BILL ANALYSIS Ó
SB 586
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Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
586 (Hernandez) - As Amended June 8, 2016
SENATE VOTE: 40-0
SUBJECT: Children's services.
SUMMARY: Extends the sunset date on the California Children's
Services (CCS) "carve out" to 2025, and establishes the Whole
Child Model (WCM) program for CCS eligible children under the
age of 21. Specifically, this bill:
1)Prohibits CCS covered services from being incorporated into
any Medi-Cal managed care (MCMC) contract (known as the CCS
"carve out") entered into after August 1, 1994 until January
1, 2025, with the exception of contracts entered into by
county organized health systems (COHS) or regional health
authority (RHA) in the Counties of San Mateo, Santa Barbara,
Solano, Yolo, Marin, and Napa.
2)Defines a CCS Provider as a provider that is approved by the
CCS program to treat a CCS-eligible condition.
3)Defines a COHS as county organized health system contracting
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with the Department of Health Care Services (DHCS) to provide
Medi-Cal services to beneficiaries or a RHA.
4)Defines a WCM site as a managed care plan under a COHS that is
selected to participate in the WCM program under a capitated
payment model.
Establishing the WCM and WCM goals
5)Permits DHCS, no sooner than July 1, 2017, to establish a WCM
program for Medi-Cal and State Children's Health Insurance
Program (S-CHIP) eligible CCS children and youth enrolled in a
managed care plan under a COHS or RHA in an undefined number
of counties.
6)Establishes the goals for the WCM program for children and
youth under 21 years of age who meet CCS eligibility
requirements and are enrolled in a managed care plan under a
COHS or RHA, including all of the following:
a) Improving the coordination of primary and preventive
services with specialty care services, medical therapy
units (MTU), Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT), long-term services and supports (LTSS),
and regional center services, and home- and community-based
services using a child and youth and family-centered
approach;
b) Maintaining or exceeding CCS program standards and
specialty care access, including access to appropriate
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subspecialties;
c) Ensuring the continuity of child and youth access to
expert, CCS dedicated case management and care
coordination, provider referrals, and service
authorizations through contracting with or the employment
of county CCS staff to perform these functions.
d) Improving the transition of youth from CCS to adult
Medi-Cal managed care systems through better coordination
of medical and nonmedical services and supports and
improved access to appropriate adult providers for youth
who age out of CCS; and,
e) Identifying, tracking, and evaluating the transition of
children and youth from CCS to the WCM program to inform
future CCS program improvements.
Application Process for COHS
7)Requires DHCS, no sooner than July 1, 2017, to establish an
application process by which an undefined number of MCMC plans
under a COHS may participate in the WCM program. Requires the
DHCS Director (Director) to consult with the Legislature, the
federal Centers for Medicare and Medicaid Services, counties,
CCS providers, and CCS families when determining the
implementation date.
8)Requires a managed care plan under a COHS or RHA, in order to
apply to become a WCM site, to provide a written application
of interest that provides the Director with evidence of the
following:
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a) Written approval by the county board of supervisors to
partner with the managed care plan for the integration of
CCS medical and case management and service authorizations
for CCS Medi-Cal beneficiaries into the managed care plan;
b) Written support from the local bargaining units
representing affected CCS worker classifications;
c) Written support from CCS providers that serve a
preponderance of the CCS children and youth in the county,
home- and community-based services networks, and the
regional center or centers that serve CCS children and
youth in that county; and,
d) Written support from the family resource center or
family empowerment center serving the affected county.
DHCS Requirements Prior to Implementation of WCM
9)Requires DHCS to post its written approval of an application
of interest on its Internet Website at least 90 days before
CCS services are incorporated into the managed care plan under
the WCM program.
10)Prohibits DHCS from implementing the WCM in any county until
DHCS has developed and implemented specific CCS program
monitoring and oversight standards for managed care plans,
including access monitoring, quality measures, and ongoing
public data reporting.
11)Requires DHCS to work with the statewide stakeholder advisory
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group (SAG) to develop and implement robust monitoring
processes to ensure that managed care plans are in compliance
with all of the CCS requirements. Requires DHCS to monitor
managed care plan compliance on at least an annual basis and
post all monitoring data on its Internet Website within 90
days.
12)Requires DHCS, in order to aid the transition of CCS services
into MCMC plans participating in the WCM program, commencing
January 1, 2017, and continuing through the completion of the
transition of CCS enrollees into the WCM program, to begin
requesting and collecting from MCMC plans 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 MCMC.
13)Requires DHCS to analyze the existing MCMC delivery system
network and the CCS fee-for-service (FFS) provider networks to
determine the overlap of the provider networks in each county,
and to furnish this information to the MCMC.
Up-front Requirements on DHCS and MCMC plans
14)Prohibits a MCMC plan from participating in the WCM program
unless all of the following conditions have been satisfied:
a) The MCMC plan has obtained written approval from the
Director of its application of interest;
b) DHCS has obtained all necessary federal approvals and
waivers;
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c) At least three months prior to implementation of the WCM
program in the county or counties served by the plan, the
MCMC 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;
d) 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, all of the
following:
i) Timely and appropriate communication with affected
CCS-eligible children and youth and their parents or
guardians. Requires communication to be tested for
readability and targeted at a 6th grade reading level.
Requires plan communications to families and providers to
be shared with the plan's local family advisory group for
feedback;
ii) 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;
iii) That the MCMC plan has established and maintains an
updated and accessible listing of providers and their
specialties and subspecialties and makes it available to
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CCS-eligible children and youth and their parents or
guardians, at a minimum by phone, written material, and
on its Internet Website;
iv) That the MCMC plan has entered into an agreement
with the county CCS program or the state, or both, for
the provision of CCS care coordination and service
authorization and how the plan will work with the CCS
program to ensure continuity; and, consistency of CCS
program expertise for that role, as specified; and,
e) Requires a MCMC plan, prior to implementation of the WCM
program, to review historical CCS FFS utilization data for
CCS-eligible children and youth upon transition of CCS
services to MCMC plans so that the MCMC plans are better
able to assist CCS-eligible children and youth and
prioritize assessment and care planning.
15)Requires each MCMC participating in the WCM program to
establish an assessment process that, at a minimum, does all
of the following:
a) 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 DHCS;
b) Assesses, in accordance with the agreement with the
county CCS program, the care needs of CCS-eligible children
and youth and coordinates their CCS specialty services,
Medi-Cal primary care services, mental health and
behavioral health benefits, and regional center services
across all settings, including coordination of necessary
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services within and, when necessary, outside of the MCMC's
provider network; and,
c) Follows timeframes for reassessment of risk and, if
necessary, circumstances or conditions that require
redetermination of risk level, to be set by DHCS.
Plan of Care and Care Coordination Requirements
16)Requires MCMC plans participating in the WCM program to meet
all of the following requirements:
a) Work with the state or county CCS program, as
appropriate, to ensure that, at a minimum, and in addition
to other statutory and contractual requirements, care
coordination and care management activities do all of the
following:
i) Reflect an outcome-based approach to care planning;
ii) 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;
iii) Adhere to the CCS beneficiary's or their family's
determination about the appropriate involvement of
medical providers and caregivers;
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iv) Are developed across CCS specialty services,
Medi-Cal primary care services, mental health and
behavioral health benefits, regional center services,
medical therapy units (MTUs), and in-home supportive
services (IHSS), including transitions among levels of
care and between service locations;
v) Include individual care plans for beneficiaries
based on the results of the risk assessment process with
a particular focus on CCS specialty care;
vi) Consider behavioral health needs of beneficiaries
and coordinate those services with the county mental
health department as part of the CCS beneficiary's
individual care plan, when appropriate, and facilitate
access to appropriate community resources and other
agencies, including referrals, as necessary and
appropriate, for behavioral services, such as mental
health services; and,
vii) Ensure access to transportation and other support
services necessary to receive treatment.
b) Incorporate all of the following into the CCS
beneficiary's plan of care patterns and processes:
i) Access for families so that they know where to go
for ongoing information, education, and support to
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 care provider, urgent care, or emergency room,
what an interdisciplinary team is, and what the community
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resources are;
ii) A primary or specialty care physician who is the
primary clinician and who provides core clinical
management functions;
iii) Care management and care coordination across the
health care system, including transitions among levels of
care and interdisciplinary care teams;
iv) Provision of referrals to qualified professionals,
community resources, or other agencies for services or
items outside the scope of responsibility of the managed
care health plan;
v) Use of clinical data to identify beneficiaries with
chronic illness or other significant health issues; and,
vi) Timely preventive, acute, and chronic illness
treatment of CCS-eligible children or youth in the
appropriate setting.
On-Going Requirements on MCMC Plans
17)Requires a MCMC plan to do all of the following:
a) Coordinate with each regional center operating within
the plan's service area to assist CCS-eligible
beneficiaries with developmental disabilities and their
families in understanding and accessing services and act as
a central point of contact for questions, access and care
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concerns, and problem resolution;
b) Coordinate with the local CCS MTU to ensure appropriate
access to MTU services. Requires the MCMC plan to enter
into a memorandum of understanding or similar agreement
with the county regarding coordination of MTU services and
services provided by the plan;
c) Ensure that families have access to ongoing information,
education, and support so they understand the care plan,
course of treatment, and expected outcomes, 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 health care and personal
care providers, including IHSS and behavioral health
providers, when appropriate;
e) Facilitate timely access to primary care, specialty
care, medications, and other health services, including
referrals to address any physical or cognitive barriers to
access;
f) Provide training for families about managed care
processes and how to navigate a health plan, including
their rights to appeal any service denials. Requires the
MCMC plan to partner with a family empowerment center or
family resource center in its service area to provide this
training;
g) Establish a mechanism to provide information, education,
and peer support through parent-to-parent liaisons or
relationships with local family resource centers or family
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empowerment centers;
h) Provide that communication and services are available in
alternative formats that are culturally, linguistically,
and physically appropriate through means, including, but
not limited to, assistive listening systems, sign language
interpreters, captioning, written communication, plain
language, and written translations in at least the Medi-Cal
threshold languages;
i) Provide that materials are available and provided to
inform CCS children and youth and their families of
procedures for obtaining CCS specialty services and
Medi-Cal primary care and mental health benefits, including
grievance and appeals procedures that are offered by the
managed care plan or are available through the Medi-Cal
program;
j) Identify and track children and youth with CCS-eligible
conditions for the duration of the child's or youth's
participation in the WCM program and for children and youth
who age into adult Medi-Cal systems, for at least 10 years
into adulthood;
aa) Provide timely processes for accepting and acting upon
complaints and grievances, including procedures for
appealing decisions regarding coverage or benefits; and,
bb) 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. Specifies that if the required
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report would result in the publication of individually
identifiable information, the plan cannot include that
information in the report.
Continuity of Care
18)Requires each MCMC plan to establish and maintain a process
by which families may maintain access to any CCS providers for
treatment of the child's CCS condition, up to the length of
the child's or youth's CCS qualifying condition or 12 months,
whichever is longer, under the following conditions:
a) The CCS-eligible child or youth has an ongoing
relationship with a provider who is a CCS-approved
provider;
b) The provider will accept the health plan's rate for the
service offered or the applicable Medi-Cal or CCS FFS rate,
whichever is higher, unless the physician and surgeon enter
into an agreement on an alternative payment methodology
mutually agreed to by the physician and surgeon and the
MCMC plan;
c) The managed care plan determines that the provider meets
applicable CCS standards and has no disqualifying quality
of care issues, in accordance with guidance from DHCS,
including all-plan letters and CCS numbered letters or
other administrative communication;
d) The provider provides treatment information to the MCMC
plan, to the extent authorized by the state and federal
patient privacy provisions; and,
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e) Specifies that these requirements apply to
out-of-network and out-of-county primary care and
specialist providers.
19)Permits a managed care plan, at its discretion, to extend the
continuity of care period beyond 12 months.
20)Requires each MCMC plan participating in the WCM program to
comply with continuity of care requirements.
Designation of a Specialist as a Primary Care Provider (PCP)
21)Requires each MCMC participating in the WCM program to
provide a mechanism to request a specialist or clinic as a
PCP.
22)Permits a CCS specialist or clinic to serve as a PCP if the
specialist or clinic agrees to serve in a PCP role and is
qualified to treat the required range of CCS-eligible
conditions.
MCMC Plan Care - Guidelines/Credentialed Providers
23)Requires a MCMC plan to meet all of the following
requirements:
a) Comply with all CCS program guidelines, including CCS
program regulations, CCS numbered letters, and CCS program
information notices;
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b) Base treatment decisions for CCS-related conditions on
CCS program guidelines or, if those guidelines do not
exist, on treatment protocols or recommendations of a
national pediatric specialty society with expertise in the
condition;
c) Use clinical guidelines or other evidence-based medicine
when applicable for treatment of the CCS-eligible child's
or youth's health care issues or timing of clinical
preventive services;
d) Utilize only appropriately credentialed CCS-paneled
providers to treat CCS conditions; and,
e) Utilize a provider dispute resolution process that
includes the following requirements:
i) Includes health plan contracts with providers that
contain provisions requiring a fast, fair, and
cost-effective dispute resolution mechanism under which
providers may submit disputes to the plan, and require
the plan to inform its providers upon contracting with
the plan, or upon change to these provisions, of the
procedures for processing and resolving disputes,
including the location and telephone number where
information regarding disputes may be submitted;
ii) Is accessible to non-contracting providers for the
purpose of resolving billing and claims disputes; and,
iii) A health care service plan to annually submit a
report to DHCS regarding its dispute resolution mechanism
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that includes information on the number of providers who
utilized the dispute resolution mechanism and a summary
of the disposition of those disputes.
Rates Paid to MCMC Plans and Rates Paid to Providers
24)Requires DHCS to pay any managed care plan participating in
the WCM program a separate, actuarially sound rate
specifically for CCS children and youth. Permits DHCS, when
contracting with managed care plans, to allow the use of risk
corridors or other methods to appropriately mitigate a plan's
risk for this population.
25)Requires a MCMC plan to reimburse providers at rates
sufficient to recruit and retain providers with appropriate
CCS expertise.
26)Requires MCMC plans to pay physician and surgeon provider
services at rates that are equal to or exceed the applicable
CCS FFS 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 MCMC plan.
State and MCMC Plan Advisory Committees
27)Requires a MCMC plan participating in the WCM program to
create and maintain a clinical advisory committee composed of
the managed care contractor's Chief Medical Officer, the
county CCS medical director, and at least four CCS-paneled
providers to review treatment authorizations and other
clinical issues relating to CCS conditions.
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28)Requires each MCMC plan participating in the WCM program to
establish a family advisory group for CCS families, including:
a) Family representatives who serve on this advisory group
to receive ongoing information and training, travel
reimbursement, child care, and other financial assistance
as appropriate to enable participation in the advisory
group; and,
b) A representative of this local group to serve on DHCS's
statewide SAG pursuant to 29) below.
29)Requires DHCS to establish a statewide WCM program SAG,
comprised of representatives of CCS providers, county CCS
program administrators, health plans, family resource centers,
family empowerment centers, CCS case managers, CCS MTUs, and a
representative from each of the local family advisory groups.
30)Requires DHCS to consult with the SAG on the implementation
of the WCM program and to incorporate the recommendations of
the SAG in developing the monitoring processes and outcome
measures by which the WCM plans will be monitored and
evaluated.
Evaluation
31)Requires DHCS to contract with an independent entity that has
experience in performing robust program evaluations to conduct
an evaluation to assess MCMC plan performance and the outcomes
and the experience of CCS-eligible children and youth
participating in the WCM program, including access to primary
and specialty care, and youth transitions from WCM program to
adult Medi-Cal coverage.
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32)Requires DHCS to provide a report on the results of this
evaluation to the Legislature by no later than January 1,
2023.
33)Requires the evaluation to compare the performance of the
plans participating in the WCM program to the performance of
the CCS program in counties where CCS is not incorporated into
managed care and collect appropriate data to evaluate whether
the inclusion of CCS services in a managed care delivery
system improves access to care, quality of care, and the
patient experience, as specified.
a) Access to specialty and primary care, and in particular,
utilization of CCS-paneled providers;
b) The level of compliance with CCS clinical guidelines and
the recommended guidelines of the American Academy of
Pediatrics;
c) The type and location of CCS services and, with respect
to health plans that have CCS services incorporated in
their contracts, the extent to which CCS services are
provided in-network compared to out of network;
d) Utilization rates of inpatient admissions, outpatient
services, durable medical equipment, behavioral health
services, home health, pharmacy, and other ancillary
services;
e) Patient and family satisfaction;
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f) Appeals, grievances, and complaints;
g) Authorization of CCS-eligible services;
h) Access to adult providers, support, and ancillary
services for youth who have aged into adult Medi-Cal
coverage from the WCM program; and,
i) 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.
34)Requires DHCS to consult with stakeholders, including, but
not limited to, the WCM SAG, regarding the scope and structure
of the review.
35)Specifies that nothing in this bill is intended, and should
not be interpreted, to permit any reduction in benefits or
eligibility levels under the CCS program.
Regulations, and Use of Contract Authority
36)Requires DHCS, without taking regulatory action, to
implement, or interpret 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.
37)Requires DHCS, by July 1, 2019, to adopt regulations.
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Requires DHCS, commencing July 1, 2017, to provide a status
report to the Legislature on a semiannual basis, until
regulations have been adopted.
38)Permits the Director to enter into exclusive or nonexclusive
contracts on a bid, nonbid, or negotiated basis and to amend
existing managed care plan contracts to provide or arrange for
services provided under this bill. Exempts their contracts
the review and approval by the Department of General Services.
EXISTING LAW:
1)Requires DHCS to establish and administer a program of
services for physically defective or handicapped persons under
the age of 21 years, in cooperation with the federal
government through its appropriate agency or instrumentality,
for the purpose of developing, extending, and improving
services. Requires DHCS to receive all funds made available
by the federal government, the state, its political
subdivisions, or from other sources. Authorizes DHCS to
supervise those services included in the state plan that are
not directly administered by the state. Requires DHCS to
cooperate with medical, health, nursing and welfare groups and
organizations concerned with the program, and any agency of
the state charged with the administration of laws providing
for vocational rehabilitation of physically handicapped
children.
2)Defines a handicapped child as a physically defective or
handicapped person under the age of 21 years who is in need of
services. Specifies that phenylketonuria, hyaline membrane
disease, cystic fibrosis, and hemophilia are included in these
conditions.
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3)Prohibits CCS covered services from being incorporated into
any MCMC contract entered into after August 1, 1994 until
January 1, 2017, with the exception of contracts entered into
by a COHS or RHA in the Counties of San Mateo, Santa Barbara,
Solano, Yolo, Marin, and Napa.
4)Authorizes DHCS to establish a pilot project in Solano County
in which reimbursement for conditions eligible under the CCS
program may be reimbursed on a capitated basis and provided
all CCS program's guidelines, standards, and regulations are
adhered to, and CCS program's case management is utilized.
5)Authorizes DHCS to 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 including, but not limited
to, coverage of different geographic areas, focusing on
certain subpopulations, and the employment of different
payment and incentive models, as specified.
6)Requires providers serving children under the CCS program who
are enrolled with a MCMC contractor but who are not enrolled
in a pilot project pursuant to continue to submit billing for
CCS covered services on a FFS basis until CCS covered services
are incorporated into the MCMC contracts.
7)Specifies that CCS covered services means any or all of the
following, regardless of the funding sources:
a) Expert diagnosis;
b) Medical treatment;
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c) Surgical treatment;
d) Hospital care;
e) Physical therapy;
f) Occupational therapy;
g) Special treatment;
h) Materials;
i) Appliances and their upkeep, maintenance, care and
transportation; and,
j) Maintenance, transportation, or care incidental to any
other form of "services."
8)Specifies that CCS-eligible children cannot be restricted or
excluded 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.
9)Requires DHCS or a designated county agency to cooperate with,
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or arrange through, local public or private agencies and
providers of medical care to seek out handicapped children,
bringing them expert diagnosis near their homes.
10)Requires financial eligibility for treatment services under
this to be limited to persons in families with an adjusted
gross income of $40,000 or less in the most recent tax year,
as calculated for California state income tax purposes.
Permits the financial documentation required to enroll in
Medi-Cal to be used instead of the person's California state
income tax return. Permits the Director to authorize
treatment services for persons in families with higher incomes
if the estimated cost of care to the family in one year is
expected to exceed 20% of the family's adjusted gross income.
11)Exempts necessary medical therapy treatment services under
the CCS Program rendered in the public schools from financial
eligibility standards and enrollment fee requirements when
rendered to any handicapped child whose educational or
physical development would be impeded without the services.
12)Requires managed care contractors serving CCS-eligible
children to maintain and follow standards of care established
by the program, including the use of paneled providers and
CCS-approved special care centers and to follow treatment
plans approved by the program, including specified services
and providers of services.
13)Requires DHCS, if there are insufficient paneled providers
willing to enter into contracts with the managed care
contractor, to establish new providers willing to contract.
If a paneled provider cannot be found, the managed care
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contractor must seek program approval to use a specific
non-paneled provider with appropriate qualifications.
14)Requires managed care contractors to report expenditures and
savings separately for CCS covered services and CCS-eligible
children.
15)Requires a separate actuarially sound rate for CCS children
if the managed care contractor is paid according to a
capitated or risk-based payment methodology.
16)Permits, with the approval of the state CCS program director,
a managed care pilot project to utilize an alternative rate
structure for CCS eligible children.
17)Requires the state and county to be responsible for any
authorized medically necessary service not available under the
managed care contracts.
18)Requires oversight by the state and local CCS program
agencies for both services covered and not covered by the
managed care contract.
FISCAL EFFECT: This bill, as amended, has not yet been analyzed
by a fiscal committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, this bill
authorizes the creation of a WCM in counties served by a
Medi-Cal COHS. CCS has been carved out of MCMC since 1993
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because the Legislature recognized this population required a
unique approach. In over two decades since that time, the CCS
carve-out has been extended numerous times, and the state has
engaged in periodic efforts to pilot CCS alternative
arrangements. The current carve out ends December 31, 2016,
and the Administration has signaled that they will support an
extension of the carve-out only if it is accompanied by a plan
for an organized delivery system that combines CCS-services in
a WCM. This bill responds to that call by establishing a WCM
in COHS MCMC plans. This bill extends the carve-out in
non-COHS counties, ensures there is an incentive to continue
to identify CCS-eligible children and adequately funds their
care by requiring a stand-alone capitation payment paid to
MCMC plans, ensures access to physician specialists by
requiring a payment floor for CCS physician services, provides
extended continuity of care so that children can continue to
see their current providers, ensures continuity and
consistency of CCS program expertise in care coordination and
service authorization, requires an evaluation of the WCM, and
ensures family involvement in the WCM at both the state and
local level.
2)BACKGROUND. Originally established in 1927, the CCS program
provides diagnostic and treatment services, medical case
management, and physical and occupational therapy services to
children under age 21 with CCS-eligible medical conditions.
Some examples of CCS-eligible conditions include chronic
medical conditions such as cystic fibrosis, hemophilia,
cerebral palsy, heart disease, cancer, traumatic injuries, and
certain infectious diseases. CCS also provides medical
therapy services that are delivered at public schools.
The CCS program is administered as a partnership between county
health departments and DHCS. As of January 2012, there were
190,507 children enrolled in CCS. According to DHCS, 90% of
CCS enrollees are also eligible for Medi-Cal and 10% were
CCS-only or were covered by other insurance. The Medi-Cal
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program reimburses providers for Medi-Cal eligible
beneficiaries.
CCS is a statewide program. In counties with populations
greater than 200,000 (independent counties), county staff
perform all case management activities for eligible children
residing within their county. This includes determining all
phases of program eligibility, evaluating needs for specific
services, determining the appropriate provider(s), and
authorizing for medically necessary care. For counties with
populations under 200,000 (dependent counties), the Children's
Medical Services Branch of DHCS provides medical case
management and eligibility and benefits determination through
its regional offices located in Sacramento, San Francisco, and
Los Angeles. CCS authorizes and pays for specific medical
services and equipment provided by CCS-approved specialists.
In 1994, legislation was enacted to provide that CCS-covered
services for CCS-eligible children would not be incorporated
into managed care, termed a "carve out" and would be provided
and paid for on a FFS basis through the CCS program for three
years and authorized pilot projects to test alternative
managed care models tailored to the special health care needs
of CCS program, including using different payment and
incentive models. No pilot projects were ever approved.
The carve out has been extended repeatedly since then, usually
for three or four year periods. The first extension allowed
the COHS in the counties of San Mateo, Santa Barbara, Solano,
and Napa to include CCS services. Later extensions allowed
Yolo and Marin counties to include CCS services
a) MCMC. MCMC contracts for health care services through
established networks of organized systems of care, which
emphasize primary and preventive care. Managed care plans
are intended to be a cost-effective use of health care
resources that improve health care access and assure
quality of care. According to DHCS, approximately 10.3
million Medi-Cal beneficiaries in all 58 California
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counties receive their health care through six main models
of managed care: Two-Plan, COHS, Geographic Managed Care,
Regional Model, Imperial, and San Benito. Medi-Cal
providers who wish to provide services to managed care
enrollees must participate in the managed care plan's
provider network.
b) COHS. This bill permits DHCS, beginning July 1, 2017,
to establish a WCM program for Medi-Cal eligible CCS
children enrolled in a managed care plan under a COHS, one
of the six models of managed care, as discussed above. Each
COHS is created by a county board of supervisors and
governed by an independent commission. In COHS counties, a
single plan serves all Medi-Cal beneficiaries who are
enrolled in managed care. There are currently six COHS,
operating in 22 counties, as follows:
----------------------------------------------------------
| COHS | Counties | Number of |
| | | enrollees |
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| | | as of May |
| | | 2015 |
|---------------------+---------------------+--------------|
| CalOptima | Orange | 746,767 |
|---------------------+---------------------+--------------|
| CenCal Health | Santa Barbara | 163,264 |
| | San Luis Obispo | |
|---------------------+---------------------+--------------|
| Central California | Santa Cruz, | 331,148 |
| Alliance for Health | Monterey, Merced | |
|---------------------+---------------------+--------------|
| Gold Coast Health | Ventura | 190,750 |
| Plan | | |
|---------------------+---------------------+--------------|
| Health Plan of San | San Mateo | 106,080 |
| Mateo | | |
|---------------------+---------------------+--------------|
| Partnership Health |Del Norte, Humboldt, | 542,890 |
| Plan of California |Lake, Lassen, Marin, | |
| | Mendocino, Modoc, | |
| | Napa, Shasta, | |
| | Siskiyou, Solano, | |
| |Sonoma, Trinity, and | |
| | Yolo Counties | |
----------------------------------------------------------
-----------------------------------------------------------
| Total COHS Enrollment |2,080,899 |
| | |
-----------------------------------------------------------
MCMC plans are generally subject to: i) consumer protections
provided by the California Knox-Keene Health Care Service Plan
Act of 1975 (Knox-Keene) and overseen by the Department of
Managed Health Care (DMHC); ii) federal and state rules and
regulations for Medi-Cal; and, iii) terms set forth and agreed
upon in contracts between the plans and DHCS.
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However, unlike other MCMC plans, COHS plans are not required to
obtain Knox Keene licensure for their Medi-Cal lines of
business, and unless they choose to obtain a Knox-Keene license,
they are not directly regulated by the DMHC. Rather than
operating under specific statutory mandates, the county is bound
by the rules, terms, and conditions negotiated by the contract.
Despite the exemption, one COHS, the Health Plan of San Mateo,
voluntarily obtained a Knox-Keene license. Additionally, all
other COHS, except for Gold Coast Health Plan, have obtained a
Knox-Keene license for other, non-Medi-Cal lines of business.
c) CCS PILOTS. SB 208 (Steinberg), Chapter 714, Statutes
of 2010, requires DHCS to seek proposals to test
alternative managed care models either statewide or on a
more limited geographic basis and not limited to the
provision of CCS services. SB 208 requires the models to
be established by January 1, 2012, and requires they be
selected from among the models developed by the Children
with Special Health Care Needs Technical Workgroup. There
was no specified number of pilots and no ending date.
Five CCS pilots were authorized under the 2010 Medi-Cal Section
1115 Waiver, focused on exploring new service delivery models
that would improve the CCS Program and meet both stakeholder and
the state's needs. The proposed pilots varied by types of
providers participating, enrollment criteria, and eligibility
criteria. Traditionally designed as research and demonstration
programs to test innovative program improvements and to
facilitate coverage expansions to populations not otherwise
eligible, they are also used to modify benefits structures and
financing mechanisms. Ultimately, only two pilot projects were
undertaken, the Health Plan of San Mateo (HPSM) Managed Care
Organization (MCO) pilot and the Rady Children's Hospital
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Provider Based MCO pilot. The Medi-Cal 2020 Waiver program
includes extended authorization for the CCS pilot programs
authorized in 2010.
i) Rady Children's Hospital San Diego Pilot. The
county CCS program determines if CCS children meet the
criteria to be in the accountable care organization
demonstration project based on five qualifying health
conditions: cystic fibrosis; sickle cell; hemophilia;
acute lymphoid leukemia; and, diabetes. The pilot was
scheduled to launch in the spring of 2015, and it was
estimated that 625 children would be eligible. As of
January 2016 the pilot has not launched.
ii) HPSM Pilot. The HPSM pilot is a partnership between
San Mateo County CCS and the HPSM. The goal of the pilot
is to improve care and services for CCS kids by
coordinating care between specialists and primary care
doctors; and coordinating referrals and authorizations
between CCS and HPSM. In the HPSM pilot, a dedicated case
manager oversees a child's total care. This includes
coordinating social and mental health services for
caregivers, in addition to a child's medical services.
In April, 2013, around 1,400 children were enrolled in
the HPSM pilot. The chart below delineates the
responsibilities of the county and the plan:
----------------------------------------------------------
| San Mateo County | HPSM |
|------------------------------+---------------------------|
| Provides care coordination | Contracts with State for |
| and | pilot |
|utilization review | Medical oversight of |
| Public Health Nurse Care | whole child care |
| Coordinator provides whole | coordination and |
| child care coordination and | utilization review |
| utilization review | Processes and pays |
| Determines medical, | claims for the |
| financial, and | whole-child |
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|residential eligibility for | Provider network |
| CCS Program | contracts and provider |
| Performs enrollment & | relations |
| disenrollment into CCS | Grievances & appeals |
| program and the pilot | Pharmacy |
| Provides oversight of all | Mental health services |
| County CCS Staff | Member services & |
| Continue to operate CCS MTU | Marketing |
| services at 3 sites (outside | |
| the pilot) |Facilities |
| | |
| | |
| | |
----------------------------------------------------------
These models were required to meet specified standards including
establishing a network that includes CCS-approved providers and
maintain the current system of regionalized pediatric specialty
and subspecialty services. Additionally, DHCS was required to
conduct a simultaneous evaluation, to assess the effectiveness
of each model in improving the delivery of health care services
for these children and specify the measures for the evaluation.
These measures included, but were not limited to, the following:
i) The types of services and expenditures for
services;
ii) Improvement in the coordination of care for
children;
iii) Improvement in the quality of care;
iv) Improvement in the value of care provided;
v) The rate of growth of expenditures; and,
vi) Parent/Provider satisfaction.
As of January, 2016, none of these evaluations had been
completed.
d) DHCS Proposal. In September of 2014, DHCS implemented a
stakeholder process to investigate potential improvements
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or changes to the CCS program, in partnership with the
University of California, Los Angeles Center for Health
Policy Research. The CCS Redesign Stakeholder Advisory
Board (RSAB) is composed of individuals from various
organizations and backgrounds with expertise in both the
CCS program and care for children and youth with special
health care needs, and meets on a bi-monthly bases. In
August of 2015, DHCS released proposed bill language, based
in part on feedback received by the RSAB. This language
was the starting point for extensive negotiations between
DHCS, stakeholders, and legislative staff on the future of
the CCS program. Some of the key issues on which there is
still disagreement include whether or not sign-off from
affected entities prior to implementation of WCM should be
required, the relationship between the plans and the
counties regarding case management, care coordination,
provider referral and service authorization, the role and
responsibilities of county CCS workers regarding care
coordination and management services they currently
provide, the duration of continuity of care provisions,
standards for care, whether there should be a stand-alone
rate paid to plans for children enrolled in CCS, and
tracking outcomes and health for CCS children for 10 years.
3)SUPPORT. The California Children's Hospital Association
(CCHA), the California Chronic Care Coalition, Children Now,
Hemophilia Council of California and other supporters state
that the WCM has the potential to improve the coordination of
services for children along the whole continuum of medical
care, but as with any major health care transition, it also
has the potential to cause disruptions to care delivery. CCHA
is particularly concerned that the transition could jeopardize
long-standing relationships between CCS-eligible children and
the providers who currently treat them, and upset the State's
high quality pediatric specialty network. In addition,
integrating the CCS program with managed care does not
necessarily guarantee that coordination will occur. CCHA
states that this bill sets forth a comprehensive framework for
implementing the WCM that will help ensure a smoother
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transition and preserve the positive aspects of the CCS
program while creating an integrated delivery system tailored
to the needs of children with complex medical conditions and
their families. In particular, CCHA believes several
components of this bill are particularly critical to ensuring
CCS-eligible children and youth continue to receive the
highest quality of care through the WCM.
Supporters state this bill maintains CCS Program Standards in
WCM counties which ensures that children obtain care from
experienced providers with appropriate pediatric-specific
expertise. For example, the program requires that cardiac
surgery on neonates can only be performed by appropriately
credentialed, board-certified pediatric cardiac surgeons.
Similarly, the WCM requires that a pulmonary special care
center must include a social worker and a dietician, to help
address the psycho-social and dietary needs of patients with
cystic fibrosis. CCS clinical standards form the core of the
program and are one of the reasons for its success.
Supporters believe it is imperative that managed care plans
should not be permitted to use their own utilization review
criteria in place of CCS treatment standards.
This bill requires that a robust evaluation be completed after
the initial phase of implementation, in order to learn what is
working and what improvements may be necessary. CCHA believes
this evaluation should be undertaken by an entity that is
independent from DHCS, and should be concluded and presented
to the Legislature prior to any further expansion of the WCM.
This bill requires such an evaluation and asks that it measure
1) the extent to which the model affected access to primary
care and CCS specialty care, 2) whether or not the model
improved patient and family satisfaction and, 3) whether or
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not the model improved efficiency and outcomes.
This bill requires that DHCS pay managed care plans a separate
capitation rate for CCS children, rather than a blended
capitation rate for all children. CCHA strongly supports the
approach in this bill because it will ensure that children and
youth with CCS-eligible conditions are identified early and
properly tracked so their health outcomes can be monitored and
evaluated over time. It is important to note that DHCS
currently pays separate rates for other special-needs
populations, including disabled populations, dual-eligibles,
and certain children.
4)SUPPORT IF AMENDED. Disability Rights California (DRC) states
that the CCS program is critically important to their clients
and constituents. It is the means by which disabled
individuals receive the health care services that enable them
to live and to progress to realize their potential including
progressing towards greater independence and quality of life.
Access to CCS program paneled physicians and the hospitals in
which they work as well as registered nurse case management is
critical. Because a number of DRC clients and constituents
have low incidence disabilities, access to CCS program paneled
providers who are out of county is important in order to
ensure access to CCS program providers with experience and
expertise to address their particular medical condition. Of
particular importance for DRC clients and constituents with
the most severe and complex disabilities have access to
special care centers. DRC also stresses the importance of due
process procedures and access to the Medicaid EPSDT medical
necessity standard.
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5)PREVIOUS
LEGISLATION.
a) AB 187 (Bonta), Chapter 738, Statutes of 2015, extends
the sunset date on the prohibition on incorporating CCS
covered services in a MCMC contract until DHCS has
completed evaluations of CCS pilot programs.
b) AB 301 (Pan), Chapter 460, Statutes of 2011, extends the
sunset date from January 1, 2012, to January 1, 2016 on the
CCS carve-out.
c) SB 208 implements the new 2010 Medi-Cal Section 1115
Waiver, and requires DHCS to establish a pilot project and
seek proposals to test four models exploring potential
options to redesign the CCS program.
d) AB 2379 (Chan), Chapter 333, Statutes of 2007, extends
the sunset date from August 1, 2008, to January 1, 2012 on
the CCS carve-out.
e) SB 1103 (Committee on Budget and Fiscal Review),
Chapter 228, Statutes of 2004, extends the sunset on the
carve-out from August 1, 2005 to September 1, 2008.
f) AB 3049 (Committee on Health), Chapter 536, Statutes of
2002, extends the sunset on the carve-out from August 1,
2003 to August 1, 2005 and added COHS in Yolo and Marin
counties to the list of exceptions to the carve-out.
g) AB 1107 (Cedillo), Chapter 146, Statutes of 1999,
extends the sunset on the carve-out until August 1, 2003.
h) AB 469 (Papan) of 1999 would have allowed Medi-Cal
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beneficiaries in the CCS Program to disenroll from
mandatory managed care if certain conditions are met. AB
469 was vetoed by then Governor Davis.
i) SB 391 (Solis), Chapter 294, Statutes of 1997, extended
the CCS carve-out until August 1, 2000, except for
contracts entered into for COHS in the counties of San
Mateo, Santa Barbara, Solano, and Napa.
j) SB 1371 required that CCS-eligible services be carved
out of any MCMC contract until three years after the
effective date of the contract.
6)POLICY COMMENT. As currently drafted, this bill does not
address what entity is responsible for a variety of
specialized services including Neonatal Intensive Care Unit
services, High-Risk Infant Follow-Up, EPSDT supplemental
services related to a CCS condition, medically necessary
occupational and physical therapy services, and specialty
mental health services. The author may wish to consider
language clarifying whether the plans, counties, or state CCS
program is responsible for these services as appropriate.
7)SUGGESTED AMENDMENTS.
a) Itemizing COHS Counties. Currently this bill permits
DHCS, no sooner than July 1, 2017, to establish a WCM
program in counties that operate a COHS managed care plan
and in an undefined number of counties. The Committee may
wish to clarify that beginning July 1, 2017 only COHS
counties, including 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
counties, are eligible to participate in the WCM.
b) Appeals process. This suggested amendment is at the
request of stakeholders seeking clarification of the
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appeals process available to families under the WCM. Not
all COHS counties are subject to Knox-Keene regulations and
the appeals and reviews that come with that licensing
structure. Additionally, an existing process exists in
regulation for purposes of resolving CCS disputes but it is
unclear if that would only continue to apply under the WCM.
The Committee may wish to consider an amendment clarifying
that the appeals process currently required by law for
health care service plans applies for "carved-in" counties,
and the current CCS appeals process in regulation applies
for "carved-out" counties.
c) Carve-out Date. Currently this bill extends the CCS
carve-out until 2025. This has been a subject of
negotiation between stakeholders, the author and DHCS.
DHCS' original proposal included a carve-out date through
2019, and DHCS has proposed January 1, 2021 in most recent
amendments. The Committee may wish to consider extending
the carve-out through January 1, 2022, which would be the
second year of a two-year legislative session.
d) Technical Amendments. The Committee, at the request of
DHCS, and stakeholders, may wish to recommend to the author
various clarifying and technical amendments throughout the
bill.
REGISTERED SUPPORT / OPPOSITION:
Support
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Alta California Regional Center
American Academy of Pediatrics, California
American Nurses Association California
Apoyo de Padres Para Padres
Arthritis Foundation
California Children's Health Coverage Coalition
California Children's Hospital Association
California Chronic Care Coalition
California Coverage & Health Initiatives
California Down Syndrome Advocacy Coalition
California Hepatitis C Task Force
California Society of Health-System Pharmacists
California State Council of the Service Employees International
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Union
Children Now
Children's Defense Fund - California
Children's Defense Fund
Cystic Fibrosis Foundation
Children's Specialty Care Coalition
Club 21
Diabetes Health Magazine
Down Syndrome Connection of the Bay Area
Down Syndrome Information Alliance
Exceptional Family Center
Fair Allocations in Research Foundation
Hemophilia Council of California
International Foundation for Autoimmune Arthritis
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LIUNA Locals 777
March of Dimes
National Association of Hepatitis Task Forces
National Association of Social Workers, California Chapter
National Down Syndrome Society
Native Sons of the Golden West
PICO-California
San Luis Obispo County Employees Association (SLOCEA)
The Arc of California
Tuberous Sclerosis Foundation
United Cerebral Palsy
UPEC LiUNA 792
Western Center on Law and Poverty
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Opposition
None on file.
Analysis Prepared by:Paula Villescaz / HEALTH / (916)
319-2097