Amended in Assembly August 2, 2016

Amended in Assembly June 30, 2016

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, Chávez, and Wood)

February 26, 2015

An act to amend Section begin insert 123850 of the Health and Safety Code, and to amend Sections 14093.06, 14094.2, and end insert 14094.3 of, and to add 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 (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 CCS program 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, 2022, 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 served by a county organized health system or Regional Health Authority in designated counties would provide CCS services under a capitated payment model to Medi-Cal 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 begin delete establish an application process end delete begin insert implement the program, as specified, end insert and would require a managed care plan to begin delete provide the department with a written end delete begin insert obtain from the department written approval of its end insert application of interest begin delete 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. end delete begin insert and establish a local stakeholder process, as prescribed. end insert 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 specific CCS monitoring and oversight standards for managed care plans. The bill would require the department to begin delete establish end delete begin insert establish, through December 31, 2021, end insert a statewide Whole Child Model stakeholder advisory group comprised of specified stakeholders, including representatives from health plans and family resource centers, begin insert or modify an existing stakeholder advisory group end insert 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 impose various requirements on a Medi-Cal managed care plan serving children and youth with CCS-eligible conditions under the CCS program, including, but not limited to, coordinating services, as specified, providing appropriate access to care, services, and information, begin insert providing for case management, care coordination, provider referral, and service authorization services, end insert and providing a timely process for accepting and acting upon complaints and grievances of CCS-eligible children and youth. 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, begin delete 2023. end delete begin insert 2021. end 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. The bill would require the department, by July 1, 2021, 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.

begin insert

By imposing new duties on counties with respect to the transaction of CCS program services, this bill would impose a state-mandated local program.

end insert begin insert

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

end insert begin insert

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.

end insert

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program:  begin delete no end delete begin insert yes end insert .

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 begin delete specialized integrated
delivery systems end delete begin insert the Whole Child Model, end insert focused on the unique
needs of CCS-eligible begin delete children, end delete begin insert children in counties served by
County Organized Health Systems end insert 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.

(i) It is further the intent of the Legislature to continue the
pediatric specialty expertise and statewide network of CCS
providers by promoting contractual relationships between those
providers and managed care plans. Accordingly, it is the intent of
the Legislature that reimbursement under the Whole Child Model
program be sufficient to attract and retain these specialists in the
CCS program.

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 123850 of the end insert begin insert Health and Safety Code end insert begin insert is
amended to read: end insert

123850.  

begin insert (a) end insert begin insert   end insert The board of supervisors of each county shall
designate the county department of public health or the county
department of social welfare as the designated agency to administer
the California Children’s Services begin delete Program. end delete begin insert (CCS) program. end insert
Counties with total population under 200,000 persons may
administer the county program independently or jointly with the
department. Counties with a total population in excess of 200,000
persons shall administer the county program independently. Except
as otherwise provided in this article, the director shall establish
standards relating to the local administration and minimum services
to be offered by counties in the conduct of the begin delete California Children’s
Services Program. end delete begin insert CCS program. end insert

begin insert

(b) (1) Upon determination of readiness by the director, the
designated county agency and a Medi-Cal managed care health
plan or plans serving the county, as determined by the director,
shall provide for the transition of CCS program services, except
for services provided pursuant to subdivision (c), into the Medi-Cal
managed care health plan contract in Whole Child Model counties
pursuant to Article 2.985 (commencing with Section 14094.4) for
children who are enrolled in the Medi-Cal managed care plan and
CCS. For children enrolled in a Medi-Cal managed care plan and
CCS in Whole Child Model counties pursuant to Article 2.985
(commencing with Section 14094.4), the case management, care
coordination, provider referral, and service authorization
administrative functions of the CCS program shall then be the
responsibility of the Medi-Cal managed care health plan in
accordance with Section 14094.13 and a written transition plan
prepared by the designated county agency and the Medi-Cal
managed care health plan. The director’s written determination
shall provide an implementation date for the transition, at which
point the Medi-Cal managed care health plan is also responsible
for fulfillment of the requirements set forth in Sections 123855,
123925, and 123960. CCS program eligibility determination shall
remain the responsibility of the designated county agency in
accordance with the provisions of this article.

end insert begin insert

(2) The case management, care coordination, provider referral,
and service authorization functions of the CCS program shall
remain the responsibility of the county for CCS beneficiaries
exempt from mandatory enrollment in the Medi-Cal managed care
plan.

end insert begin insert

(c) The CCS Medical Therapy Unit shall remain responsible
for the provision of medically necessary occupational and physical
therapy services prescribed by the CCS Medical Therapy Unit
Conference Team Physician.

end insert begin insert

(d) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the department may implement, interpret, or make specific this
article, Article 2.97 (commencing with Section 14093) and Article
2.985 (commencing with Section 14094.4) of Chapter 7 of Part 3
of Division 9 of the Welfare and Institutions Code, 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, without taking
regulatory action in order to implement the Whole Child Model
established pursuant to Article 2.985 (commencing with Section
14094.4). By July 1, 2020, 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 January 1, 2018, the department
shall provide a status report to the Legislature on a semiannual
basis, in compliance with Section 9795 of the Government Code,
until regulations have been adopted.

end insert

begin insert

begin insert SEC. 3. end insert   

end insert

begin insert Section 14093.06 of the end insert begin insert Welfare and Institutions Code end insert

begin insert is amended to read: end insert

14093.06.  

(a) When a managed care contractor authorized to
provide California Children’s Services (CCS) covered services
pursuant to subdivision (a) of Section 14094.3 expands to other
counties, the contractor shall comply with CCS program standards
including, but not limited to, referral of newborns to the appropriate
neonatal intensive care level, referral of children requiring pediatric
intensive care to CCS-approved pediatric intensive care units, and
referral of children with CCS eligible conditions to CCS-approved
inpatient facilities and special care centers in accordance with
subdivision (c) of Section 14093.05.

(b)  begin delete The end delete begin insert (1) end insert begin insert   end insert begin insert In Whole Child Model program counties authorized
pursuant to Article 2.985 (commencing with Section 14094.4), the end insert
managed care contractor shall comply with CCS program medical
eligibility regulations. Questions regarding interpretation of begin delete state
CCS end delete begin insert CCS program end insert medical eligibility regulations, or disagreements
between the begin delete county CCS program, end delete begin insert CCS program end insert and the managed
care contractor regarding interpretation of those regulations, shall
be resolved by the begin delete local CCS program, in consultation with the
state CCS program. end delete begin insert department. end insert The resolution determined by the
begin delete CCS program end delete begin insert department end insert shall be communicated in writing to the
managed care contractor.

begin insert

(2) Managed care contractors in counties not listed in Section
14094.5 shall comply with CCS program medical eligibility
regulations. Questions regarding interpretation of CCS program
medical eligibility regulations, or disagreements between the CCS
program medical eligibility regulations, or disagreements between
the county CCS program and the managed care contractor
regarding interpretation of those regulations, shall be resolved
by the local CCS program, in consultation with the department.
The resolution determined by the department shall be
communicated in writing to the managed care contractor.

end insert

(c) In following the treatment plan begin delete approved by the CCS
program, end delete begin insert developed in accordance with CCS program
requirements, end insert the managed care contractor shall ensure the timely
referral of children with special health care needs to CCS-paneled
providers who are board-certified in both pediatrics and in the
appropriate pediatric subspecialty.

(d) The managed care contractor shall report expenditures and
savings separately for CCS covered services and CCS eligible
children, in accordance with paragraph (1) of subdivision (d) of
Section 14093.05.

(e) All children who are enrolled with a managed care contractor
who are seeking CCS program benefits shall retain all rights to
CCS program appeals and fair hearings of denials of medical
eligibility or of service authorizations. Information regarding the
number, nature, and disposition of appeals and fair hearings shall
be part of an annual report to the Legislature on managed care
contractor compliance with CCS standards, regulations, and
procedures. This report shall be made available to the public.

(f) The begin delete state, end delete begin insert department, end insert in consultation with stakeholder
groups, shall develop unique pediatric plan performance standards
and measurements, including, but not limited to, the health
outcomes of children with special health care needs.

begin insert

begin insert SEC. 4. end insert   

end insert

begin insert Section 14094.2 of the end insert begin insert Welfare and Institutions Code end insert

begin insert is amended to read: end insert

14094.2.  

(a) This article is not intended, and shall not be
interpreted, to permit any reduction in benefits or eligibility levels
under the CCS program. Any medically necessary service not
available under the managed care contracts authorized under this
article shall remain the responsibility of the state and county.

begin delete

(b) In order to ensure that CCS benefits are provided to enrollees
with a CCS eligible condition according to CCS program standards,
there shall be oversight by the state and local CCS program
agencies for both services covered and not covered by the managed
care contract.

end delete begin insert

(b) (1) In Whole Child Model counties authorized pursuant to
Article 2.985 (commencing with Section 14094.4), in order to
ensure that CCS benefits are provided to enrollees with a
CCS-eligible condition according to CCS program standards,
there shall be oversight by the department for both services covered
and not covered by the managed care contract.

end insert begin insert

(2) In counties not listed in Section 14094.5, in order to ensure
that CCS benefits are provided to enrollees with a CCS-eligible
condition according to CCS program standards, there shall be
oversight by the department and local CCS program agencies for
both services covered and not covered by the managed care
contract.

end insert begin insert

(c) To the extent that any changes in CCS medical eligibility
are proposed by the department, there shall be a stakeholder
process that shall include both of the following:

end insert begin insert

(1) A draft of the proposed regulatory changes shall be shared
publicly at least 120 days prior to the filing of a regulatory change.
The proposed changes shall also be shared with the appropriate
policy and fiscal committees of the Legislature as well as posted
publicly on the department’s Internet Web site.

end insert begin insert

(2) The department shall utilize existing stakeholder committees
to receive input and comments on any proposed changes and
provide written comments back after input is provided. This input
may be provided to all stakeholders, including, but not limited to,
advocates, clinical experts, associations, county CCS program
administrators, families, and CCS providers.

end insert

begin delete SEC. 2. end delete

begin insert SEC. 5. end insert   

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, 2022, and until the evaluation required pursuant to
Section 14094.18 has been completed, except for contracts entered
into pursuant to the Whole Child Model program, as described in
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) This section shall not 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.

(f) This section shall not be construed to exclude or restrict the
specialty of neonatology from reimbursement under the CCS
program, subject to the program’s existing or applicable prior
authorization requirements or utilization review. Neonatology shall
be included in the CCS program.

begin delete SEC. 3. end delete

begin insert SEC. 6. end insert   

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 begin delete a medical provider that is paneled
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. end delete begin insert all of the
following: end insert

begin insert

(1) A medical provider that is paneled 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.

end insert begin insert

(2) A licensed acute care hospital approved by the CCS program
to treat a CCS-eligible condition.

end insert begin insert

(3) A special care center approved by the CCS program to treat
a CCS-eligible condition.

end insert

(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 eligible
CCS children and youth enrolled in a managed care plan served
by a county organized health system or Regional Health Authority
in the following counties: Del Norte, Humboldt, Lake, Lassen,
Marin, Mendocino, Merced, Modoc, Monterey, Napa, Orange,
San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Shasta,
Siskiyou, Solano, Sonoma, Trinity, and Yolo.

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), 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)  begin delete Ensuring end delete begin insert Providing for end insert the continuity of child and youth
access to expert, CCS dedicated case management and care
coordination, provider referrals, and service authorizations begin delete through
contracting with or the employment of county CCS staff to perform
these functions. end delete begin insert by giving parents, guardians, or the youth the
option to continue receiving these services from his or her county
public health nurse. end insert

(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 begin delete shall
establish an application process by which Medi-Cal managed care
plans under a county organized health system or Regional Health
Authority, 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 end delete begin insert may implement end insert the Whole Child Model program
established under this section, pursuant to the criteria described in
this article. The director shall provide notice to the Legislature,
the federal Centers for Medicare and Medicaid Services, counties,
CCS providers, and CCS families when each managed care plan,
including a transition plan with the county CCS program, has been
reviewed and certified as ready to enroll children based on the
criteria described in this article.

begin delete

(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.

end delete begin insert

(b) Prior to the implementation of the Whole Child Model, the
department shall do both of the following:

end insert begin insert

(1) Develop 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.

end insert begin insert

(2) Establish a stakeholder process pursuant to Section
14094.17. Consult with the statewide stakeholder advisory group
established pursuant to Section 14094.17 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
CCS-specific monitoring dashboards on its Internet Web site on
at least an annual basis.

end insert begin insert

(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.

end insert begin insert

(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.

end insert begin insert

(d) 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:

end insert begin insert

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

end insert begin insert

(2) The department has obtained any necessary federal
approvals.

end insert begin insert

(3) 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.

end insert begin insert

(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:

end insert begin insert

(A) That the managed care contractor has demonstrated 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 licensed acute care hospitals and special care centers.

end insert begin insert

(B) 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.

end insert begin insert

(C) That the Medi-Cal managed care plan has entered into an
agreement with the county CCS program or the state, or both, for
the transition 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 and subdivisions (e) and (f) of
Section 14094.13.

end insert begin insert

(e) 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.

end insert

begin delete

14094.8.  

(a) The department shall not implement the Whole
Child Model program in any county until it has developed 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 consult with the statewide stakeholder
advisory group established pursuant to Section 14094.17 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 CCS-specific monitoring dashboards 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 any necessary federal
approvals.

(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 transition 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.

end delete begin insert

begin insert 14094.9. end insert   

(a) The department shall develop a memorandum of
understanding template, which shall be utilized by participating
counties and health plans, and which shall include, but not be
limited to, the standards relating to the local administration of,
and minimum services to be provided by, counties and Medi-Cal
managed care plans in the administration of the Whole Child
Model program. The department shall consult with counties and
Medi-Cal managed care plans in the development of the Whole
Child Model memorandum of understanding template.

(b) The department shall provide written notice to the county
agency, as designated in Section 123850 of the Health and Safety
Code, of the calculation for determining the administrative
allocation to the county CCS program by means of county
information notice. The department shall consult with the Whole
Child Model program counties in determining the calculation for
determining the administrative allocation.

end insert

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 transition agreement with
the county CCS program, the begin insert health end insert care needs of CCS-eligible
children and youth and coordinates their CCS specialty services,
Medi-Cal primary care begin delete services, mental health and behavioral
health benefits, end delete begin insert services and mild to moderate mental health
services, specialty mental health as appropriate through the county
specialty mental health plan, and Drug Medi-Cal services as
appropriate through county substance use disorder program, end insert and
regional center services across all settings, including coordination
of necessary services within and, when necessary, outside of the
managed care 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:

begin insert

(a) Ensure that each CCS-eligible child or youth receives case
management, care coordination, provider referral, and service
authorization services from an employee of the plan who has
knowledge of and clinical experience with the CCS program
pursuant to subdivision (e) of Section 14094.13.

end insert begin delete

(a)

end delete

begin insert (b) end insert  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).

begin delete

(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.

end delete begin delete

(5)

end delete

begin insert (4) end insert  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.

begin delete

(6)

end delete

begin insert (5) end insert  Consider behavioral health needs of CCS-eligible children
and youth and coordinate those services begin delete with the county mental
health department end delete 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 begin insert specialty end insert mental health begin insert services and
substance use disorder end insert services.

begin delete

(7)

end delete

begin insert (6) end insert  Ensure that children and youth and their families have
appropriate access to transportation and other support services
necessary to receive treatment.

begin delete

(b)

end delete

begin insert (c) end insert  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 information about qualified professionals,
community resources, or other agencies for services or items
outside the scope of responsibility of the managed care 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
begin delete questions, end delete begin insert questions related to health care end insert 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 other non-MTU 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,
pharmacy, and other health services begin insert provided by CCS providers
and facilities with clinical expertise in treating the enrollee’s
specific CCS condition that are end insert needed by the CCS child or youth,
including referrals to address any physical or cognitive disabilities.

(f) Provide begin delete training end delete begin insert information end insert for families about managed
care processes and how to navigate a health plan, including their
rights to appeal any service begin delete denials. The managed care plan shall
partner with a family empowerment center or family resource
center in its service area to provide this training. end delete begin insert denials, and how
to request continuity of care for pharmacy, specialized durable
medical equipment and health care providers, and nurses pursuant
to Section 14094.13. end insert

(g) Establish a mechanism to provide begin delete information, education,
and peer support to parents of CCS-eligible children and youth
through parent-to-parent liaisons or relationships with end delete begin insert information
on how to access end insert 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 begin delete at least
the end delete begin insert the applicable end insert 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 begin delete systems, for at least 10 years into
adulthood. end delete begin insert systems and who continue to be enrolled in the same
Medi-Cal managed care plan for at least three years into
adulthood, to the extent feasible. end insert

(k) (1)  begin delete Provide end delete begin insert Comply with Medi-Cal due process and
reauthorization requirements and provide end insert 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.

(2) Upon denial, denial of reauthorization, or termination of
services, a notice of action shall be sent to the CCS-eligible child
or youth, or person legally authorized to act on behalf of the child
or youth. The notice of action shall include information about the
option to file a Medi-Cal appeal and Medi-Cal due process rights.

(3) If a child, youth, or his or her authorized person elects to
participate in the process described in this section and disagrees
with the decision of the designated CCS agency, the child, youth,
or authorized person may appeal that decision, except when the
service under dispute has been ordered or terminated by a CCS
physician with responsibility for the medical supervision of the
child or youth. If the child, youth, or authorized person disagrees
with the CCS physician, he or she shall be provided with names
of three expert physicians. The child, youth, or authorized person
shall choose one of the expert physicians, and the physician shall
evaluate the child or youth at CCS expense. The opinion of the
expert physician shall be final.

(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 begin delete families end delete begin insert a CCS- end insert begin insert eligible child or
youth end insert may maintain access to begin delete any CCS providers end delete begin insert CCS providers
that the child or youth has an existing relationship with end insert for
treatment begin delete of the child’s CCS condition, up to the length end delete of the
child’s or youth’s CCS begin delete qualifying end delete condition begin delete or 12 months,
whichever is longer, end delete begin insert for three years, end insert under the following
conditions:

(1) The CCS-eligible child or youth has begin delete an ongoing relationship
with a provider who is a CCS-approved provider. end delete begin insert seen the
out-of-network CCS provider for a nonemergency visit at least
once during the 12 months immediately preceding the date the
Medi-Cal managed care plan assumed responsibility for the child’s
or youth’s CCS care under the Whole Child Model program. end insert

(2) The begin insert CCS end insert provider begin delete will end delete begin insert shall end insert 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 begin delete physician and
surgeon enter end delete begin insert CCS provider enters end insert into an agreement on an
alternative payment methodology mutually agreed to by the
begin delete physician and surgeon end delete begin insert CCS provider end insert and the Medi-Cal managed
care plan.

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

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

begin delete

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

end delete begin insert

(b) Each Medi-Cal managed care plan shall establish and
maintain a process by which a CCS-eligible child or youth may
maintain access to specialized or customized durable medical
equipment providers for up to 12 months under the conditions in
paragraph (2):

end insert begin insert

(1) For the purposes of this subdivision, “specialized or
customized durable medical equipment” means durable medical
equipment that meets all of the following criteria:

end insert begin insert

(A) Is uniquely constructed from raw materials or substantially
modified from the base material solely for the full-time use of the
specific beneficiary according to a physician’s description and
orders.

end insert begin insert

(B) Is made to order or adapted to meet the specific needs of
the beneficiary.

end insert begin insert

(C) Is uniquely constructed, adapted, or modified to permanently
preclude the use of the equipment by another individual, and is so
different from another item used for the same purpose that the two
items cannot be grouped together for pricing purposes.

end insert begin insert

(2) (A) The CCS-eligible child or youth has an ongoing
relationship with a durable medical equipment provider who has
previously provided specialized or customized equipment, such as
power wheelchairs, repairs, and replacement parts; prosthetic
limbs; customized orthotic devices; and individualized assistive
technology. This does not include generally available or
noncustomized durable medical equipment.

end insert begin insert

(B) The durable medical equipment provider shall 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 durable medical equipment provider enters into an agreement
on an alternative payment methodology mutually agreed upon by
the durable medical equipment provider and the Medi-Cal
managed care plan.

end insert begin insert

(C) The durable medical equipment provider provides
information to the Medi-Cal managed care plan as requested by
the plan, to the extent authorized by state and federal patient
privacy provisions.

end insert begin insert

(3) The department may extend the continuity of care duration
period described in this subdivision for highly specialized or
customized durable medical equipment that is under warranty as
specified by the department.

end insert begin delete

(b)

end delete

begin insert (c) end insert  A managed care plan, at its discretion, may extend the
continuity of care period beyond the length of time specified in

begin delete subdivision (a). end delete begin insert subdivisions (a) and (b). end insert

begin delete

(c)

end delete

begin insert (d) end insert   begin insert (1) end insert begin insert   end insert 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 begin delete Code
and Section 14185 of this code. end delete begin insert Code. end insert

begin insert

(2) Each Medi-Cal managed care plan shall permit a
CCS-eligible child or youth enrolled as part of the Whole Child
Program to continue use of any prescription drug that is part of
a prescribed therapy for the enrollee’s CCS-eligible condition or
conditions immediately prior to the date of enrollment, whether
or not the prescription drug is covered by the plan, until the
prescription drug is no longer prescribed by the enrollee’s
plan-contracting CCS provider.

end insert begin insert

(e) Each Medi-Cal managed care plan participating in the
Whole Child Model program shall ensure that children and youth
are provided expert case management, care coordination, service
authorization, and provider referral. Each plan shall meet this
requirement by, at the request of the child, youth, or his or her
parent or guardian, allowing the child or youth to continue to
receive case management, care coordination, provider referrals
and service authorizations from his or her public health nurse.
This election shall be made within 90 days of the transition of CCS
services into the Medi-Cal managed care plan. A plan shall meet
this requirement by either or both of the following:

end insert begin insert

(1) By entering into a memorandum of understanding with the
county for case management, care coordination, provider referral,
and service authorization services to the child.

end insert begin insert

(2) By collocating county public health nurses who provide case
management and coordination within the Medi-Cal managed care
plan.

end insert begin insert

(f) In the event the county public health nurse leaves the CCS
program, the Medi-Cal managed care plan may transition the care
coordination and case management of a child or youth to an
employee of the plan who has education, knowledge, and
experience with the CCS program and pediatric patients or who
has knowledge and experience treating CCS-eligible conditions
in pediatric patients.

end insert begin insert

(g) A family or caregiver of a child or youth may appeal the
three-year continuity of care limitation in subdivision (a) to a panel
of three CCS providers with relevant clinical experience and
expertise who do not contract with the plan in order to continue
to receive services from a noncontracting CCS provider who meets
the criteria in subdivision (a). The family or caregiver shall choose
one, who shall evaluate the child at CCS expense and make a
decision on whether the child or youth can continue to receive
continuity of care from the CCS-paneled provider, subject to the
conditions in paragraphs (1) to (3), inclusive. The opinion of the
expert physician shall be final and binding upon the plan.

end insert

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)  begin delete Comply with all end delete begin insert Use all current and applicable end insert CCS program
guidelines, including CCS program regulations, CCS numbered
letters, and CCS program information begin delete notices. end delete begin insert notices in developing
criteria for use by the plan’s chief medical officer or the equivalent
and other care management staff. end insert

begin delete

(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.

end delete begin insert

(b) In cases in which CCS program guidelines do not exist, use
evidence-based guidelines or treatment protocols that are
medically appropriate given the child’s CCS-eligible condition.

end insert begin delete

(d)

end delete

begin insert (c) end insert  Utilize only begin delete appropriately credentialed CCS-paneled end delete begin insert CCS end insert
providers to treat CCS conditions.

begin delete

(e)

end delete

begin insert (d) end insert  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 begin delete youth. end delete
begin insert youth, as long as an actuarially sound rate can be developed for
the managed care plan’s CCS population. end insert 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.

begin delete

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

end delete begin delete

(c)

end delete

begin insert (b) end insert  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
begin delete Chief Medical Officer, end delete begin insert chief medical officer or the equivalent, end insert the
county CCS medical director, and at least four CCS-paneled
providers to begin delete review treatment authorizations and other clinical
issues relating to CCS conditions. end delete begin insert advise on clinical issues relating
to CCS conditions, including treatment authorization guidelines,
and serve as clinical advisers on other clinical issues relating to
CCS conditions. end insert

(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 begin delete ongoing information and training, travel
reimbursement, child care, and other financial assistance as
appropriate to enable participation in the advisory group. end delete begin insert a
reasonable per diem payment to enable in-person participation in
the advisory group. A plan may conduct family advisory group
meetings by teleconference or through other similar electronic
means to facilitate family participation in the advisory group. end insert

(3) A representative of this local group shall begin insert be invited to end insert 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, begin insert or modify an existing
Whole Child Model program stakeholder advisory group, end insert
comprised of representatives of CCS providers, county CCS
program administrators, health plans, family resource centers,
begin delete family empowerment centers, end delete begin insert regional centers, labor
organizations, end insert CCS case managers, CCS MTUs, and begin delete a
representative from each of the local end delete begin insert representatives from end insert 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 begin delete incorporate end delete begin insert consider end insert the recommendations of the
stakeholder advisory group in developing the monitoring processes
and outcome measures by which the plans participating in the
Whole Child Model program shall be monitored and evaluated.

begin insert

(3) The statewide Whole Child Model program stakeholder
advisory group established under this section shall terminate
December 31, 2021.

end insert

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, begin delete 2023. end delete begin insert 2021. end insert 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
begin delete compare end delete begin insert evaluate end insert the performance of the plans participating in the
Whole Child Model program begin insert as compared end insert to the performance of
the CCS program begin delete in counties where CCS is not incorporated into
managed care and collect appropriate data to end delete begin insert prior to the
implementation of the Whole Child Model in those same counties.
The evaluation shall end insert 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.

begin delete

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

end delete begin delete

(3)

end delete

begin insert (2) end insert  The type and location of CCS services begin delete and, with respect to
health plans that have CCS services incorporated in their contracts, end delete
begin insert and end insert the extent to which CCS services are provided in-network
compared to out of network.

begin delete

(4)

end delete

begin insert (3) end insert  Utilization rates of inpatient admissions, outpatient services,
durable medical equipment, behavioral health services, home
health, pharmacy, and other ancillary services.

begin delete

(5)

end delete

begin insert (4) end insert  Patient and family satisfaction.

begin delete

(6)

end delete

begin insert (5) end insert  Appeals, grievances, and complaints.

begin delete

(7)

end delete

begin insert (6) end insert  Authorization of CCS-eligible services.

begin delete

(8)

end delete

begin insert (7) end insert  Access to adult providers, support, and ancillary services
for youth who have aged into adult Medi-Cal coverage from the
Whole Child Model program.

begin delete

(9)

end delete

begin insert (8) end insert  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.

begin insert

(9) The ability of a child or youth who ages out of CCS and
remains in the same Medi-Cal managed care plan to retain his or
her existing providers.

end insert begin insert

(c) The evaluation required by this section shall also evaluate
the performance of managed care plans participating in the Whole
Child Model program as compared to the performance of the CCS
program in counties where CCS services are not incorporated into
managed care, and collect appropriate data to evaluate whether
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:

end insert begin insert

(1) The rate of new CCS enrollment in each county.

end insert begin insert

(2) The percentage of CCS-eligible children and youth with a
diagnosis requiring a referral to a CCS special care center who
have been at a CCS special care center.

end insert begin insert

(3) The percentage of CCS children and youth discharged from
a hospital who had at least one followup contact or visit within
20 days after discharge.

end insert begin delete

(c)

end delete

begin insert (d) end insert  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, 2021, 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.

begin insert

begin insert SEC. 7. end insert   

end insert begin insert

If the Commission on State Mandates determines that
this act contains costs mandated by the state, reimbursement to
local agencies and school districts for those costs shall be made
pursuant to Part 7 (commencing with Section 17500) of Division
4 of Title 2 of the Government Code.

end insert