Amended in Assembly May 4, 2016

Amended in Senate April 28, 2015

Senate Bill No. 586

Introduced by Senator Hernandez

(Coauthors: Assembly Members Alejo, Bonta, and Chávez)

February 26, 2015

An act to amend Section 14094.3 of, and to add Section begin delete 14094.24 end delete begin insert 14094.4 end insert to, the Welfare and Institutions Code, relating to children’s services.

LEGISLATIVE COUNSEL’S DIGEST

SB 586, as amended, 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, begin delete 2016, end delete begin insert 2017, end insert except with respect to contracts entered into for county organized health systems begin insert or Regional Health Authority end insert in specified counties.

This bill would exempt begin delete KIDS contracts, end delete begin insert contracts entered into under the Whole Child Model program, end insert described below, from that begin delete prohibition, end delete begin insert prohibition end insert and would begin delete delete the January 1, 2016 time limit. end delete begin insert extend to January 1, 2025, and until the evaluation required under the Whole Child Model program has been completed, the termination of the prohibition against CCS covered services being incorporated in a Medi-Cal managed care contract entered into after August 1, 1994. end insert

begin delete

This bill would require the department, no later than January 1, 2018, to contract with one or more Kids Integrated Delivery System (KIDS) networks, 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 network and eligibility standards, as well as the qualifications and exclusions required for KIDS network contracts. The KIDS network would be required to coordinate, integrate, and provide or arrange for the full range of Medi-Cal and CCS services.

end delete begin delete

This bill would require the department to seek all necessary federal approvals to ensure federal financial participation for expenditures under these provisions, and would prohibit implementation of these provisions 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 network 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.

end delete begin insert

The bill would authorize the department, no sooner than July 1, 2017, to establish a Whole Child Model program, under which managed care plans under county organized health systems or Regional Health Authority that elect, and are selected, to participate would provide CCS services under a capitated payment model to Medi-Cal and S-CHIP eligible CCS children and youth. The bill would limit the number of managed care plans under a county organized health system or Regional Health Authority that are eligible to participate in the program. The bill would require the department to establish an application process and would require a managed care plan to provide the department with a written application of interest that contains specified information, including evidence that the managed care plan received written support from specified individuals and entities, including CCS providers, as defined, that serve a preponderance of CCS children and youth in the county. The bill would prohibit the department from approving the application of a managed care plan until the Director of Health Care Services has verified the readiness of the managed care plan to address the unique needs of CCS-eligible beneficiaries, including, among other things, that the managed care contractor demonstrates the availability of an appropriate provider network to serve the needs of children and youth with CCS conditions and complies with all CCS program guidelines.

end insert begin insert

The bill would prohibit the department from implementing the program in any county until it has developed and implemented specific CCS monitoring and oversight standards for managed care plans. The bill would require the department to establish a statewide Whole Child Model stakeholder advisory group comprised of specified stakeholders, including representatives from health plans and family resource centers, and would require the department to consult with the Whole Child Model stakeholder advisory group on the implementation of the program, as specified. The bill would require the department to contract with an independent entity to conduct an evaluation to assess health plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the program, and would require the department to provide a report on the results of this evaluation to the Legislature no later than January 1, 2023. The bill would require the department, by July 1, 2018, to adopt regulations and, commencing July 1, 2017, would require the department to provide a status report to the Legislature until regulations have been adopted.

end insert

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

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

SECTION 1.  

The Legislature finds and declares all of the
following:

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

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

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

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

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

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

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

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

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

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

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

(5) Ensure that children with CCS-eligible conditions receive
care in the most appropriate, least restrictive setting.

(6) Maintain existing patient-provider relationships, whenever
possible.

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

begin delete

SEC. 2.  

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

14094.24.  

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

(1) “CCS tertiary hospital” means a hospital that is designated
as a tertiary hospital pursuant to the Standards for Tertiary
Hospitals set forth in the California Children’s Services Manual
of Procedures.

(2) “Kids Integrated Delivery System (KIDS)” means a network
approved by the department to coordinate and manage the provision
of Medi-Cal and CCS services for eligible children, on a county
or regional basis, consistent with managed care principles,
techniques, and practices, to ensure access to cost-effective, quality
care for enrolled children.

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

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

(B) An individual up to 26 years of age, if the individual was
previously treated for a CCS-eligible condition in the 12 months
prior to his or her 21st birthday, is eligible for full-scope Medi-Cal
services, and voluntarily chooses to remain in a KIDS network
that accepts individuals up to age 26 pursuant to its contract with
the department.

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

(b) Consistent with Sections 14093.05 and 14093.06 and the
requirements of this chapter, no later than January 1, 2018, in
counties or regions where there is no demonstration project
pursuant to Section 14094.3, the department shall select and enter
into contracts with one or more KIDS networks, to provide
comprehensive health care services to eligible children. In order
to contract with the department pursuant to this section, a KIDS
network shall meet all of the following criteria:

(1) Demonstrate experience in effectively serving eligible
children and providing services in compliance with CCS program
standards and requirements.

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

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

(4) Incorporate specific strategies to actively engage families
as partners in decisions affecting the health care and well-being
of children enrolled in the KIDS network.

(5) Be anchored by a hospital that is designated as a CCS tertiary
hospital, or by a CCS provider in partnership with a CCS tertiary
hospital.

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

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

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

(B) Benefits of the medical therapy program may be provided
or coordinated by a KIDS network, in collaboration and
consultation with the designated county CCS agency or agencies
in the KIDS network service area.

(2) Operate under a contract with the department that satisfies
the requirements of this chapter, including Sections 14093.05 and
14093.06.

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

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

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

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

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

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

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

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

(1) Children shall be deemed eligible for enrollment in a KIDS
network based on eligibility for the CCS program pursuant to
Section 14005.26, except as provided by paragraph (2).

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

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

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

(C) Pursuant to this section, and subject to necessary federal
approvals, if a KIDS network becomes newly available in a service
area, the department shall determine, in consultation with counties,
KIDS networks, local KIDS family advisory councils, and existing
Medi-Cal managed care plans in the service area, the timing and
process for enrollment in KIDS networks to ensure a smooth
transition for eligible children.

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

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

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

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

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

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

(6) A child who is enrolled in a KIDS network shall retain all
rights to CCS program appeals and fair hearings of denials of
medical eligibility or of service authorizations, as well as all due
process and fair hearing rights under the Medi-Cal program.

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

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

SEC. 3.  

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

14094.3.  

(a) Notwithstanding this article or Section 14093.05
or 14094.1, CCS covered services shall not be incorporated into
any Medi-Cal managed care contract entered into after August 1,
1994, pursuant to Article 2.7 (commencing with Section 14087.3),
Article 2.8 (commencing with Section 14087.5), Article 2.9
(commencing with Section 14088), Article 2.91 (commencing
with Section 14089), Article 2.95 (commencing with Section
14092); or either Article 2 (commencing with Section 14200), or
Article 7 (commencing with Section 14490) of Chapter 8, except
for either or both of the following:

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

(2) Contracts entered into pursuant to Section 14094.24.

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

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

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

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

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

end delete

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 14094.3 of the end insert begin insert Welfare and Institutions Code end insert

begin insert is amended to read: end insert

14094.3.  

(a) Notwithstanding this article or Section 14093.05
or 14094.1, CCS covered services shall not be incorporated into
any Medi-Cal managed care contract entered into after August 1,
1994, pursuant to Article 2.7 (commencing with Section 14087.3),
Article 2.8 (commencing with Section 14087.5), Article 2.9
(commencing with Section 14088), Article 2.91 (commencing
with Section 14089), Article 2.95 (commencing with Section
14092); or either Article 1 (commencing with Section 14200), or
Article 7 (commencing with Section 14490) of Chapter 8, until
January 1, begin delete 2017, end delete begin insert 2025, and until the evaluation required pursuant
to subdivision (j) of Section 14094.4 has been completed, end insert except
for contracts entered into begin insert pursuant to the Whole Child Model
program, as described in Section 14094.4, or end insert for county organized
health systems or Regional Health Authority in the Counties of
San Mateo, Santa Barbara, Solano, Yolo, Marin, and Napa.

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

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

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

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

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

begin insert

begin insert SEC. 3. end insert   

end insert

begin insert Section 14094.4 is added to the end insert begin insert Welfare and Institutions
Code end insert begin insert , to read: end insert

begin insert

begin insert 14094.4. end insert   

(a) For the purposes of this section, the following
definitions shall apply:

(1) “CCS Provider” means a provider that is approved by the
CCS program to treat a CCS-eligible condition pursuant to Article
5 (commencing with Section 123800) of Chapter 3 of Part 2 of
Division 106 of the Health and Safety Code.

(2) “County organized health system” or “COHS” means a
county organized health system contracting with the department
to provide Medi-Cal services to beneficiaries pursuant to Article
2.8 (commencing with Section 14087.5).

(3) “Whole Child Model site” means a managed care plan
under a county organized health system or Regional Health
Authority that is selected to participate in the Whole Child Model
program under a capitated payment model.

(b) The department may establish a Whole Child Model program
for Medi-Cal and S-CHIP eligible CCS children and youth enrolled
in a managed care plan under a county organized health system
or Regional Health Authority in up to __ counties no sooner than
July 1, 2017.

(c) The goals for the Whole Child Model program for children
and youth under 21 years of age who meet the eligibility
requirements of Section 123805 of the Health and Safety Code
and are enrolled in a managed care plan under a county organized
health system or Regional Health Authority shall include all of
the following:

(1) Improving the coordination of primary and preventive
services with specialty care services, medical therapy units, Early
and Periodic Screening, Diagnosis, and Treatment (EPSDT),
long-term services and supports (LTSS), and regional center
services, and home- and community-based services using a child
and youth and family-centered approach.

(2) Maintaining or exceeding CCS program standards and
specialty care access, including access to appropriate
subspecialties.

(3) Ensuring the continuity of child and youth access to expert,
CCS dedicated case management and care coordination, provider
referrals, and service authorizations through contracting with or
the employment of county CCS staff to perform these functions.

(4) Improving the transition of youth from CCS to adult
Medi-Cal managed systems of care through better coordination
of medical and nonmedical services and supports and improved
access to appropriate adult providers for youth who age out of
CCS.

(5) Identifying, tracking, and evaluating the transition of
children and youth from CCS to the Whole Child Model program
to inform future CCS program improvements.

(d) (1) No sooner than July 1, 2017, the department shall
establish an application process by which up to __ managed care
plans under a county organized health system, including the county
organized health systems and Regional Health Authority that have
incorporated CCS covered services into their contracts pursuant
to Section 14094.3, may participate in the Whole Child Model
program established under this section, pursuant to the criteria
described in this section. The director shall consult with the
Legislature, the federal Centers for Medicare and Medicaid
Services, counties, CCS providers, and CCS families when
determining the implementation date for this section.

(2) In order to apply to become a Whole Child Model site, a
managed care plan under a county organized health system or
Regional Health Authority shall provide a written application of
interest that provides the director with evidence of all of the
following:

(A) Written approval by the county board of supervisors to
partner with the managed care plan for the integration of CCS
medical and case management and service authorizations for CCS
Medi-Cal beneficiaries into the managed care plan.

(B) Written support from the local bargaining units representing
affected CCS worker classifications.

(C) Written support from CCS providers that serve a
preponderance of the CCS children and youth in the county, home-
and community-based services networks, and the regional center
or centers that serve CCS children and youth in that county.

(D) Establishment and demonstration of a local stakeholder
process with the meaningful engagement of a diverse group of
families that represent a range of conditions, disabilities, and
demographics, and local providers, including, but not limited to,
the parent centers, such as family resource centers, family
empowerment centers, and parent training and information centers,
that support families in the affected county.

(E) Written support from the family resource center or family
empowerment center serving the affected county.

(3) The department shall post its written approval of an
application of interest on its Internet Web site at least 90 days
before CCS services are incorporated into the managed care plan
under the Whole Child Model program pursuant to this section.

(e) A managed care plan shall not be approved to participate
in the Whole Child Model program unless all of the following
conditions have been satisfied:

(1) The managed care plan has obtained written approval from
the director of its application of interest.

(2) The department has obtained all necessary federal approvals
and waivers.

(3) The director has verified the readiness of the managed care
plan to address the unique needs of CCS-eligible beneficiaries,
including, but not limited to, the requirements set forth in
subdivision (b) of Section 14087.48, subdivisions (b) to (f),
inclusive, of Section 14093.05, and all of the following:

(A) Timely and appropriate communication with affected
CCS-eligible children and youth and their parents or guardians.
Communication shall be tested for readability by a health literacy
and readability professional and targeted at a 6th grade reading
level. Plan communications to families and providers shall also
be shared with the plan’s local family advisory group established
pursuant to clause (xx) of subparagraph (E) for feedback and
approval.

(B) That the managed care contractor demonstrates the
availability of an appropriate provider network to serve the needs
of children and youth with CCS conditions, including primary care
physicians, pediatric specialists and subspecialists, professional,
allied, and medical supportive personnel, and an adequate number
of accessible facilities within each CCS service area.

(C) That the managed care contractor has established and
maintains an updated and accessible listing of providers and their
specialties and subspecialties and makes it available to
CCS-eligible children and youth and their parents or guardians,
at a minimum by phone, written material, and Internet Web site.

(D) That the managed care contractor has entered into an
agreement with the county CCS program or the state, or both, for
the provision of CCS care coordination and service authorization
and how the plan will work with the CCS program to ensure
continuity and consistency of CCS program expertise for that role,
in accordance with this section.

(E) That the managed care contractor serving children and
youth with CCS-eligible conditions under the CCS program shall
do all of the following:

(i) Comply with continuity of care requirements in Section
1373.96 of the Health and Safety Code and Section 14185.

(ii) Coordinate with each regional center operating within the
plan’s service area to assist CCS-eligible children and youth with
developmental disabilities and their families in understanding and
accessing services and act as a central point of contact for
questions, access and care concerns, and problem resolution.

(iii) Coordinate with the local CCS Medical Therapy Unit
(MTU) to ensure appropriate access to MTU services.

(iv) Create and maintain a clinical advisory committee
composed of the managed care contractor’s Chief Medical Officer,
the county CCS medical director, and at least four CCS-paneled
providers to review treatment authorizations and other clinical
issues relating to CCS conditions.

(v) (I) Establish and maintain a process by which families may
maintain access to any CCS providers for up to the length of the
child’s or youth’s CCS qualifying condition or 12 months,
whichever is longer, under the following conditions:

(ia) The CCS-eligible child or youth has an ongoing relationship
with a provider who is a CCS-approved provider.

(ib) The provider will accept the health plan’s rate for the
service offered or the applicable Medi-Cal or CCS fee-for-service
rate, whichever is higher.

(ic) The managed care plan determines that the provider meets
applicable CCS standards and has no disqualifying quality of care
issues, in accordance with guidance from the department, including
all-plan letters and CCS numbered letters or other administrative
communication.

(id) The provider shall provide treatment information to the
health plan, to the extent authorized by the state and federal patient
privacy provisions.

(II) This clause shall apply to out-of-network and out-of-county
primary care and specialist providers.

(III) A managed care plan, at its discretion, may extend the
continuity of care period beyond the length of time specified in
this clause.

(vi) Facilitate communication among a CCS child’s or youth’s
health care and personal care providers, including in-home
supportive services and behavioral health providers, when
appropriate, with the CCS-eligible child or youth, parent, or
guardian.

(vii) Facilitate timely access to primary care, specialty care,
medications, and other health services needed by the CCS child
or youth, including referrals to address any physical or cognitive
barriers to access.

(viii) Provide training for families about managed care
processes and how to navigate a health plan, including their rights
to appeal any service denials. The managed care plan shall partner
with a family empowerment center or family resource center in its
service area to provide this training.

(ix) Provide a mechanism for a CCS-eligible child’s and youth’s
parent or caregiver to request a specialist or clinic as a primary
care provider. A specialist or clinic may serve as a primary care
provider if the specialist or clinic agrees to serve in a primary
care provider role and is qualified to treat the required range of
CCS-eligible conditions of the CCS child or youth.

(x) Provide that communication to, and services for, the
CCS-eligible children or youth and their families are available in
alternative formats that are culturally, linguistically, and physically
appropriate through means, including, but not limited to, assistive
listening systems, sign language interpreters, captioning, written
communication, plain language, and written translations in at
least the Medi-Cal threshold languages.

(xi) Provide that materials are available and provided to inform
CCS children and youth and their families of procedures for
obtaining CCS specialty services and Medi-Cal primary care and
mental health benefits, including grievance and appeals procedures
that are offered by the managed care plan or are available through
the Medi-Cal program.

(xii) Identify and track children and youth with CCS-eligible
conditions for the duration of the child’s or youth’s participation
in the Whole Child Model program and for children and youth
who age into adult Medi-Cal systems, for at least 10 years into
adulthood.

(xiii) Provide timely processes for accepting and acting upon
complaints, grievances, and disenrollment requests, including
procedures for appealing decisions regarding coverage or benefits.
The grievance process shall comply with Section 14450, and
Sections 1368 and 1368.01 of the Health and Safety Code.

(xiv) Establish an assessment process that, at a minimum, does
all of the following:

(I) Ensures that families have access to ongoing information,
education, and support so they understand the care plan, course
of treatment, and expected outcomes for their child or youth, the
assessment process, what it means, their role in the process, and
what services their child or youth may be eligible for.

(II) Assesses each CCS child’s or youth’s risk level and needs
by performing a risk assessment process using means such as
telephonic or in-person communication, review of utilization and
claims processing data, or by other means as determined by the
department. The risk assessment process shall be performed in
accordance with all applicable federal and state laws.

(III) Assesses, in accordance with the agreement with the county
CCS program specified in paragraph (3) of subdivision (b), the
care needs of CCS-eligible children and youth and coordinates
their CCS specialty services, Medi-Cal primary care services,
mental health and behavioral health benefits, and regional center
services across all settings, including coordination of necessary
services within and, when necessary, outside of the managed care
health plan’s provider network.

(IV) Reviews historical CCS fee-for-service utilization data for
CCS-eligible children and youth upon transition of CCS services
to managed care contractors so that the managed care plans are
better able to assist CCS-eligible children and youth and prioritize
assessment and care planning.

(V) Follows timeframes for reassessment of risk pursuant to
this clause and, if necessary, circumstances or conditions that
require redetermination of risk level, which shall be set by the
department.

(xv) Work with the state or county CCS program, as appropriate,
to ensure that, at a minimum, and in addition to other statutory
and contractual requirements, care coordination and care
management activities do all of the following:

(I) Reflect a CCS child or youth family-centered, outcome-based
approach to care planning.

(II) Ensure families have access to ongoing information,
education, and support so that they understand the vision of care
for their child or youth and their role in the individual care
process, the benefits of mental health services, what
self-determination means, and what services might be available.

(III) Adhere to the CCS child’s or youth’s or the CCS child’s
or youth’s family’s determination about the appropriate
involvement of his or her medical providers and caregivers,
according to the federal Health Insurance Portability and
Accountability Act of 1996 (Public Law 104-191).

(IV) Are developed for the CCS child or youth across CCS
specialty services, Medi-Cal primary care services, mental health
and behavioral health benefits, regional center services, MTUs,
and in-home supportive services (IHSS), including transitions
among levels of care and between service locations.

(V) Include individual care plans for CCS-eligible children and
youth based on the results of the risk assessment process with a
particular focus on CCS specialty care.

(VI) Consider behavioral health needs of CCS-eligible children
and youth and coordinate those services with the county mental
health department as part of the CCS child’s or youth’s individual
care plan, when appropriate, and facilitate a CCS child’s or
youth’s ability to access appropriate community resources and
other agencies, including referrals, as necessary and appropriate,
for behavioral services, such as mental health services.

(VII) Ensure that children and youth and their families have
appropriate access to transportation and other support services
necessary to receive treatment.

(xvi) Incorporate all of the following into the CCS child’s or
youth’s plan of care patterns and processes:

(I) Access for families so that families know where to go for
ongoing information, education, and support in order that they
understand the goals, treatment plan, and course of care for their
child or youth and their role in the process, what it means to have
primary or specialty care for their child or youth, when it is time
to call a specialist, primary, urgent care, or emergency room, what
an interdisciplinary team is, and what the community resources
are.

(II) A primary or specialty care physician who is the primary
clinician for the CCS-eligible child or youth and who provides
core clinical management functions.

(III) Care management and care coordination for the
CCS-eligible child or youth across the health care system,
including transitions among levels of care and interdisciplinary
care teams.

(IV) Provision of referrals to qualified professionals, community
resources, or other agencies for services or items outside the scope
of responsibility of the managed care health plan.

(V) Use of clinical data to identify CCS-eligible children or
youth at the care site with chronic illness or other significant health
issues.

(VI) Timely preventive, acute, and chronic illness treatment of
CCS-eligible children or youth in the appropriate setting.

(VII) Use of clinical guidelines or other evidence-based medicine
when applicable for treatment of the CCS-eligible child’s or
youth’s health care issues or timing of clinical preventive services.

(xvii) Comply with all CCS program guidelines, including CCS
program regulations, CCS numbered letters, and CCS program
information notices.

(xviii) Base treatment decisions for CCS-related conditions on
CCS program guidelines or, if those guidelines do not exist, on
treatment protocols or recommendations of the national pediatric
specialty society with expertise in the condition.

(xix) Establish a mechanism to provide information, education,
and peer support to parents of CCS-eligible children and youth
through parent-to-parent liaisons or relationships with local family
resource centers or family empowerment centers.

(xx) Establish a family advisory group for CCS families. Family
representatives who serve on this advisory group shall receive
ongoing information and training, travel reimbursement, child
care, and other financial assistance as appropriate to enable
participation in the advisory group. A representative of this local
group shall serve on the department’s statewide stakeholder
advisory group established pursuant to subdivision (i).

(xxi) Reimburse providers at rates sufficient to recruit and retain
qualified providers with appropriate CCS expertise. Managed care
plans shall pay physician and surgeon provider services at rates
that are equal to or exceed the applicable CCS fee-for-service
rates.

(xxii) Utilize only appropriately credentialed CCS-paneled
providers to treat CCS conditions.

(xxiii) Utilize a provider dispute resolution process that meets
the standards established under Section 1371.38 of the Health and
Safety Code.

(xxiv) Annually publicly report on the number of CCS-eligible
children and youth served in their county by type of condition and
services used and the number of youth who aged out of the CCS
program by type of condition.

(f) The department shall pay any managed care plan
participating in the Whole Child Model program a separate,
actuarially sound rate specifically for CCS children and youth.
When contracting with managed care plans, the department may
allow the use of risk corridors or other methods to appropriately
mitigate a plan’s risk for this population.

(g) In implementing this section, the department may alter the
medical home elements described in clause (xvi) of subparagraph
(E) of paragraph (3) of subdivision (e) as necessary to secure the
increased federal financial participation associated with the
provision of medical assistance in conjunction with a health home,
as made available under the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and codified in Section 1945 of Title XIX
of the federal Social Security Act. The department shall notify the
appropriate policy and fiscal committees of the Legislature of its
intent to alter medical home elements under this section at least
five days in advance of taking this action.

(h) The department shall not implement the Whole Child Model
program in any county until it has developed and implemented
specific CCS program monitoring and oversight standards for
managed care plans that are subject to this section, including
access monitoring, quality measures, and ongoing public data
reporting. The department shall work with the stakeholder advisory
group established pursuant to subdivision (i) to develop and
implement robust monitoring processes to ensure that managed
care plans are in compliance with all of the provisions of this
section. The department shall monitor managed care plan
compliance with the provisions of this section on at least an annual
basis and post all monitoring data on its Internet Web site within
90 days.

(i) The department shall establish a statewide Whole Child
Model stakeholder advisory group, comprised of representatives
of CCS providers, county CCS program administrators, health
plans, family resource centers, family empowerment centers, CCS
case managers, CCS MTUs, and a representative from each of the
local family advisory groups established pursuant to clause (xx)
of subparagraph (E) of paragraph (3) of subdivision (e). The
department shall consult with the stakeholder advisory group on
the implementation of the Whole Child Model and shall incorporate
the recommendations of the stakeholder advisory group in
developing the monitoring processes and outcome measures by
which the Whole Child Model plans shall be monitored and
evaluated.

(j) The department shall contract with an independent entity
that has experience in performing robust program evaluations to
conduct an evaluation to assess health plan performance and the
outcomes and the experience of CCS-eligible children and youth
participating in the Whole Child Model program, including access
to primary and specialty care, and youth transitions from Whole
Child Model program to adult Medi-Cal coverage, and shall
provide a report on the results of this evaluation to the Legislature
by no later than January 1, 2023. A report submitted to the
Legislature pursuant to this subdivision shall be submitted in
compliance with Section 9795 of the Government Code. The
department shall consult with stakeholders, including, but not
limited to, the Whole Child Model stakeholder advisory group,
regarding the scope and structure of the review. This evaluation,
at a minimum, shall compare the performance of the plans
participating in the Whole Child Model program to the
performance of the CCS program in counties where CCS is not
incorporated into managed care and collect appropriate data to
evaluate whether the inclusion of CCS services in a managed care
delivery system improves access to care, quality of care, and the
patient experience by analyzing all of the following by the child’s
or youth’s race, ethnicity, and primary language spoken at home:

(1) Access to specialty and primary care, and in particular,
utilization of CCS-paneled providers.

(2) The level of compliance with CCS clinical guidelines and
the recommended guidelines of the American Academy of
Pediatrics.

(3) The type and location of CCS services and, with respect to
health plans that have CCS services incorporated in their contracts,
the extent to which CCS services are provided in-network
compared to out of network.

(4) Utilization rates of inpatient admissions, outpatient services,
durable medical equipment, behavioral health services, home
health, pharmacy, and other ancillary services.

(5) Patient and family satisfaction.

(6) Appeals, grievances, and complaints.

(7) Authorization of CCS-eligible services.

(8) Access to adult providers, support, and ancillary services
for youth who have aged into adult Medi-Cal coverage from the
Whole Child Model program.

(9) For health plans with CCS incorporated into their contracts,
network and provider participation, including participation of
pediatricians, pediatric specialists, and pediatric subspecialists,
by specialty and subspecialty.

(k) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department, without taking regulatory action, shall implement,
interpret, or make specific this article, Article 2.97 (commencing
with Section 14093), Article 2.98 (commencing with Section
14094), and any applicable federal waivers and state plan
amendments by means of all-county letters, plan letters, CCS
numbered letters, plan or provider bulletins, or similar instructions
until the time regulations are adopted. By July 1, 2018, the
department shall adopt regulations in accordance with the
requirements of Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code.
Commencing July 1, 2017, the department shall provide a status
report to the Legislature on a semiannual basis, in compliance
with Section 9795 of the Government Code, until regulations have
been adopted.

end insert