Senate BillNo. 586


Introduced by Senator Hernandez

February 26, 2015


An act to amend Section 14094.3 of, and to add Section 14094.24 to, the Welfare and Institutions Code, relating to children’s services.

LEGISLATIVE COUNSEL’S DIGEST

SB 586, as introduced, Hernandez. Children’s services.

The California Children’s Services Program (CCS program) is a statewide program providing medically necessary services required by physically handicapped children whose parents are unable to pay for those services. The State Department of Health Care Services administers the CCS program. Counties, based on population size, are also charged with administering the program, either independently or jointly with the department. The services covered by the CCS program include expert diagnosis, medical treatment, surgical treatment, hospital care, physical therapy, occupational therapy, special treatment, materials, and the supply of appliances and their upkeep, maintenance, and transportation. Funding for the program comes from county, state, and federal sources. In order to be eligible for the CCS program, an applicant must be under 21 years of age, have or be suspected of having a condition covered by the program, and meet certain financial eligibility standards established by the department.

Existing law prohibits services covered by the California Children’s Services program (CCS) from being incorporated into a Medi-Cal managed care contract entered into after August 1, 1994, until January 1, 2016, except with respect to contracts entered into for county organized health systems in specified counties.

This bill would exempt KIDS contracts, described below, from that prohibition, and would delete the January 1, 2016 time limit.

This bill would require the department, no later than January 1, 2018, to contract with one or more Kids Integrated Delivery System (KIDS) plans, as defined, for the purpose of coordinating and managing the provision of Medi-Cal and CCS program services to eligible children, to ensure access to cost-effective quality care. The bill would define “eligible child” and other relevant terms in this regard. The bill would establish criteria the department would be required to consider in selecting a KIDS plan and eligibility standards, as well as the qualifications and exclusions required for KIDS plan contracts. The KIDS plan would be required to coordinate, integrate, and provide or arrange for the full range of Medi-Cal and CCS services.

This bill would require the department to seek all necessary federal approvals to ensure federal financial participation for expenditures under the bill and would prohibit implementation of the bill until federal financial participation is obtained. The bill would additionally authorize the department to seek federal approval to require all eligible children to enroll in an available KIDS plan for the length of their CCS eligibility plus 6 months, and if the child remains eligible for Medi-Cal, for up to 12 months following termination of CCS eligibility.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

P2    1

SECTION 1.  

The Legislature finds and declares all of the
2following:

3(a) The California Children’s Services (CCS) program is the
4nation’s oldest Title V Maternal and Child Health Services Block
5Grant program.

6(b) The CCS program has provided critical access to specialized
7medical care for California’s most complex and fragile pediatric
8patients since 1927.

9(c) The strong standards and credentialing created under the
10CCS program ensure that eligible children obtain care from
11experienced providers with appropriate pediatric-specific expertise.

12(d) CCS providers form a regional backbone for all specialty
13pediatric care in California, benefitting children of every income
14level and insurance status.

P3    1(e) Over the past 20 years, coordinated and integrated health
2care delivery models have been shown to improve delivery of
3health care, reduce costs, and improve outcomes.

4(f) As California expanded the reach of integrated delivery
5systems in Medi-Cal, CCS services were often excluded from
6managed care arrangements in recognition of the specialty nature
7of CCS services and the complicated health status of enrolled
8children.

9(g) Accordingly, it is the intent of the Legislature to modernize
10the CCS program, through development of specialized integrated
11delivery systems focused on the unique needs of CCS-eligible
12children, to accomplish the following:

13(1) Improve coordination and integration of services to meet
14the needs of the whole child, not just address the CCS-eligible
15condition.

16(2) Retain CCS program standards to maintain access to
17high-quality specialty care for eligible children.

18(3) Support active participation by parents and families, who
19are frequently the primary caregivers for CCS-eligible children.

20(4) Established specialized programs to manage and coordinate
21the care of CCS-enrolled children.

22(h) It is further the intent of the Legislature to protect the unique
23access to pediatric specialty services provided by CCS while
24promoting modern organized delivery systems to meet the medical
25care needs of eligible children.

26

SEC. 2.  

Section 14094.24 is added to the Welfare and
27Institutions Code
, to read:

28

14094.24.  

(a) The following definitions shall apply for
29purposes of this section:

30(1) “Children’s hospital” means a hospital identified in Sections
3110727 and 10728.

32(2) “Kids Integrated Delivery System (KIDS)” means an entity
33selected by the department to coordinate and manage the provision
34of Medi-Cal and CCS services for eligible children, on a county
35or regional basis, consistent with managed care principles,
36techniques, and practices, to ensure access to cost-effective, quality
37care for enrolled children. A KIDS plan may include either of the
38following organizational models:

39(A) An entity coordinated through a children’s hospital with a
40shared governance structure comprised of providers who are held
P4    1jointly accountable for achieving measured quality improvements
2and reductions in the rate of spending growth for Medi-Cal services
3for enrolled children.

4(B) An entity coordinated by a CCS-approved provider with a
5shared governance structure comprised of providers, including
6participation by at least one children’s hospital, who are held jointly
7accountable for achieving measured quality improvements and
8reductions in the rate of spending growth for Medi-Cal services
9for enrolled children.

10(3) “Eligible child” means either of the following:

11(A) A minor child under 21 years of age, who is eligible for
12both Medi-Cal and the California Children’s Services Program
13(Article 5 (commencing with Section 123800) of Chapter 3 of Part
142 of Division 106 of the Health and Safety Code), excluding those
15children eligible under the program for neonatal intensive care
16services.

17(B) An individual up to 26 years of age, if the individual was
18previously treated for a CCS-eligible condition in the twelve
19months prior to his or her 21st birthday, is eligible for full-scope
20Medi-Cal services, and voluntarily chooses to remain in a KIDS
21plan that accepts individuals up to age 26 pursuant to its contract
22with the department.

23(4) “Enrollee” means an eligible child enrolled in a KIDS plan
24and who receives Medi-Cal and CCS services through the KIDS
25plan.

26(b) Consistent with Sections 14093.05 and 14093.06 and the
27requirements of this chapter, no later than January 1, 2018, in
28counties or regions where there is no demonstration project
29pursuant to Section 14094.3, the department shall select and enter
30into contracts with one or more KIDS plans, to provide
31comprehensive health care services to eligible children. In the
32selection process, the department shall give special consideration
33to entities that meet all of the following criteria:

34(1) Demonstrates experience in effectively serving eligible
35children and providing services in compliance with CCS program
36standards and requirements.

37(2) Includes in the KIDS plan a sufficient number of
38CCS-paneled providers, including board-certified pediatricians,
39CCS-approved special care centers, and other providers who have
40been providing services to eligible children in the proposed KIDS
P5    1plan service area to ensure continuity of care, timely access to
2quality services, and the least disruption to existing patient-provider
3relationships.

4(3) Develops the KIDS plan through a local collaborative
5stakeholder process that includes, but is not limited to, families of
6eligible children, local consumer advocates, CCS providers, and
7staff of the CCS program in the county or counties in the proposed
8KIDS plan service area.

9(4) Incorporates specific strategies to actively engage families
10as partners in decisions affecting the health care and well-being
11of children enrolled in the KIDS plan.

12(c) A KIDS plan shall do all of the following:

13(1) Contract with the department to coordinate, integrate, and
14provide or arrange for the full range of Medi-Cal and CCS services
15to eligible children enrolled in the KIDS plan pursuant to this
16subdivision.

17(A) A KIDS plan contract shall exclude, at a minimum, specialty
18mental health services provided by county mental health plans and
19neonatal intensive care services. A KIDS contract may exclude
20other Medi-Cal services, as determined by the department,
21including, but not limited to, long-term care, transplantation, and
22dental services.

23(B) Benefits of the Medical Therapy Program may be provided
24or coordinated by a KIDS plan, in collaboration and consultation
25with the designated county CCS agency or agencies in the KIDS
26plan service area.

27(2) Operate under a contract with the department that satisfies
28the requirements of this chapter, including Sections 14093.05 and
2914093.06.

30(3) Provide services to enrollees through a team-based,
31patient-centered health home model, ensure that enrolled children
32receive services in the most appropriate and least restrictive setting,
33and adopt effective strategies to manage and coordinate care and
34services for enrolled children.

35(4) Report and comply with quality measures, including, but
36not limited to, Medi-Cal Healthcare Effectiveness Data and
37Information Set (HEDIS) measures appropriate for enrolled
38children, the national Pediatric Quality Measurement System
39(PQMS) for children’s hospitals, and other quality measures
40developed by the department in consultation with stakeholders.

P6    1(5) Participate in a nationally recognized pediatric patient safety
2organization.

3(6) Comply with readiness criteria, network adequacy standards,
4and other appropriate standards applicable to Medi-Cal managed
5care plans, as determined by the department in consultation with
6stakeholders, and any terms of the federal approvals obtained by
7the department.

8(7) Establish and maintain a family advisory council composed
9of families of eligible children and convene the advisory council
10at least quarterly.

11(d) (1) Contracts with KIDS plans may include opportunities
12to share in the risk of providing services to KIDS enrollees,
13pursuant to an agreement between the department and the KIDS
14plan. Any shared savings that result from the implementation of
15these arrangements shall be reinvested in services provided to
16children enrolled in the KIDS plan.

17(2) The department shall not enter into risk-sharing arrangements
18with a KIDS plan for specific covered services unless the KIDS
19plan is responsible for the management and authorization of those
20services.

21(3) Payments to a KIDS plan that agrees to accept risk-sharing
22shall be actuarially sound.

23(e) Eligibility for enrollment in a KIDS plan shall be determined
24in accordance with all of the following:

25(1) Children shall be deemed eligible for enrollment in a KIDS
26plan based on eligibility for the CCS program pursuant to Section
2714005.26, except as provided by paragraph (2).

28(2) A child receiving neonatal intensive care unit (NICU)
29services shall not be eligible for enrollment until the child is
30discharged from the NICU and meets the other requirements of
31this subdivision.

32(3) (A) To the extent that the department obtains federal
33approval to require eligible children to enroll in an available KIDS
34plan in order to receive Medi-Cal and CCS services, eligible
35children shall be enrolled on a mandatory basis pursuant to this
36section and the provisions of this chapter applicable to Medi-Cal
37managed care plan enrollments.

38(B) Enrollment in a KIDS plan shall be, at a minimum, for the
39period of a child’s CCS eligibility plus an additional six months,
40provided that the child remains eligible for Medi-Cal. KIDS plan
P7    1enrollees who continue to remain eligible for Medi-Cal may remain
2in the KIDS plan for up to 12 months following the termination
3of CCS eligibility if the KIDS program and the parent, guardian
4or person responsible for care of the child agree that it is in the
5best interests of the child.

6(C) Pursuant to this section, and subject to necessary federal
7approvals, if a KIDS plan becomes newly available in a service
8area, or if a child becomes newly eligible for a KIDS plan, the
9child shall be enrolled in the available KIDS plan. The department
10shall determine, in consultation with counties, KIDS plans, local
11KIDS family advisory councils, and existing Medi-Cal managed
12care plans in the service area and the timing and process for
13enrollment in KIDS plans to ensure a smooth transition for eligible
14children.

15(D) If there is more than one KIDS plan in the county or region
16in which the child lives, the parent, guardian, or person responsible
17for the care of the eligible child may select the KIDS plan in which
18the child will be enrolled. If the family does not select a KIDS
19plan, the child shall be assigned to a KIDS plan in a manner that
20ensures the least disruption in existing patient-provider
21relationships.

22(E) Upon enrollment of an eligible child in a KIDS plan, the
23parent, guardian, or person responsible for the care of the child
24shall be informed that the child may choose to continue an
25established patient-provider relationship if his or her treating
26provider is a primary care provider or clinic contracting with the
27KIDS, has the available capacity, and agrees to continue to treat
28that eligible child. KIDS plans shall comply with the continuity
29of care requirements in Section 1373.96 of the Health and Safety
30Code.

31(4) Within 30 days of notice that a child is no longer eligible
32for a KIDS plan pursuant to this section, a child who continues to
33be eligible for Medi-Cal shall be enrolled in the Medi-Cal delivery
34system in the county in which he or she resides. The department
35shall ensure that families receive information about the Medi-Cal
36delivery systems available in their county and the process for
37enrolling in and selecting among the available options. Children
38disenrolling from a KIDS plan because they are no longer eligible
39shall be enrolled in county Medi-Cal delivery systems as follows:

P8    1(A) If there is a Medi-Cal managed care plan in the county of
2the child’s residence, the child shall be enrolled in the managed
3care plan. In counties where there is more than one Medi-Cal
4managed care plan, if the family does not choose a plan for the
5child within 30 days of notice of disenrollment from the KIDS,
6the child shall be enrolled into the Medi-Cal managed care health
7plan that contains his or her primary care provider. If the primary
8care provider participates in more than one managed care health
9plan in the county, the child shall be assigned to one of the health
10plans containing his or her primary care provider in accordance
11with the assignment process applicable in the county.

12(B) In a county that is not a managed care county, children no
13longer eligible for the KIDS plan shall be provided services under
14the Medi-Cal fee-for-service delivery system.

15(5) The department shall instruct KIDS plans, counties, and
16managed care plans, by means of all-county and all-plan letters or
17similar instruction, as to the processes to be used to enroll and
18disenroll children in KIDS plans and to re-enroll eligible children
19in local Medi-Cal coverage options, to ensure each child
20experiences a smooth transition among coverage types with no
21gap in coverage or care.

22(6) A child who is enrolled in a KIDS plan shall retain all rights
23to CCS program appeals and fair hearings of denials of medical
24eligibility or of service authorizations.

25(f) The department shall seek all necessary federal approvals to
26ensure federal financial participation in expenditures under this
27section. This section shall not be implemented until necessary
28federal approvals have been obtained.

29(g) The department may seek federal approval to require all
30eligible children to enroll in an available KIDS plan during the
31length of their eligibility for CCS plus an additional six months,
32and, if the child remains eligible for Medi-Cal, to voluntarily
33remain in the KIDS for up to 12 months following termination of
34CCS eligibility.

35

SEC. 3.  

Section 14094.3 of the Welfare and Institutions Code
36 is amended to read:

37

14094.3.  

(a) Notwithstanding this article or Section 14093.05
38or 14094.1, CCS covered services shall not be incorporated into
39any Medi-Cal managed care contract entered into after August 1,
401994, pursuant to Article 2.7 (commencing with Section 14087.3),
P9    1Article 2.8 (commencing with Section 14087.5), Article 2.9
2(commencing with Section 14088), Article 2.91 (commencing
3with Section 14089), Article 2.95 (commencing with Section
414092); or either Article 2 (commencing with Section 14200), or
5Article 7 (commencing with Section 14490) of Chapter 8,begin delete until
6January 1, 2016,end delete
except forbegin delete contracts entered into for county
7organized health systems or Regional Health Authority in the
8Counties of San Mateo, Santa Barbara, Solano, Yolo, Marin, and
9Napa.end delete
begin insert either or both of the following:end insert

begin insert

10(1)  Contracts entered into for county organized health systems
11or Regional Health Authority in the Counties of San Mateo, Santa
12Barbara, Solano, Yolo, Marin, and Napa.

end insert
begin insert

13(2) Contracts entered into pursuant to Section 14094.24.

end insert

14(b) Notwithstanding any other provision of this chapter,
15providers serving children under the CCS program who are enrolled
16with a Medi-Cal managed care contractor but who are not enrolled
17in a pilot project pursuant to subdivision (c) shall continue to
18submit billing for CCS covered services on a fee-for-service basis
19until CCS covered services are incorporated into the Medi-Cal
20managed care contracts described in subdivision (a).

21(c) (1) The department may authorize a pilot project in Solano
22County in which reimbursement for conditions eligible under the
23CCS program may be reimbursed on a capitated basis pursuant to
24Section 14093.05, and provided all CCS program’s guidelines,
25standards, and regulations are adhered to, and CCS program’s case
26management is utilized.

27(2) During the time period described in subdivision (a), the
28department may approve, implement, and evaluate limited pilot
29projects under the CCS program to test alternative managed care
30models tailored to the special health care needs of children under
31the CCS program. The pilot projects may include, but need not be
32limited to, coverage of different geographic areas, focusing on
33certain subpopulations, and the employment of different payment
34and incentive models. Pilot project proposals from CCS
35program-approved providers shall be given preference. All pilot
36projects shall utilize CCS program-approved standards and
37providers pursuant to Section 14094.1.

38(d) For purposes of this section, CCS covered services include
39all program benefits administered by the program specified in
P10   1Section 123840 of the Health and Safety Code regardless of the
2funding source.

3(e) Nothing in this section shall be construed to exclude or
4restrict CCS eligible children from enrollment with a managed
5care contractor, or from receiving from the managed care contractor
6with which they are enrolled primary and other health care
7unrelated to the treatment of the CCS eligible condition.



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