BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 586
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|AUTHOR: |Hernandez |
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|VERSION: |August 19, 2016 |
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|HEARING DATE: |August 25, | | |
| |2016 | | |
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|CONSULTANT: |Scott Bain |
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PURSUANT TO SENATE RULE 29.10
SUBJECT : Children's services
SUMMARY : This bill allows the Department of Health Care Services to
establish a Whole Child Model for children enrolled in both
Medi-Cal and the California Children's Services (CCS) Program in
21 counties served by four county organized health systems,
instead of the existing arrangement in most counties where CCS
services are "carved out" from the Medi-Cal managed care plan.
Continues the CCS carve out in the remaining 37 counties until
January 1, 2022.
Assembly Amendments insert the above described provisions and
delete the prior version of this bill, which would have
established a Kids Integrated Delivery System (KIDS) network to
provide CCS and Medi-Cal services to children eligible for both
CCS and Medi-Cal, which would have allowed an individual meeting
specific criteria to remain in a KIDS network, and provisions
that would have made the CCS "carve out" of CCS services from
Medi-Cal managed care permanent, except for existing carved out
counties and areas served by the proposed KIDS.
Existing law:
1)Establishes the Medi-Cal Program, administered by the
Department of Health Care Services (DHCS), which provides
comprehensive health benefits to low-income children in
families with incomes up to 266 percent of the federal poverty
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level (FPL), parents and adults up to 138 percent of the FPL,
pregnant women, and elderly, blind or disabled persons, who
meet specified eligibility criteria.
2)Establishes the CCS Program to provide specified medical care
and therapy services to children with eligible conditions.
3)Prohibits CCS covered services from being be incorporated into
any Medi-Cal managed care contract entered into after August
1, 1994 until January 1, 2017, except for contracts entered
into for county organized health systems (COHS) or Regional
Health Authority in the Counties of San Mateo, Santa Barbara,
Solano, Yolo, Marin, and Napa. This is known as the CCS "carve
out."
This bill:
1) Authorizes DHCS, no sooner than July 1, 2017, to establish a
"Whole Child Model" (WCM) program for Medi-Cal enrolled
children who are also enrolled in CCS in 21 counties served
by four COHS plans. Those counties are as follows: 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.
2) Extends the CCS "carve out" from Medi-Cal managed care in
the remaining counties until January 1, 2022.
3) Requires the case management, care coordination, provider
referral, and service authorization administrative functions
of the CCS program in WCM counties to be the responsibility
of the plan in accordance with the continuity of care
requirements of this bill and a written transition plan
prepared by the designated county agency and the plan.
4) Establishes requirements for DHCS as part of WCM, including
the following:
a) Request information about each plan's provider network;
b) Analyze the existing plan delivery system network and
the CCS FFS provider networks to determine the overlap of
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the provider networks;
c) Develop specific CCS program monitoring and oversight
standards for plans, including access monitoring, quality
measures, and ongoing public data reporting;
d) Establish a stakeholder process, and consult with the
statewide stakeholder advisory group to develop and
implement robust monitoring processes;
e) Monitor plan compliance, and post CCS-specific
monitoring dashboards on its web site on at least an annual
basis;
f) Consult with the WCM counties in determining the
calculation for determining the county administrative
allocation;
g) Consult with counties and plans in the development of
the WMC program memorandum of understanding (MOU) template,
which is to be used by counties and plans;
h) Pay any plan participating in the WCM program a
separate, actuarially sound rate specifically for CCS
children and youth, to the extent that an actuarially sound
rate can be developed for the plan's CCS population, except
in counties where CCS services are already carved in and
paid through a blended rate;
i) Contract with an independent entity that has experience
in performing robust program evaluations to conduct an
evaluation to assess plan performance and the outcomes and
the experience of CCS-eligible children and youth
participating in the WMC; and,
j) Establish a stakeholder process to the extent DHCS
proposes any changes in CCS medical eligibility.
5)Prohibits a plan from being approved to participate in the WCM
program unless specified conditions have been satisfied,
including DHCS approval, plan readiness, an appropriate
provider network and an agreement with the county CCS program
or the state 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.
6)Establishes requirements for COHS participating in the WCM,
including the following:
a) Review, prior to implementation, historical CCS FFS
utilization data for CCS-eligible children and youth upon
transition of CCS services;
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b) Perform an assessment process that assesses each CCS
child's risk level and needs;
c) Coordinate a child's CCS services with other services;
d) Ensure each CCS child receive case management, care
coordination, provider referral and service authorization
from an employee or contractor of the plan who has
knowledge of, and receive adequate training on the CCS
program, and who has clinical experience with the CCS
population or with pediatric patients with complex medical
conditions;
e) Pay physician services at rates that are equal to or
exceed the applicable CCS FFS rates, unless the physician
enters into an agreement on an alternative payment
methodology mutually agreed to by the physician and the
plan;
f) Use clinical data to identify CCS-eligible children or
youth at the care site with chronic illness or other
significant health issues;
g) Arrange for timely preventive, acute, and chronic
illness treatment of CCS-eligible children or youth in the
appropriate setting;
h) 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;
i) 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;
j) Comply with Medi-Cal due process requirements and
provide timely processes for accepting and acting upon
complaints and grievances;
aa) Allow 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;
bb) 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;
cc) 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;
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dd) Use evidence-based guidelines or treatment protocols
that are medically appropriate given the child's
CCS-eligible condition in case in which applicable CCS
clinical guidelines do not exist;
ee) Utilize only CCS providers to treat CCS conditions in
any circumstance in which the child's CCS-eligible
condition requires treatment from a CCS provider, as
defined, 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;
ff) Utilize a provider dispute resolution process that meets
the standards established under the Knox-Keene Act;
gg) Create and maintain a clinical advisory committee 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;
hh) Establish a family advisory group for CCS families;
ii) Establish and maintain a process by which a CCS-eligible
child or youth may maintain access to a CCS providers that
the child has an existing relationship with for treatment
of the child's CCS condition for up to 12 months, under
specified conditions, to specialized or customized durable
medical equipment providers for up to 12 months, and for
currently prescribed prescription drugs until specified
conditions are met;
jj) Ensure that children and youth are provided expert case
management, care coordination, service authorization, and
provider referral services. Requires each plan to meet the
requirement by allowing the child to continue to receive
case management and care coordination from his or her
public health nurse by making an election within 90 days of
the transition of CCS services into the plan. Requires a
plan to meet this requirement by entering into a MOU with
the county for case management and care coordination
services, by entering into a MOU with the county for case
management, care coordination, provider referral, and
service authorization to all or some WCM program
participants; and,
aaa) Provide a written notice at least 60 days before the
transition of CCS services to the plan explaining their
right to continue receiving case management and care
coordination services;
7)Exempts a plan from the continuity of care obligation in the
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event the county public health nurse leaves the CCS program or
is no longer available to provide the services requested.
Requires in such a circumstance the plan to transition the
care coordination and case management of a child or youth to
an employee or contractor of the plan who has received
adequate training on the CCS program and who has clinical
experience with the CCS population or pediatric patients with
complex medical conditions.
8)Permits DHCS to waive the public health nurse continuity of
care requirement if the 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 DHCS through the annual Budget Act.
Requires DHCS to confirm the information provided by the 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
bill, while also ensuring that the arrangement is not in
excess of the current county program allocation.
9)Permits a family or caregiver of a child or youth to appeal
the continuity of care limitation to DHCS, and requires the
DHCS director to take into account specified factors in
determining whether or not to grant the appeal.
10)Requires plans to notify the CCS child or youth, in writing,
60 days prior to the end of his or her authorized continuity
of care period, explaining 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.
11)Prohibits this bill from being construed to exclude or
restrict the specialty of neonatology from reimbursement under
CCS, subject to the program's existing or applicable prior
authorization requirements or utilization review. Requires
neonatology to be included in the CCS program.
FISCAL
EFFECT : Appropriation: No Fiscal
Com.:YesLocal: Yes
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 (GF/federal), including
a) Monitoring and oversight standards: $500,000 per year;
b) A stakeholder advisory group: $50,000 per year; and
c) An 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 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 currently no plans
to eliminate the CCS services carve-out for non-COHS counties,
so it essentially continues current practice.
Comments
1)Author's statement. According to the author, this bill
authorizes a WCM for CCS under which four COHS plans would
provide both CCS and Medi-Cal services to children enrolled in
Medi-Cal and CCS, instead of the existing arrangement in most
counties where CCS services are carved out from the Medi-Cal
managed care plan. The Administration has indicated it will
not continue the existing CCS carve out without some CCS
children being enrolled in an organized delivery system. This
bill contains a number of provisions to ensure the expertise
and quality of care in CCS is preserved as part of the
transition to the WCM, including requirements for plan
readiness; time-limited continuity of care; ensuring CCS
benefits are provided according to CCS program standards;
requiring Medi-Cal managed care plans to facilitate timely
access to services by CCS providers and facilities with
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clinical expertise in treating the enrollee's specific CCS
condition; requiring DHCS to pay plans participating in the
WCM in a new area a separate, actuarially sound rate
specifically for CCS children and youth; requiring a "rate
floor" for CCS providers; and requiring an independent
evaluation that compares CCS services in WCM counties before
and after CCS services are carved into the plan, and that
compares the WCM counties to other counties where CCS.
2)Background on CCS. Established in 1927 to help children obtain
treatment for services that were amenable to surgery, the CCS
program serves the state's most medically fragile pediatric
population. CCS provides diagnostic and treatment services,
medical case management, and physical and occupational therapy
services to children under 21 years of age with CCS-eligible
conditions (e.g., cancer, sickle cell, congenital heart
defects, severe genetic diseases, chronic and severe medical
conditions, and traumatic injuries) from families unable to
afford catastrophic health care costs. The CCS program is
administered as a partnership between county health
departments and DHCS. Counties determine medical, financial
and residential eligibility for CCS, and in counties with
populations greater than 200,000 individuals, county staff
perform case management and care coordination activities for
CCS children residing within their county.
In order to ensure appropriate medical care is delivered, the
CCS program has developed rigorous standards for providers and
facilities. The CCS program currently serves approximately
184,000 children, 93% of whom are also eligible for Medi-Cal.
There are 27,510 children enrolled in both CCS and Medi-Cal in
the 21 counties who would be affected by the WCM proposal
under this bill.
3)CCS and Medi-Cal managed care. Most Medi-Cal beneficiaries,
including most children, are required to enroll in Medi-Cal
managed care plans. However, for children who are enrolled in
both Medi-Cal and CCS, CCS services are "carved-out" of
Medi-Cal managed care. This is known as the "CCS carve out."
Under the carve-out, medical services provided through the CCS
program for the child's CCS condition are reimbursed by DHCS
on a FFS basis, rather than through the Medi-Cal managed care
plan. The carve out was originally enacted in 1994 and has
been extended multiple times, including last session by AB 187
(Bonta), Chapter 738, Statutes of 2015. There are five
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counties (Marin, Napa Santa Barbara, Solano, and Yolo) where
the Medi-Cal managed care plan pays CCS claims, but CCS care
coordination and case management continue to be performed by
the county. A sixth county (San Mateo County) has a CCS pilot
where county workers are co-located within the Health Plan of
San Mateo (the COHS serving San Mateo County) under an MOU
between the county and the plan.
4)Support. This bill is supported by provider, consumer, labor
groups to help ensure that the re-design of CCS WCM program
proceeds smoothly, with adequate safeguards in place to
preserve the quality of care CCS-eligible children and youth
receive. Supporters argue this bill sets forth a thoughtful,
patient-centered framework that preserves the positive aspects
of the CCS program while reducing fragmentation of care
delivery to better serve children with complex medical needs
and their
Support:
Alta California Regional Center
American Academy of Pediatrics, California
American Nurses Association California
Apoyo de Padres Para Padres
Arthritis Foundation
California Children's Hospital Association
California Chronic Care Coalition
California Down Syndrome Advocacy Coalition
California Hepatitis C Task Force
California Rheumatology Alliance
California Society of Health-System Pharmacists
Children Now
Children's Defense Fund - California
Children's Specialty Care Coalition
Club 21 Learning and Resource Center
Diabetes Health Magazine
Down Syndrome Connection of the Bay Area
Down Syndrome Information Alliance
Epilepsy California
Exceptional Family Center
Fair Allocations in Research Foundation
Hemophilia Council of California
International Foundation for Autoimmune Arthritis
LIUNA Local 777
National Association of Hepatitis Task Forces
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National Down Syndrome Society
Native Sons of the Golden West
San Luis Obispo County Employees Association
SEIU California
The Arc of California
Tuberous Sclerosis Alliance
United Cerebral Palsy
UPEC LIUNA 792
Opposition:
None received
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