BILL ANALYSIS Ó
SB 586
Page 1
SENATE THIRD READING
SB
586 (Hernandez)
As Amended August 2, 2016
Majority vote
SENATE VOTE: 40-0
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|Committee |Votes|Ayes |Noes |
| | | | |
| | | | |
| | | | |
|----------------+-----+----------------------+--------------------|
|Health |18-0 |Wood, Maienschein, | |
| | |Bonilla, Burke, | |
| | |Campos, Chiu, Gomez, | |
| | |Roger Hernández, | |
| | |Lackey, Nazarian, | |
| | |Olsen, Patterson, | |
| | |Ridley-Thomas, | |
| | |Rodriguez, Santiago, | |
| | |Steinorth, McCarty, | |
| | |Waldron | |
| | | | |
|----------------+-----+----------------------+--------------------|
|Appropriations |20-0 |Gonzalez, Bigelow, | |
| | |Bloom, Bonilla, | |
| | |Bonta, Calderon, | |
| | |Chang, Daly, Eggman, | |
| | |Gallagher, Eduardo | |
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| | |Garcia, Holden, | |
| | |Jones, Obernolte, | |
| | |Quirk, Santiago, | |
| | |Wagner, Weber, Wood, | |
| | |McCarty | |
| | | | |
| | | | |
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SUMMARY: Extends the sunset date on the California Children's
Services (CCS) "carve out" to 2021, and establishes the Whole
Child Model (WCM) program for CCS eligible children under the
age of 21 in counties with county organized health systems for
delivery of Medi-Cal managed care (COHS counties).
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, 2021, 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)Permits Department of Health Care Services (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 the Counties of 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.
3)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:
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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
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.
4)Requires neonatology to be included in the CCS program and
specifies that the specialty of neonatology is not excluded or
restricted from reimbursement under the CCS program, subject
to the program's existing or applicable prior authorization
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requirements or utilization review.
DHCS and MCMC Requirements Prior to Implementation of WCM
5)Requires the director to provide notice to the Legislature,
the federal Centers for Medicare and Medicaid Services (CMS),
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 specified criteria.
6)Requires DHCS, prior to the implementation of the WCM, to
develop specific CCS program monitoring and oversight
standards for managed care plans, including access monitoring,
quality measures, and ongoing public data reporting, and
establish a stakeholder process.
7)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, and 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.
8)Prohibits a MCMC plan from being approved to participate in
the WCM program unless certain conditions have been satisfied,
as specified.
9)Requires a MCMC plan, prior to implementation of the WCM
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program, to review historical CCS FFS 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.
10)Requires DHCS to develop a memorandum of understanding (MOU)
template, to be utilized by participating counties and health
plans, and which includes, but is not limited to, the
standards relating to the local administration of, and minimum
services to be provided by, counties and MCMC plans in the
administration of the WCM program. Requires DHCS to consult
with counties and MCMC plans in the development of the WCM MOU
template.
11)Requires DHCS to provide written notice to the appropriate
county agency of the calculation for determining the
administrative allocation to the county CCS program by means
of county information notice and requires DHCS to consult with
the WCM program counties in determining the calculation for
determining the administrative allocation.
12)Requires each MCMC participating in the WCM program to
establish an assessment process of CCS beneficiary risk level
and care needs, as specified.
Plan of Care and Care Coordination Requirements
13)Requires MCMC plans participating in the WCM program to meet
all of the following requirements:
a) Ensure that each CCS-eligible child or youth receives
case management, care coordination, provider referral, and
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service authorization services from an employee of the plan
who has knowledge of and clinical experience with the CCS
program.
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:
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;
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;
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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.
c) 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
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;
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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.
14)Establishes on-going requirements for MCMC plans that ensure
appropriate coordination with regional care centers and MTUs,
access to necessary information for families, timely access to
care, communication in culturally appropriate formats, access
to information about grievance and appeals procedures,
compliance with Medi-Cal due process requirements coordination
as appropriate and other information as specified.
CCS Provider Continuity of Care
15)Requires each MCMC plan to 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 three years, under the following conditions:
a) 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
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date the MCMC plan assumed responsibility for the child's
or youth's CCS care under the WCM program;
b) The provider must accept the health plan's rate for the
service offered or the applicable Medi-Cal or CCS FFS 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 MCMC plan;
c) The managed care plan confirms that the provider meets
applicable CCS standards and has no disqualifying quality
of care issues; and,
d) The CCS provider provides treatment information to the
MCMC plan, to the extent authorized by the state and
federal patient privacy provisions.
DME Continuity of Care
16)Requires each MCMC to establish and maintain a process by
which a CCS-eligible beneficiary can maintain access to
specialized or customized durable medical equipment (DME)
providers for up to 12 months under the following conditions:
a) The CCS-eligible beneficiary has an ongoing relationship
with a DME 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 DME;
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b) Requires the DME provider to accept the health plan's
rate for the service offered or the applicable Medi-Cal or
CCS FFS rate, whichever is higher, unless the DME provider
enters into an agreement on an alternative payment
methodology mutually agreed upon by the DME provider and
the MCMC plan; and,
c) The DME provider provides information to the MCMC plan
as requested by the plan, to the extent authorized by state
and federal patient privacy provisions.
17)Defines "specialized or customized durable medical equipment"
as DME 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; and,
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.
18)Permits DHCS to extend the continuity of care duration for
highly specialized or customized DME that is under warranty.
Prescription Drug Continuity of Care
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19)Requires each MCMC plan to permit a CCS-eligible child or
youth enrolled as part of the WCM program to continue use of
any prescription drug that is part of a prescribed therapy for
the enrollee's CCS-eligible condition or conditions
immediately prior to the date of enrollment, whether or not
the prescription drug is covered by the plan, until the
prescription drug is no longer prescribed by the enrollee's
plan-contracting CCS provider.
Case Manager Continuity of Care
20)Requires each MCMC plan participating in the WCM program to
ensure that children and youth are provided expert case
management, care coordination, service authorization, and
provider referral. Requires each MCMC plan to meet this
requirement by, at the request of the child, youth, or his or
her parent or guardian, allowing the child or youth to
continue to receive case management, care coordination,
provider referrals and service authorizations from his or her
public health nurse. Requires this election to be made within
90 days of the transition of CCS services into the MCMC plan.
Requires a MCMC to meet this requirement by either or both of
the following:
a) By entering into a MOU with the county for case
management, care coordination, provider referral, and
service authorization services to the child; or,
b) By collocating county public health nurses who provide
case management and coordination within the MCMC plan.
21)Permits the MCMC plan, in the event the county public health
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nurse leaves the CCS program, to transition the care
coordination and case management of a child or youth to an
employee of the plan who has education, knowledge, and
experience with the CCS program and pediatric patients or who
has knowledge and experience treating CCS-eligible conditions
in pediatric patients.
MCMC Plan Care Guidelines Regarding Credentialed Providers
22)Requires a MCMC plan to 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 CCS program 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 conditions; and,
d) 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
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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
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
23)Requires DHCS to pay any managed care plan participating in
the WCM program a separate, actuarially sound rate
specifically for CCS children and youth, as long as an
actuarially sound rate can be developed for the managed care
plan's CCS population. 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.
24)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
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25)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 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.
26)Requires each MCMC plan participating in the WCM program to
establish a family advisory group for CCS families and
requires family representatives who serve on this advisory
group to receive a reasonable per diem payment to enable
in-person participation in the advisory group.
27)Requires DHCS to establish a statewide WCM program
stakeholder advisory group (SAG), 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.
28)Sunsets the statewide WCM program SAG on December 31, 2021.
Evaluation
29)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
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and specialty care, and youth transitions from WCM program to
adult Medi-Cal coverage.
30)Requires DHCS to provide a report on the results of this
evaluation to the Legislature by no later than January 1,
2021.
31)Requires the evaluation to evaluate the performance of the
plans participating in the WCM program as compared to the
performance of the CCS program prior to the implementation of
the WCM in those same counties and 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.
32)Requires the evaluation to also evaluate the performance of
managed care plans participating in the WCM program as
compared to the performance of the CCS program in counties
where CCS services are not incorporated into managed care, and
collect appropriate data to evaluate whether inclusion of CCS
services in a managed care delivery system improves access to
care, quality of care, and the patient experience, by
analyzing all of the following:
a) The rate of new CCS enrollment in each county;
b) The percentage of CCS-eligible children and youth with a
diagnosis requiring a referral to a CCS special care center
who have been at a CCS special care center; and,
c) The percentage of CCS children and youth discharged from
a hospital who had at least one followup contact or visit
within 20 days after discharge.
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Regulations and Use of Contract Authority
33)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.
34)Requires DHCS, by July 1, 2019, to adopt regulations.
Requires DHCS, commencing July 1, 2017, to provide a status
report to the Legislature on a semiannual basis, until
regulations have been adopted and 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, as
specified.
EXISTING LAW:
1)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.
2)Specifies that CCS covered services means any or all of the
following, regardless of the funding sources:
a) Expert diagnosis;
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b) Medical treatment;
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."
3)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. .
FISCAL EFFECT: According to the Assembly Appropriations
Committee:
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1)This bill largely aligns with existing administrative plans to
implement a WCM program. However, there are several required
activities that will result in costs (General Fund/federal):
a) Monitoring and oversight standards: $500,000 per year.
b) Stakeholder advisory group: $50,000 per year.
c) Independent evaluation: $300,000-$500,000 one-time.
2)The requirements for managed care plans to pay providers at
existing rates results in unknown fiscal impact. To the
extent access to care could be maintained with lower payment
rates, this may lead to potential unrealized savings.
3)Extending the carve-out result in non-COHS counties results in
an unknown, potentially significant fiscal impact to the
extent it reduces flexibility to provide care in a more
cost-efficient manner. However, there are no plans to "carve
in" CCS services for non-COHS counties.
COMMENTS: 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 1994 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
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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.
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. 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 program reimburses providers
for Medi-Cal eligible beneficiaries.
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. The
carve-out was approved 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
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1)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 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.
2)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:
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----------------------------------------------------------
| COHS | Counties | Number of |
| | | enrollees |
| | | 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, | |
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| |Sonoma, Trinity, and | |
| | Yolo Counties | |
----------------------------------------------------------
-----------------------------------------------------------
| Total COHS Enrollment |2,080,899 |
| | |
| | |
| | |
| | |
-----------------------------------------------------------
MCMC plans are generally subject to: a) 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); b) federal and state rules and
regulations for Medi-Cal; and, c) terms set forth and agreed
upon in contracts between the plans and DHCS.
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.
3)DHCS Proposal. In September of 2014, DHCS implemented a
stakeholder process to investigate potential improvements 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
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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.
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 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.
SB 586
Page 24
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.
Analysis Prepared by:
Paula Villescaz / HEALTH / (916) 319-2097 FN:
0004071