BILL NUMBER: SB 586 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MAY 4, 2016
AMENDED IN SENATE APRIL 28, 2015
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
14094.24 14094.4 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, 2016, 2017, except with
respect to contracts entered into for county organized health systems
or Regional Health Authority in specified counties.
This bill would exempt KIDS contracts,
contracts entered into under the Whole Child Model program,
described below, from that prohibition,
prohibition and would delete the January 1, 2016 time
limit. 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.
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.
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.
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.
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.
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.
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.
SEC. 2. 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 1
(commencing with Section 14200), or Article 7 (commencing with
Section 14490) of Chapter 8, until January 1, 2017,
2025, and until the evaluation required pursuant to
subdivision (j) of Section 14094.4 has been completed, except
for contracts entered into pursuant to the Whole Child Model
program, as described in Section 14094.4, or 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 CCS eligible 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 CCS-
eligible condition.
SEC. 3. Section 14094.4 is added to the
Welfare and Institutions Code , to read:
14094.4. (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.