BILL NUMBER: SB 586 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 8, 2016
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
14094.4 to, Article 2.985 (commencing with Section
14094.4) to Chapter 7 of Part 3 of Division 9 of, 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)
(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 CCS program (CCS)
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
S-CHIP State Children's Health Insurance
Program (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. This bill would provide that its provisions are not
intended to permit any reduction in benefits or eligibility levels
under the existing CCS program. 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. The
bill would authorize the Director of Health Care Services to
enter into exclusive or nonexclusive contracts on a bid, nonbid,
or negotiated basis and amend existing managed
care contracts to provide or arrange for services provided under the
bill.
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 subdivision (j) of Section
14094.4 Section 14094.18 has been completed,
except for contracts entered into pursuant to the Whole Child Model
program, as described in Section 14094.4,
Article 2.985 (commencing with 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 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. 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.
SEC. 3. Article 2.985 (commencing with Section
14094.4) is added to Chapter 7 of Part 3 of Division 9 of the
Welfare and Institutions Code , to read:
Article 2.985. Whole Child Model Program
14094.4. 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.
14094.5. 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.
14094.6. 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.
14094.7. (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.
14094.8. (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.
14094.9. (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.
14094.10. (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.
14094.11. 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.
14094.12. 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.
14094.13. (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.
14094.14. (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.
14094.15. 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.
14094.16. (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
14094.17. (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.
14094.18. (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.
14094.19. This article is not intended, and shall not be
interpreted, to permit any reduction in benefits or eligibility
levels under the CCS program.
14094.20. (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.