BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 586|
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UNFINISHED BUSINESS
Bill No: SB 586
Author: Hernandez (D), et al.
Amended: 8/19/16
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 4/22/15
AYES: Hernandez, Nguyen, Mitchell, Monning, Nielsen, Pan,
Roth, Wolk
NO VOTE RECORDED: Hall
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
SENATE HEALTH COMMITTEE: 9-0, 8/25/16 (Pursuant to Senate Rule
29.10)
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,
Pan, Roth, Wolk
SENATE FLOOR: 40-0, 6/1/15
AYES: Allen, Anderson, Bates, Beall, Berryhill, Block,
Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall,
Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson,
Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning,
Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner,
Stone, Vidak, Wieckowski, Wolk
ASSEMBLY FLOOR: 80-0, 8/23/16 - See last page for vote
SUBJECT: Childrens services
SOURCE: Author
DIGEST: This bill allows the Department of Health Care Services
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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 the
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.
ANALYSIS:
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 up to
266 percent of the federal poverty 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.
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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
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
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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;
b) Perform an assessment process that assesses each CCS
child's risk level and needs;
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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
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for use by the plan;
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;
aaa) Requires each plan to meet this 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,
bbb) Provide a written notice at least 60 days before the
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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
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.
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Requires neonatology to be included in the CCS program.
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
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 is not
carved into the plan.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
According to the Assembly Appropriations Committee:
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
monitoring and oversight standards: $500,000 per year.; a
stakeholder advisory group: $50,000 per year; and an
independent evaluation: $300,000-$500,000 one-time.
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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.
SUPPORT: (Verified 8/25/16)
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
Disability Rights California
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: (Verified 8/22/16)
None received
ARGUMENTS IN 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
families.
ASSEMBLY FLOOR: 80-0, 8/23/16
AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker,
Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke,
Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley,
Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth
Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto,
Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper,
Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim,
Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,
Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte,
O'Donnell, Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez,
Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting,
Wagner, Waldron, Weber, Wilk, Williams, Wood, Rendon
Prepared by:Scott Bain / HEALTH / (916) 651-4111
8/25/16 14:09:56
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