Amended in Assembly June 8, 2016

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 begin delete Section 14094.4 to, end delete begin insert Article 2.985 (commencing with Section 14094.4) to Chapter 7 of Part 3 of Division 9 of, end insert 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 begin delete Program (CCS program) end delete begin insert (CCS) program end insert 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 begin delete California Children’s Services end delete begin insert CCS end insert program begin delete (CCS) end delete from being incorporated into a Medi-Cal managed care contract entered into after August 1, 1994, until January 1, 2017, except with respect to contracts entered into for county organized health systems or Regional Health Authority in specified counties.

This bill would exempt contracts entered into under the Whole Child Model program, described below, from that prohibition and would 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.

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 begin delete S-CHIP end delete begin insert State Children’s Health Insurance Program (S-CHIP) end insert 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. begin insert This bill would provide that its provisions are not intended to permit any reduction in benefits or eligibility levels under the existing CCS program. end insert 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. begin insert The bill would authorize the Director of Health Care Services to end insert begin insert enter into exclusive or nonexclusive contracts on a bid, nonbid, or negotiated basis and end insert begin insert amend existing managed care contracts to provide or arrange for services provided under the bill. 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.

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, 2025, and until the evaluation required pursuant to
begin delete subdivision (j) of Section 14094.4 end delete begin insert Section 14094.18 end insert has been
completed, except for contracts entered into pursuant to the Whole
Child Model program, as described in begin delete Section 14094.4, end delete begin insert Article
2.985 (commencing with Section 14094.4), end insert 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 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.

begin delete

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.

end delete

begin insert

begin insert SEC. 3. end insert   

end insert

begin insert Article 2.985 (commencing with Section 14094.4) is
added to Chapter 7 of Part 3 of Division 9 of the end insert begin insert Welfare and
Institutions Code end insert begin insert , to read: end insert

begin insert

 

Article begin insert 2.985. end insert   Whole Child Model Program

 

begin insert 14094.4. end insert   

For the purposes of this article, the following
definitions shall apply:

(a) “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.

(b) “County organized health system” or “COHS” means:

(1) 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).

(2) A regional health authority.

(c) “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.

(d) “Medi-Cal managed care plan” means a COHS.

begin insert 14094.5. end insert   

No sooner than July 1, 2017, the department may
establish a Whole Child Model program for Medi-Cal and State
Children’s Health Insurance Program (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.

begin insert 14094.6. end insert   

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:

(a) 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.

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

(c) 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.

(d) 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.

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

begin insert 14094.7. end insert   

(a) No sooner than July 1, 2017, the department shall
establish an application process by which up to __ Medi-Cal
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.

(b) 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:

(1) 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.

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

(3) 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.

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

(c) 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.

begin insert 14094.8. end insert   

(a) 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 article,
including access monitoring, quality measures, and ongoing public
data reporting.

(b) The department shall work with the statewide stakeholder
advisory group established pursuant to this article 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.

(c) (1) In order to aid the transition of CCS services into
Medi-Cal managed care plans participating in the Whole Child
Model program, commencing January 1, 2017, and continuing
through the completion of the transition of CCS enrollees into the
Whole Child Model program, the department shall begin requesting
and collecting from Medi-Cal managed care information about
each health plan’s provider network, including, but not limited to,
the contracting primary care, specialty care providers, and hospital
facilities contracting with the Medi-Cal managed care plan.

(2) The department shall analyze the existing Medi-Cal managed
care delivery system network and the CCS fee-for-service provider
networks to determine the overlap of the provider networks in each
county, and shall furnish this information to the Medi-Cal managed
care plan.

begin insert 14094.9. end insert   

(a) 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) At least three months prior to implementation of the Whole
Child Model program in the county or counties served by the plan,
the Medi-Cal managed care plan has established 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.

(4) 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 this article for feedback.

(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.

(C) That the Medi-Cal managed care plan 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 Medi-Cal managed care plan 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.

(b) A Medi-Cal managed care plan, prior to implementation of
the Whole Child Model program, shall review historical CCS
fee-for-service utilization data for CCS-eligible children and youth
upon transition of CCS services to managed care plans so that the
managed care plans are better able to assist CCS-eligible children
and youth and prioritize assessment and care planning.

begin insert 14094.10. end insert   

(a) Each Medi-Cal managed care plan participating
in the Whole Child Model program shall establish an assessment
process that, at a minimum, does all of the following:

(1) 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.

(2) Assesses, in accordance with the agreement with the county
CCS program, 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.

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

(b) The risk assessment process shall be performed in
accordance with all applicable federal and state laws.

begin insert 14094.11. end insert   

A Medi-Cal managed care plan participating in the
Whole Child Model program shall meet all of the following
requirements:

(a) 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:

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

(2) Ensure families have access to ongoing information,
education, and support so that they understand the care plan 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.

(3) 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).

(4) 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.

(5) 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.

(6) 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.

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

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

(1) 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.

(2) 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.

(3) 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.

(4) 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.

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

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

begin insert 14094.12. end insert   

A Medi-Cal managed care plan serving children
and youth with CCS-eligible conditions under the CCS program
shall do all of the following:

(a) 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.

(b) Coordinate with the local CCS Medical Therapy Unit (MTU)
to ensure appropriate access to MTU services. The Medi-Cal
managed care plan shall enter into a memorandum of
understanding or similar agreement with the county regarding
coordination of MTU services and services provided by the plan.

(c) Ensure 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.

(d) 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.

(e) 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.

(f) 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.

(g) 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.

(h) 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.

(i) 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.

(j) 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.

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

(l) 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, provided the required report does
not contain individually identifiable information. If the required
report would result in the publication of individually identifiable
information, the plan shall not include that information in the
required report.

begin insert 14094.13. end insert   

(a) Each Medi-Cal managed care plan shall
establish and maintain a process by which families may maintain
access to any CCS providers for treatment of the child’s CCS
condition, up to the length of the child’s or youth’s CCS qualifying
condition or 12 months, whichever is longer, under the following
conditions:

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

(2) 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, unless the physician and surgeon enter into
an agreement on an alternative payment methodology mutually
agreed to by the physician and surgeon and the Medi-Cal managed
care plan.

(3) 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.

(4) The provider provides treatment information to the Medi-Cal
managed care plan, to the extent authorized by the state and federal
patient privacy provisions.

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

(b) A managed care plan, at its discretion, may extend the
continuity of care period beyond the length of time specified in
subdivision (a).

(c) Each Medi-Cal managed care plan participating in the
Whole Child Model program shall comply with continuity of care
requirements in Section 1373.96 of the Health and Safety Code
and Section 14185 of this code.

begin insert 14094.14. end insert   

(a) Each Medi-Cal managed care plan participating
in the Whole Child Model program shall 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.

(b) A CCS 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.

begin insert 14094.15. end insert   

A Medi-Cal managed care plan shall meet all of the
following requirements:

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

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

(c) Use 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.

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

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

begin insert 14094.16. end insert   

(a) 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.

(b) A Medi-Cal managed care plan shall reimburse providers
at rates sufficient to recruit and retain qualified providers with
appropriate CCS expertise.

(c) Medi-Cal 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, unless the physician and
surgeon enters into an agreement on an alternative payment
methodology mutually agreed to by the physician and surgeon and
the Medi-Cal managed care plan

begin insert 14094.17. end insert   

(a) A Medi-Cal managed care plan participating
in the Whole Child Model program shall 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.

(b) (1) Each Medi-Cal managed care plan participating in the
Whole Child Model program shall establish a family advisory
group for CCS families.

(2) 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.

(3) A representative of this local group shall serve on the
department’s statewide stakeholder advisory group established
pursuant to subdivision (c).

(c) (1) The department shall establish a statewide Whole Child
Model program 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 subdivision (b).

(2) The department shall consult with the stakeholder advisory
group on the implementation of the Whole Child Model program
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.

begin insert 14094.18. end insert   

(a) (1) The department shall contract with an
independent entity that has experience in performing robust
program evaluations to conduct an evaluation to assess Medi-Cal
managed care 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.

(2) The department shall provide a report on the results of this
evaluation required pursuant to this section 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.

(b) The evaluation required by this section, 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.

(c) 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.

begin insert 14094.19. end insert   

This article is not intended, and shall not be
interpreted, to permit any reduction in benefits or eligibility levels
under the CCS program.

begin insert 14094.20. end insert   

(a) 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, 2019, 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.

(b) The director may enter into exclusive or nonexclusive
contracts on a bid, nonbid, or negotiated basis and may amend
existing managed care contracts to provide or arrange for services
provided under this article. Contracts entered into or amended
pursuant to this section shall be exempt from the provisions of
Chapter 2 (commencing with Section 10290) of Part 2 of Division
2 of the Public Contract Code and Chapter 6 (commencing with
Section 14825) of Part 5.5 of Division 3 of Title 2 of the
Government Code, and shall be exempt from the review and
approval of any division of the Department of General Services.

end insert