and supports and behavioral health services, including
mental health and substance use disorder treatment services.
The purpose of this demonstration project is to integrate
services authorized under Medi-Cal and Medicare.
5.Requires demonstration sites to be established in up to eight
counties, and to include at least one county that provides
Medi-Cal services via the two-plan model of Medi-Cal managed
care.
6.Requires DHCS to enroll dual eligible beneficiaries into a
demonstration site unless the beneficiary makes an affirmative
choice to opt out of enrollment, with specified exceptions.
7.Requires DHCS to require dual eligibles to be assigned as
mandatory enrollees into new or existing Medi-Cal managed care
health plans for their Medi-Cal benefits in Coordinated Care
Initiative (CCI) counties. CCI counties are the Counties of
Alameda, Los Angeles, Orange, Riverside, San Bernardino, San
Diego, San Mateo, and Santa Clara. Allows individuals to opt
out of Medi-Cal managed care for the Medicare portion of their
benefits.
8.Requires all Medi-Cal long-term services and supports (LTSS) to
be services that are covered under Medi-Cal managed care health
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plan contracts and to be available only through managed care
health plans to beneficiaries residing in CCI counties, except
for specified exemptions.
This bill:
1.Requires a consumer under the CCI to have all of the following
rights:
a. The right to self-direction. Requires the
individual to have the option to coordinate his or her
care and services. Urges a statutory option be made
available to allow for a surrogate or informal
caregiver chosen by the individual to coordinate care
if the individual is unable to do so due to cognitive
impairment;
b. The right to choice. Plan networks should
ensure that individuals have access to, and choice of,
a range of providers and settings across the continuum
of care, including health care services, behavioral
health services, and long-term services and supports;
c. The right to coordination. Requires that an
individual have access to care coordination, in
accordance with his or her needs and preferences;
d. The right to integration of services. Requires
services to be delivered to the individual in an
integrated manner, regardless of the source of payment;
e. The right to flexibility. Requires services
within a plan's contracted services to meet the
individual's changing needs and incorporate new modes
of service and supports;
f. The right to quality. Requires all services and
supports to be of high quality and to be
person-centered. Urges statutory standards be
established to provide a mechanism for enforcement;
g. The right to cultural competence. Individuals
shall have access to threshold language services. Urges
services be appropriate and responsive to the needs of
all populations;
h. The right to accessibility. Requires services
and information to be easy to access. Requires, in
accordance with the federal Americans with Disabilities
Act, services to be delivered in a manner that is
physically, cognitively, and programmatically
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accessible;
i. The right to personal assistants and
caregivers. Requires the system of care to support the
role of quality paid and unpaid caregivers, including
family caregivers, and shall recognize the importance
of workforce development, caregiver needs assessment,
and the availability of training;
j. The right to independence. Requires services
across the continuum to support maximum independence,
full social integration, and quality of life;
aa. The right to grievances and appeals. Requires
participants to have access to an independent grievance
and appeals process. Requires access and resolution to
be prompt, without disruption in service delivery; and,
bb. The right to timeliness. Requires all services
and supports to be delivered in a timely manner, in
order to ensure the individual's optimal health and
functioning.
2.Requires DHCS to post the CCI Consumer Bill of Rights on its
Internet Web site, and to also provide copies to providers and
the public upon request. Requires DHCS to make the bill of
rights available to the public in prevalent languages.
3.Requires this bill to be implemented only to the extent
permitted by all of the following:
a. Applicable federal Medicare law;
b. Applicable Medi-Cal law; and,
c. The Memorandum of understanding (MOU) between
CMS and the State of California Regarding A
Federal-State Partnership to Test a Capitated Financial
Alignment Model for Medicare-Medicaid Enrollees -
California Demonstration to Integrate Care for Dual
Eligible Beneficiaries."
4.Makes legislative findings and declarations that:
a. The CCI is an innovative health care service
delivery model for Californians who are eligible for
services under both the Medi-Cal and Medicare programs;
b. Individuals eligible for services under the CCI
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represent a diverse group of older adults and persons
with disabilities, and include some of the most
vulnerable members of our population;
c. Incorporation of services from two programs
requires a variety of changes in federal and state law,
and complex contractual agreements between the state
and CMS, and between health plans and the various
administering state agencies; and,
d. A key component of the CCI is the inclusion of
comprehensive beneficiary protections, to ensure that
eligible individuals receive appropriate, safe, and
high-quality care. However, these protections are
provided for throughout the various statutes and
contractual documents that govern the establishment and
operation of the CCI.
5.States legislative intent in enacting this bill:
a. To recognize the diversity of individuals
receiving services under the CCI, and encourage
implementation of an individualized, person-centered
service delivery model.
b. The CCI Bill of Rights is intended to empower
beneficiaries to effectively participate in decisions
affecting their health care, by consolidating and
clarifying the protections afforded to them under the
CCI.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, fragmentation in
access to and delivery of CCI services has generated great
confusion among consumers both with respect to enrollment and
their rights as qualifying individuals in the program. This
bill codifies the rights of CCI individuals. By requiring the
Bill of Rights to be posted on the DHCS website and requiring
it to be disseminated in multiple languages, the bill aims to
increase consumer awareness while also recognizing the ethnic
and cultural diversity of the CCI population and promoting
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cultural and linguistic competency in delivering services.
2.CCI. The CCI is a program intended to integrate and coordinate
the delivery of health benefits, including behavioral health
benefits and LTSS to dual eligibles and SPDs living in seven
California counties: Los Angeles, Orange, Riverside, San
Bernardino, San Diego, San Mateo and Santa Clara (state law
allows for CCI implementation in eight counties, but CCI will
not be implemented in Alameda County). Goals for the CCI
include coordinating Medi-Cal benefits and Medicare benefits,
across health care settings and improving continuity of acute
care, long-term care, and home- and community-based services,
coordinating access to acute and long-term care services for
dual eligibles, maximizing the ability of dual eligibles to
remain in their homes and communities with appropriate services
and supports in lieu of institutional care, and increasing the
availability of and access to home- and community-based
alternatives. The three major components of the CCI are as
follows:
a. Cal MediConnect Program: A three-year demonstration
project designed to coordinate medical, behavioral health,
long-term institutional, and home and community-based
services (HCBS) services for dual eligibles by combining
Medicare and Medi-Cal benefits into one integrated health
plan;
b. Mandatory enrollment of dual eligibles and Medi-Cal-only
seniors and persons with disabilities into Medi-Cal managed
care; and,
c. Managed Long-Term Supports and Services (MLTSS):
Integration of nursing facility care, In-Home Supportive
Services, Community-Based Adult Services, and Multipurpose
Senior Services Program as managed care benefits.
1.Select Committee on Aging and Long Term Care Hearing. In August
2014, the Select Committee on Aging and Long Term Care held an
informational hearing entitled "California's Service Delivery
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System for Older Adults: Envisioning the Ideal." At the
hearing, one of the presenters from the SCAN Foundation
presented "California in Comparison to Other States: A Look at
the LTSS Scorecard" which was a framework for assessing LTSS
System Performance among the 50 states and the District of
Columbia. One of the five recommendations in that presentation
was that California establish a "Dual Eligible Bill of Rights"
that outlines in statute the rights of dual eligible
individuals including access to an array of services in an
integrated setting, consumer choice, and empowerment. These
rights would establish the foundation of system change efforts,
establish accountability for the health plans, and communicate
what people can expect from coordinated services that are
grounded in meeting the needs, desires, and preferences of
consumers.
2.Related legislation. AB 461 (Mullin), would authorize a
beneficiary receiving services through a regional center who
resides in the County of San Mateo to voluntarily enroll in the
CCI demonstration project, upon receipt of all legal
notifications. AB 461 passed out of the Assembly Health
Committee on April, 2015 on a vote.
3.Prior legislation.
a. SB 857 (Committee on Budget and Fiscal Review), Chapter
31, Statutes of 2014, institutes various requirements
regarding contracts and enrollment limitations on D-SNP
plans in the context of the CCI.
b. SB 1008 (Committee on Budget and Fiscal Review), Chapter
33, Statutes of 2012, establishes the main components of the
CCI, including the provisions for the Cal MediConnect
Program, mandatory Medi-Cal managed care for SPDs, and
MLTSS.
c. SB 1036 (Committee on Budget and Fiscal Review), Chapter
45, Statutes of 2012, authorizes other components of the
CCI, includes provisions that require the development and
pilot implementation of a universal assessment tool as well
as data-sharing agreements between managed care plans and
HCBS administrators.
d. SB 208 (Steinberg), Chapter 714, Statutes of 2010,
authorizes a pilot project in up to four counties, to
integrate the full range of Medicare and Medi-Cal services,
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including LTSS and behavioral health services for dual
eligible individuals.
4.Support. The Government Action and Communications Institute
(GACI) writes in support that the rules for the CCI are found
in federal law, state law, a memorandum of understanding
between the federal and state governments, and a three-party
contract among CMS, DHCS, and each participating health plans.
All of these documents are binding, and each provides
protections to consumers. However, GACI states those
protections are not easily found, nor are they expressed in
plain language. SB 492 puts the fundamental rights of CCI
consumers in one place, giving both consumers and providers a
clear summary. The United Domestic Workers/American Federal of
State, County and Municipal Employees Local 3930 (UDW/AFSCME
Local 3930) writes this bill codifies the rights of CCI
consumers and requires DHCS to post the Bill of Rights on the
DHCS website and to disseminate hard copies upon consumer
request. UDW/AFSCME Local 3930 writes this bill is needed to
provide CCI consumers with a clear sense of their rights and to
improve access to programs and services.
5.Opposition. The California Association of Health Plans (CAHP)
writes in opposition that this bill is unnecessary because
enrollees in managed care are already afforded extensive rights
in statute, regulations, and in the CCI's MOU between the DHCS
and the federal CMS. In addition to mimicking existing rights,
the rights contained in this bill are unenforceable because
they are extremely vague. CAHP members are concerned that they
will be held legally responsible for ensuring the new rights
are enforced on matters that are outside of the plans' control.
The goals contained in these rights are dependent upon all
parties involved in the program fulfilling their obligations.
For example, the list of rights includes cultural competence;
however, this phrase is undefined in the bill. This leaves
cultural competence open for interpretation with no clear
guidelines for enforcement. CAHP concludes that the
establishment of rights specifically for consumers in the CCI
creates more issues than it resolves.
6.Policy issues.
a. Language on Consumer Bill of Rights. This bill
establishes broad and generally worded rights in a new
code section in several areas where there is existing
state law, federal law, a three-way contract, and the MOU.
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To attempt to address potential conflicts between this
bill, existing state law, federal preemption of state law
related to Medicare, and the MOU, this bill contains
language that implements its provisions only to the extent
permitted by applicable federal Medicare law, applicable
Medi-Cal law, and the MOU. However, the rights in this
bill do not refer back to the underlying source of the
right or otherwise define what the right would mean in
practice. It is not clear how a consumer seeking to
enforce a right under this bill would be informed as to
the specific details of that right, or how departments
implementing this bill would enforce the rights contained
in this bill.
b. Codification of rights for consumer information. The
stated goal of the author and proponents is to codify the
existing rights of individuals enrolled in the CCI in
order to address the confusion among consumers after CCI
rollout and the lack of public awareness of existing
rights by consolidating existing rights into a simple one
page document with understandable language to consumers.
There is currently information on consumer rights and
responsibilities for individuals on CalMediConnect, but
there does not appear to be a similar document for those
individuals who are now required to receive their LTSS in
Medi-Cal managed care. Given the stated goal of providing
consumers and providers with information about their
existing consumer rights in plain language, is adding a
new code section to existing state law the best way to
meet the stated policy goal of this bill? For example, if
the goal of this bill is providing additional information
to consumers, would a better way of doing so be to require
DHCS to prepare a consumer brochure in areas in where the
existing consumer information is inadequate?
SUPPORT AND OPPOSITION :
Support: American Federation of State, County, and Municipal
Employees
California Association for Health Services at Home
California Association of Public Authorities for IHSS
California Commission on Aging
California Long-Term Care Ombudsman Association
California Primary Care Association
California Program of All-inclusive Care for the
Elderly
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California Senior Legislature
Government Action and Communications Institute
Community Clinic Association of Los Angeles County
United Domestic Workers/American Federal of State,
County and Municipal Employees Local 3930
Oppose: California Association of Health Plans
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