Amended in Assembly August 19, 2016

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 begin delete Section end delete begin insert Sections 123835 and end insert 123850 of the Health and Safety Code, and to amend Sections 14093.06, 14094.2, and 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 begin delete CCS covered end delete begin insert CCS-covered end insert 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 implement the program, as specified, and would require a managed care plan to obtain begin insert written approval end insert from the department begin delete written approval of its application of interest end delete and establish a local stakeholder process, as prescribed. 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 establish, through December 31, 2021, a statewide Whole Child Model begin insert program end insert stakeholder advisory group comprised of specified stakeholders, including representatives from health plans and family resource centers, or modify an existing stakeholder advisory group and would require the department to consult with the Whole Child Model begin insert program end insert 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 begin delete specified, end delete begin insert specified; end insert providing appropriate access to care, services, and information, begin insert including continuity of care requirements; and end insert providing for case management, care coordination, provider referral, and service authorization begin delete services, and providing end delete begin insert services. The bill would require a Medi-Cal managed care plan participating in the Whole Child Model program to ensure provision of case management, care coordination, provider referral, and service authorization services to children and youth, as prescribed, but would authorize the department to waive this requirement if the plan demonstrates that it cannot meet the requirement because it would result in substantially increased program costs, as specified. This bill would require a managed care plan to provide end insert a timely process for accepting and acting upon complaints and grievances of CCS-eligible children and youth. begin insert The bill would require a specified stakeholder process to address proposed changes to CCS medical eligibility requirements. end insert 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, 2021. begin delete This end delete

begin insert This end insert 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, begin delete 2021, end delete begin insert 2020, end insert to adopt regulations and, commencing begin delete July 1, 2017, end delete begin insert July 1, 2018, end insert 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.

By imposing new duties on counties with respect to the begin delete transaction end delete begin insert transition and implementation end insert of CCS program services, this bill would impose a state-mandated local program.

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.

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.

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

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 the Whole Child Model,
focused on the unique needs of CCS-eligible children in counties
served by county organized health systems 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 123835 of the end insert begin insert Health and Safety Code end insert begin insert is
amended to read: end insert

123835.  

begin insert (a) end insert begin insert   end insert The department shall keep the begin insert California
Children’s Services (CCS) end insert program abreast of advances in medical
science, leading to the inclusion of other handicapping conditions
and services within the limits of and consistent with the most
beneficial use of funds appropriated for this purpose. With the
approval of the agency administrator the department may carry
out pilot studies to determine the need for, or the feasibility of,
including other handicapping conditions and services in the
program within the limits of available funds appropriated for the
program.

begin insert

(b) 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 and 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 shall
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. 3. end insert   

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

123850.  

(a) 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 (CCS) program. 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 CCS program.

(b) (1) Upon begin insert a end insert determination begin delete of readiness by the director, end delete begin insert by
the director that a Medi-Cal managed care plan and participating
county have met all of the State Department of Health Care
Services’ readiness requirements, end insert the designated county agency
and a Medi-Cal managed care health plan begin delete or plans end delete 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 begin delete director’s
written determination end delete begin insert director end insert shall provide an implementation
date for the begin delete transition, at which point the Medi-Cal managed care
health plan is also responsible for fulfillment of end delete begin insert transition and
identify how the state shall continue to fulfill end insert 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.

(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.

(c) The CCS Medical Therapy begin delete Unit end delete begin insert program end insert shall remain
responsible for the provision of medically necessary occupational
and physical therapy services prescribed by the CCS Medical
Therapy Unit Conference Team begin delete Physician. end delete begin insert Physician or the
CCS-paneled physician who is providing the medical direction for
occupational and physical therapy services. end 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.

begin delete SEC. 3. end delete

begin insert SEC. 4. end insert   

Section 14093.06 of the Welfare and Institutions Code
is amended to read:

14093.06.  

(a) When a managed care contractor begin insert that is end insert
authorized to provide California Children’s Services (CCS) covered
services pursuant to subdivision (a) of Section 14094.3 begin insert or Article
2.985 (commencing with Section 14094.4) end insert expands begin insert a managed
care plan’s CCS coverage area end insert 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.

begin delete

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

(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 delete begin insert

(b) The managed care contractor shall comply with CCS
program medical eligibility regulations. Questions regarding
interpretation of state CCS 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
state CCS program. The resolution determined by the CCS program
shall be communicated in writing to the managed care contractor.

end insert

(c) In following the treatment plan developed in accordance
with CCS program requirements, 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 department, 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 delete SEC. 4. end delete

begin insert SEC. 5. end insert   

Section 14094.2 of the Welfare and Institutions Code
is amended to read:

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.

(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.

(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.

begin delete

(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:

(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.

(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 delete

begin delete SEC. 5. end delete

begin insert SEC. 6. 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 begin insert the end insert 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.

begin delete

(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.

end delete

begin delete SEC. 6. end delete

begin insert SEC. 7. 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)  begin delete “CCS Provider” means all end delete begin insert “CCS provider” means any end insert of
the following:

(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.

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

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

(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.

begin delete

(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.

end delete begin delete

(d)

end delete

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

begin insert

begin insert 14094.65. end insert   

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

end insert

14094.7.  

(a) No sooner than July 1, 2017, the department may
implement 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.

(b) Prior to the implementation of the Whole Child Model, the
department shall do begin delete both end delete begin insert all end insert of the following:

(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.

(2) Establish a stakeholder process pursuant to Section 14094.17.

begin delete Consult end delete

begin insert (3) end insert begin insert   end insert begin insert Consult end insert 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.

(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 begin insert plans end insert 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.

(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:

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

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

(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.

(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) 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, begin delete and an adequate number
of end delete licensed acute care begin delete hospitals end delete begin insert hospitals, end insert and special care centers.

(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.

(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 begin delete section and subdivisions (e) and (f) of
Section 14094.13. end delete begin insert section. end 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.

14094.9.  

(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
begin insert program end insert 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.

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 health care needs of CCS-eligible
children and youth and coordinates their CCS specialty services,
Medi-Cal primary care 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, 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:

(a) Ensure that each CCS-eligible child or youth receives case
management, care coordination, provider referral, and service
authorization services from an employee begin insert or contractor end insert of the plan
who has knowledge begin delete of and end delete begin insert of, and receives adequate training on,
the CCS program, and who has end insert clinical experience with the CCS

begin delete program pursuant to subdivision (e) of Section 14094.13. end delete

begin insert population, or clinical experience with pediatric patients with
complex medical conditions. end insert

(b) 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) 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.

(5) Consider behavioral health needs of CCS-eligible children
and youth and coordinate those services 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 specialty mental health
services and substance use disorder services.

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

(c) Incorporate all of the following into the CCS child’s or
youth’s plan of begin delete care patterns and processes: end delete begin insert care: end insert

(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.

begin delete

(5)

end delete

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

begin delete

(6) Timely

end delete

begin insert (e) end insert begin insert   end insert begin insert Arrange for timely end insert 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
related to health care 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 provided by CCS providers
and facilities with clinical expertise in treating the enrollee’s
specific CCS condition that are needed by the CCS child or youth,
including referrals to address any physical or cognitive disabilities.

(f) Provide information for families about managed care
processes and how to navigate a health plan, including their rights
to appeal any service denials, and how to request continuity of
care for pharmacy, specialized durable medical begin delete equipment end delete
begin insert equipment, end insert and health care begin delete providers, and nurses end delete begin insert providers end insert pursuant
to Section 14094.13.

(g) Establish a mechanism to provide information on how to
access 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 the
applicable 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 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.

(k) (1) Comply with Medi-Cal due process begin delete and reauthorization end delete
requirements and 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 begin delete Code. end delete begin insert Code and
applicable federal law and regulations. end insert

(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.

begin delete

(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.

end delete begin insert

(l) Comply with Section 1383.15 of the Health and Safety Code
by allowing a child or youth or the parent or guardian of a child
or youth to receive a second opinion from an appropriately
qualified health care professional.

end insert

14094.13.  

(a) Each Medi-Cal managed care plan shall establish
and maintain a process by which a CCS-eligible child or youth
may maintain access to CCS providers that the child or youth has
an existing relationship with for treatment of the child’s or youth’s
CCS condition for begin delete three years, end delete begin insert up to 12 months, end insert under the following
conditions:

(1) The CCS-eligible child or youth has 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.

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

(3) The managed care plan confirms that the provider meets
applicable CCS standards and has no disqualifying quality of care
issues.

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

(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):

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

(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.

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

(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.

(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.

(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.

(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.

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

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

(d) (1) 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. end delete

begin insert Code and Section 14185 of this code. end insert

(2) Each Medi-Cal managed care plan shall permit a
CCS-eligible child or youth begin delete enrolled as part of the Whole Child
Program end delete begin insert transitioned into the Whole Child Model program end insert to
continue use of any begin insert currently prescribed end insert 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 begin insert Medi-Cal managed care plan and the child’s or youth’s
prescribing CCS provider has completed an assessment of the
child or youth, created a treatment plan, and agrees with the
Medi-Cal managed care plan that the particular prescription drug
is no longer medically necessary, or the end insert prescription drug is no
longer prescribed by the enrollee’s begin delete plan-contracting end delete CCS provider.

(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 begin delete referral. end delete begin insert referral services. end insert 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 begin delete management, care coordination, provider
referrals and service authorizations end delete begin insert management and care
coordination end insert 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:

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

begin delete

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

end delete begin insert

(2) By entering into a memorandum of understanding with the
county for case management, care coordination, provider referral,
and service authorization to all or some Whole Child Model
program participants.

end insert begin insert

(f) At least 60 days before the transition of CCS services to the
Medi-Cal managed care plan, a written notice shall be provided
to all CCS children and youth whose CCS care will become the
responsibility of the plan explaining their right to continue
receiving case management and care coordination services
pursuant to subdivision (e), including a written explanation of the
process for that election. A reminder notification shall be sent 30
days prior to the start of the transition.

end insert begin delete

(f)

end delete

begin insert (g) end insert  In the event the county public health nurse leaves the CCS
begin delete program, end delete begin insert program or is no longer available to provide the services
requested under this section, end insert the Medi-Cal managed care plan begin delete may end delete
begin insert shall end insert transition the care coordination and case management of a
child or youth to an employee begin insert or contractor end insert of the plan who has

begin delete 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 delete begin insert received adequate
training on the CCS program and who has clinical experience
with the CCS population or pediatric patients with complex medical
conditions. end insert

begin insert

(h) The department may waive the requirement of subdivision
(e) if the Medi-Cal managed care plan demonstrates that it cannot
meet the requirement because it would result in substantially
increased program costs compared to the existing CCS program
allocation as provided by the department through the annual
Budget Act. The department shall confirm the information provided
by the Medi-Cal managed care plan and meet with the county,
affected labor organizations, and the plan in an attempt to reach
a mutually agreeable contracting arrangement that fulfills the
requirements of this section while also ensuring that the
arrangement is not in excess of the current county program
allocation.

end insert begin delete

(g)

end delete

begin insert (i) end insert   begin insert (1) end insert begin insert   end insert A family or caregiver of a child or youth may appeal the
begin delete three-year end delete continuity of care limitation in subdivision (a) to begin delete 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 delete begin insert the
director or his or her designee. When determining whether or not
to grant the appeal, the director or his or her designee shall
consider all of the following: end insert

begin insert

(A) Whether the noncontracting CCS provider has any relevant
clinical experience or unique expertise that available contracting
CCS providers do not have.

end insert begin insert

(B) If the noncontracting CCS provider is a special care center,
whether or not any of the available contracting CCS providers is
a special care center of the same type.

end insert begin insert

(C) The length of the ongoing relationship between the CCS
provider and the child or youth.

end insert begin insert

(D) The proximity of the noncontracting CCS provider to the
child’s or youth’s home as compared to the proximity of the
contracting CCS provider being put forth by the plan.

end insert begin insert

(2) The opinion of the director or his or her designee shall be
final and binding upon the plan.

end insert begin insert

(j) This section shall not preclude the right of the CCS child or
youth to appeal or be eligible for a fair hearing regarding the
extension of a continuity of care period.

end insert begin insert

(k) Each Medi-Cal managed care plan participating in the
Whole Child Model program shall notify the CCS child or youth,
in writing, 60 days prior to the end of his or her authorized
continuity of care period. The notice shall explain the right to
petition the plan for an extension of the continuity of care period,
the criteria the plan will use to evaluate the petition, and the
appeals process if the plan denies the petition.

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

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

(c) Utilize only CCS providers to treat CCS begin delete conditions. end delete

begin insert conditions in any circumstance in which the child’s CCS-eligible
condition requires treatment from the provider types in paragraph
(1), (2), or (3) of subdivision (a) of Section 14094.4, except a plan
may use an out-of-state provider if an in-state CCS provider does
not possess the clinical expertise to appropriately treat the CCS
condition of the child or youth. end insert

(d) 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, begin delete as
long as end delete begin insert to the extent that end insert an actuarially sound rate can be developed
for the managed care plan’s CCS population. 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 insert If services are already established in the rate
of a Medi-Cal managed care plan prior to January 1, 2016, the
department shall not be required to create a separate rate for the
Whole Child Model program. end insert

(b) 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 or the equivalent, the county CCS medical
director, and at least four CCS-paneled providers to 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.

(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
begin delete shall end delete begin insert may end insert receive 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.

(3) A representative of this local group shall be invited to 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, or modify an existing
Whole Child Model program stakeholder advisory group,
comprised of representatives of CCS providers, county CCS
program administrators, health plans, family resource centers,
regional centers, labor organizations, CCS case managers, CCS
MTUs, and representatives from family advisory groups established
pursuant to subdivision (b). begin insert Participation on the statewide
stakeholder advisory group shall be voluntary, and members are
not eligible for travel or other per diem payments. end insert

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

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

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, 2021. 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
evaluate the performance of the plans participating in the Whole
Child Model program as compared to the performance of the CCS
program prior to the implementation of the Whole Child Model
begin insert program end insert in those same counties. The evaluation shall 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 begin delete following by end delete begin insert following, and
when possible, disaggregating the results, based on end insert 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 type and location of CCS services and the extent to
which CCS services are provided in-network compared to out of
network.

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

(4) Patient and family satisfaction.

begin delete

(5) Appeals, grievances, and complaints.

end delete begin insert

(5) Appeals and grievances, including the number of petitions
to the plan to extend the continuity of care period for durable
medical equipment and CCS providers, the results of those appeals,
whether any subsequent appeals were made to the department,
and the results of those appeals to the department.

end insert

(6) Authorization of CCS-eligible services.

begin delete

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

end delete begin delete

(8) For health plans with CCS incorporated into their contracts,
network

end delete

begin insert (7) end insert begin insert   end insert begin insert Network end insert and provider participation, including participation
of pediatricians, pediatric specialists, and pediatric subspecialists,
by specialty and subspecialty.

begin delete

(9)

end delete

begin insert (8) end insert  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 begin delete providers. end delete begin insert providers, to the extent possible or known. end insert

(c) The evaluation required by this section shall also evaluate
begin delete the performance of end delete managed care plans participating in the Whole
Child Model program as compared to begin delete the performance of end delete the CCS
program in counties where CCS services are not incorporated into
managed care, and collect appropriate data to evaluate begin delete whether
inclusion of CCS services in a managed care delivery system
improves access to care, quality of care, and the patient experience,
by analyzing end delete all of the following:

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

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

(3) The percentage of CCS children and youth discharged from
a hospital who had at least one followup contact or visit within begin delete 20 end delete
begin insert 28 end insert days after discharge.

begin insert

(4) Appeals and grievances.

end insert

(d) The department shall consult with stakeholders, including,
but not limited to, the Whole Child Model begin insert program end insert 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, begin delete 2021, end delete begin insert 2020, end insert 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 begin delete July 1, 2017, end delete begin insert July 1, 2018, end insert 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 delete SEC. 7. end delete

begin insert SEC. 8. end 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.