BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 815
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|AUTHOR: |Hernandez and De Leon |
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|VERSION: |April 11, 2016 |
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|HEARING DATE: |April 27, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medi-Cal: demonstration project
SUMMARY : Enacts the statutory provisions of "Medi-Cal 2020," the state's
recently approved five-year federal Section 1115 waiver, which
runs through December 31, 2020. Implements the Public Hospital
Redesign and Incentive in Medi-Cal, the Global Payment Program
for county designated public hospitals, the Dental
Transformation Initiative, the Whole Person Care program and the
access assessment required under the Special Terms of Conditions
of Medi-Cal 2020. Urgency bill.
Existing law:
1)Establishes the Medi-Cal program, which is administered by the
Department of Health Care Services (DHCS) and under which
qualified low-income persons receive health care benefits.
2)Establishes a Medicaid Section 1115 demonstration project
under the Medi-Cal program until October 31, 2015 known as
California's Bridge to Reform, to implement specified
objectives, including better care coordination for Seniors and
Persons with Disabilities (SPDs) and maximization of
opportunities to reduce the number of uninsured individuals.
3)Provides for payments under the state's Bridge to Reform
waiver to designated public hospitals (DPHs are the University
of California [UC] and county hospitals), and for federal
disproportionate share (DSH), payments to private hospitals
(referred to as "DSH replacement payments") and non-designated
public hospitals (NDPHs are now referred to as
District/Municipal Public Hospitals or DMPH) through October
1, 2015. These provisions:
a) Make DPHs eligible for cost-based fee-for-service (FFS)
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Medicaid funding using county certified public expenditures
(CPEs) as the federal match, instead of state General Fund.
DPHs put up the nonfederal share of Medi-Cal FFS payments
used to draw down federal Medicaid matching funds, and
receive cost-based reimbursement, using CPEs to draw down
federal Medicaid matching funds;
b) Provide DSH payments to DPHs, using county CPEs and
county intergovernmental transfers (IGTs) to draw down
federal DSH funds;
c) Provide DSH payments to eligible DMPHs meeting DSH
eligibility criteria, using state General Fund to draw down
federal DSH funds;
d) Provide for "DSH replacement payments" to private
hospitals meeting DSH eligibility criteria, using non-DSH
Medicaid funds and state General Fund as the fund source;
e) Make DPHs eligible for payments from the federally
funded Safety Net Care Pool (SNCP) for uncompensated care;
and,
f) Make DPHs eligible for payments from the federally
funded delivery system reform incentive pool (DSRIP), based
on the DPH's progress toward and achievement of milestones
and metrics established in its DSRIP proposal, funded by
federal funds and IGTs.
1)Authorizes DHCS to request one or more temporary waiver
extensions to continue the operation of, and the authorities
provided under, the Bridge to Reform. Requires DHCS to extend
and apply the existing hospital payment methodologies and
allocations on a state fiscal year, annual, partial year, or
other basis, to the extent permitted under any approved
temporary waiver extension, an approved subsequent waiver, or
as otherwise permitted under federal Medicaid law.
This bill:
1)Requires DHCS to implement the Medi-Cal 2020 Demonstration
Project, consistent with federal law and the Special Terms and
Conditions (STCs). Requires the STCs to prevail in the event
of a conflict between this bill and the STCs.
2)Continues the current Medi-Cal FFS payment methodologies for
DPHs from the previous waiver, whereby DPHs receive cost-based
reimbursement with county CPEs used to draw down federal
Medicaid matching funds, and which require DPHs to receive
supplemental reimbursements for the costs incurred by for
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physician and non-physician services provided to Medi-Cal
beneficiaries who are patients of the hospital, to the extent
those services are not claimed as inpatient hospital services
by the hospital.
3)Requires DSH payments to be paid only to UC DPHs and DMPHs,
and requires private DSH hospitals to receive "virtual DSH"
payments (also known as "DSH replacement payments") funded by
GF and federal Medicaid funds (instead of federal DSH funds)
in the same manner as under the previous waiver, with the
federal DSH amounts going to UC DPHs capped by fiscal year.
Requires federal DSH payments and federal funds under the SNCP
to be used for a new Global Payment Program (GPP).
4)Requires DSH and SNCP payments made to DPHs under specified
timeframes to be reconciled to payments under this bill, as
specified. Requires DSH and SNCP payment determinations and
payments for 2013-14 and 2014-15 fiscal years to be deemed
final, as specified.
5)Establishes provisions for repayment in the event of a federal
deferral or disallowance, and how to account for a repayment
amount in determining a county's redirection obligation under
specified provisions of law requiring counties to shift funds
to the state required by AB 85 (Committee on Budget, Chapter
24, and Statutes of 2013).
6)Requires DHCS to implement the new GPP to supporting
participating health care systems that provide health care for
the uninsured. Requires, under GPP, GPP systems to receive
global payments based on the health care they provide to the
uninsured, in lieu of traditional DSH payments and payments
from an uncompensated care pool (referred to as the SNCP under
the prior waiver).
7)Requires GHPP systems to receive GPP payments based on a
value-based point methodology that incorporates measures of
value for patients in conjunction with the recognition of
costs. Requires the points assigned to a particular service or
activity to be the same across all GPP systems.
8)Requires DHCS to determine the maximum amount of GPP funding
each GPP system would receive, consisting of federal DSH funds
for county DPHs and amounts authorized for the uncompensated
care component of the GPP as determined under the STCs.
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9)Requires DHCS to perform a baseline analysis of the GPP's
system historical volume, cost and mix of services to the
uninsured to establish an annual threshold for purposes of
GPP. Requires DHCS to determine a pro rate allocation for each
GPP system, and an annual budget the GPP system will receive
if it achieves its threshold. Requires DHCS to develop a
methodology to redistribute unearned GPP funds for a given
year to those GPP systems that exceed their threshold in that
same year.
10)Prohibits GPP from being construed to constitute or offer
health coverage for individuals receiving services, and
permits participating GPP systems to determine the scope, type
and extent to which services are available to the extent
consistent with the STCs. Prohibits the GPP from being
construed to decrease, expand or otherwise alter the scope of
county's existing obligation to the medically indigent.
11)Requires the nonfederal share of payment under GPP to be
funded by IGTs.
12)Requires DHCS to determine the IGT amount for each GPP system
under this bill, and establishes different GPP payment amounts
for each county DPH system, as specified.
13)Requires DHCS, if it determines, after consulting with GPP
systems, to terminate the GPP in subsequent years, to notify
CMS.
14)Requires DHCS to establish and operate the PRIME program,
which is intended to accelerate efforts by participating PRIME
entities to change care delivery to maximize health care value
and strengthen their ability to successfully perform under
risk-based alternative payment models (APM). PRIME is the
successor to the DSRIP from the previous waiver.
15)Designates DPHs and DMPHs as participating PRIME entities.
Subject to the STCs, authorizes up to $1.2 billion available
to DPHs and $200 million available to DMPHs.
16)Makes participating PRIME entities eligible to earn incentive
payments by undertaking projects set forth in the STCs for
which there are required metrics.
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17)Requires that PRIME payments to be incentive payments and not
payments for services otherwise reimbursable under Medi-Cal.
Prohibits expenditures by PRIME entities from offsetting
payment amounts otherwise payable by Medi-Cal or Medi-Cal
managed care plans or otherwise supplant provider payments
payable to PRIME entities.
18)Requires PRIME entities, within 30 days following federal
approval of protocols for PRIME projects, metrics and funding,
to submit a five-year PRIME project plan containing the
specific elements of the STCs. Requires DHCS to review all
five-year PRIME project plans and take action within 60 days
to approve or disapprove each plan.
19)Requires each PRIME entity to submit reports to DHCS twice a
year demonstrating progress toward required metric targets,
using a standardized form developed jointly by DHCS and
participating PRIME entities.
20)Establishes provisions for the amount of PRIME incentive
payments payable to a participating PRIME entity, and requires
amounts payable to each PRIME entity to be determined using
the methodology in the STCs.
21)Makes each participating PRIME entity individually
responsible for progress toward and achievement of project
specific metrics targets. Requires that participating PRIME
entities earn reduced payment for partial achievement, as
described in the STCs.
22)Requires the nonfederal share of PRIME payments to consist of
voluntary IGTs.
23)Requires DPH systems to contract with at least one Medi-Cal
managed care plan in the service area where they operate using
an APM by January 1, 2018. Permits DHCS to waive this
requirement if the DPH system is unable to meet the
requirement and can demonstrate that it has made a good faith
effort to contract.
24)Requires DPHs and Medi-Cal managed care plans to seek to
strengthen their data and information sharing for purposes of
identifying and treating applicable beneficiaries, including
the timely sharing and reporting of beneficiary data,
assessment and treatment information.
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25)Requires DHCS to establish and operate the Whole Person Care
(WPC) pilot program as authorized under Medi-Cal 2020 to allow
for development of WPC pilots focused on target populations of
high-risk, high-utilizing Medi-Cal beneficiaries in local
geographic areas.
26)Establishes as the goal of WPC is the coordination of health,
behavioral health, and social services, as applicable, in a
patient-centered manner to improve beneficiary health and
well-being through more efficient and effective use of
resources.
27)Requires WPC pilots to provide an option to a county, city
and county, a health or hospital authority or a consortium of
any of these entities to receive support to integrate care for
particularly vulnerable Medi-Cal beneficiaries who have been
identified as high users of multiple systems and who continue
to have or are at-risk of poor health outcomes.
28)Defines the WPC target population as the population or
populations identified by a WPC pilot through a collaborative
data approach across partnering entities that identifies
common Medi-Cal high-risk, high-utilizing beneficiaries who
frequently access urgent and emergency services, including
across multiple systems. Permits, at the discretion of the WPC
lead entity, and in accordance with guidance as may be issued
by DHCS during the application process and approved by DHCS,
the WPC target population to include individuals who are not
Medi-Cal patients, subject to the funding restrictions in the
STCs regarding the availability of FFP for services provided
to these individuals.
29)Requires WPC pilots to include specific strategies to
increase integration among local governmental agencies, health
plans, providers, and other entities that serve high-risk,
high-utilizing beneficiaries, increase coordination and
appropriate access to care, reduce inappropriate inpatient and
emergency room utilization, improve data collection and
sharing among local entities, improve health outcomes for the
WPC target population and permits it to include other
strategies to increase access to housing and supportive
services.
30)Requires WPC pilots to be approved by DHCS through the
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process outlined in the STCs.
31)Makes receipt of WPC services voluntary, and permits
beneficiaries to opt out at any time.
32)Requires the WPC lead entity to be responsible for operating
the WPC pilot, conducting ongoing monitoring of WPC
participating entities, arranging for the required reporting,
ensuring an appropriate financial structure is in place, and
identifying and securing a permissible source of the
nonfederal share for WPC pilot payments.
33)Requires each WPC pilot to include, at a minimum, all of the
following entities as WPC participating entities in addition
to the WPC lead entity:
a) At least one Medi-Cal managed care plan operating in the
geographic area of the WPC pilot;
b) The health services agency or agencies or department or
departments for the geographic region where the WPC pilot
operates, or any other public entity operating in that
capacity for the county or city and county;
c) The local entities, agencies, or departments responsible
for specialty mental health services for the geographic
area where the WPC pilot operates;
d) At least one other public agency or department, which
may include, but is not limited to, county alcohol and
substance use disorder programs, human services agencies,
public health departments, criminal justice or probation
entities, and housing authorities, regardless of how many
of these fall under the same agency head within the
geographic area where the WPC pilot operates; and,
a) At least two other community partners serving the target
population within the applicable geographic area.
1)Permits a WPC lead entity to request an exemption from this
requirement from DHCS if a WPC lead entity cannot reach an
agreement with a required participant.
2)Requires DHCS to enter into a pilot agreement with each WPC
lead entity approved for participation in the WPC pilot
program.
3)Permits the sharing of health information, records, and other
data with and among WPC lead entities, and allows WPC
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participating entities to share health information, records,
and other data with and among prospective WPC lead entities
and WPC participating entities in the process of identifying a
proposed target population and preparing an application for a
WPC pilot.
4)Permits WPC pilots to target the focus of their pilot on
individuals at risk of or are experiencing homelessness who
have a demonstrated medical need for housing or supportive
services. Requires, in these instances, WPC participating
entities to include local housing authorities, local continuum
of care programs, community-based organizations, and others
serving the homeless population as entities collaborating and
participating in the WPC pilot.
5)Permits the housing interventions to include tenancy-based
care management services, defined as supports to assist the
target population in locating and maintaining medically
necessary housing, and countywide housing pools.
6)Permits WPC participating entities to include contributions to
a countywide housing pool that will directly provide needed
support for medically necessary housing services, with the
goal of improving access to housing and reducing churn in the
Medi-Cal population.
7)Requires payments to WPC pilots to be disbursed twice a year
to the WPC lead entity following the submission of required
reports.
8)Requires DHCS to issue a WPC pilot application and selection
criteria consistent with the STCs, requires DHCS to approve
applicants that meet the WPC pilot selection criteria
established by DHCS, and requires DHCS to allocate available
funding to those approved WPC pilots up to the full amount of
FFP authorized under the demonstration project for WPC pilots
during each calendar year from 2016 to 2020.
9)Requires that payments to the WPC pilot are intended to
support infrastructure to integrate services among local
entities that serve the WPC target population, to support the
availability of services not otherwise covered or directly
reimbursed by Medi-Cal to improve care for the WPC target
population, and to foster other strategies to improve
integration, reduce unnecessary utilization of health care
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services, and improve health outcomes.
10)Requires WPC lead entities to submit mid-year and annual
reports to DHCS, in accordance with the schedules and
guidelines established by DHCS and consistent with the STCs.
11)Requires the nonfederal share of any payments under the WPC
pilot program to consist of voluntary IGTs of funds provided
by participating governmental agencies or entities, in
accordance with this bill and the terms of the pilot
agreement.
12)Requires DHCS to claim FFP for WPC pilot payments using
moneys from the IGTs and FFP, and requires moneys disbursed
from the fund, and all associated FFP to be distributed to WPC
lead entities.
13)Requires DHCS to implement the Dental Transformation
Initiative (DTI) in accordance with the STCs, with the goal of
improving the oral health care for Medi-Cal children 0 to 20,
inclusive, years of age.
14)Establishes as the purpose of the DTI is to improve the oral
health care for Medi-Cal children with a particular focus on
increasing the statewide proportion of qualifying children
enrolled in the Medi-Cal Dental Program who receive a
preventive dental service by 10 percentage points over a
five-year period.
15)Requires the DTI to include the following four domains as
outlined in the STCs:
a) Increase Preventive Services Utilization for Children;
b) Caries Risk Assessment and Disease Management Pilot;
c) Increase continuity of care; and,
d) Local Dental Pilot Projects (LDPPs).
1)Requires, under the DTI, incentive payments within each domain
to be available to qualified providers who meet the
requirements of the domain.
2)Requires the DTI to be funded at a maximum of $148 million
annually, and for five years totaling a maximum of $740
million, except as provided in the STCs. Permits unspent funds
to be rolled over to subsequent years.
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3)Permits DHCS to earn additional demonstration authority, up to
a maximum of $10 million to be added to the DTI Pool for use
in paying incentives to qualifying providers under DTI by
achieving higher performance improvement, as indicated in the
STCs.
4)Permits providers in either the dental FFS or dental managed
care Medi-Cal delivery systems to participate in the DTI.
5)Requires DHCS to make DTI incentive payments directly to
eligible contracted service office locations.
6)Requires incentive payments to be issued to the service office
location based on the services rendered at the location and
that service office location's compliance with the criteria
enumerated in the STCs.
7)Requires that incentive payments from the DTI Pool are
intended to support and reward eligible service office
locations for achievements within one or more of the project
domains. Prohibits incentive payments from being considered as
a direct reimbursement for dental services under Medi-Cal.
8)Requires service office locations to submit all data in a
manner acceptable to DHCS within one year from the date of
service or by January 31 for the preceding year that the
service was rendered, whichever occurs sooner, to be eligible
for DTI incentive payments associated with that timeframe.
9)Permits DHCS to implement this bill or the STCs by means of
letters or bulletins without taking regulatory action.
Requires notification to the Joint Legislative Budget
Committee and to the Senate Committees on Appropriations,
Budget and Fiscal Review, and Health, and the
Assembly Committees on Appropriations, Budget, and Health within
10 business days after the above-described action is taken.
10)Permits DHCS to enter into exclusive or nonexclusive
contracts or amend existing contracts on a bid or negotiated
basis. Exempts these contracts from specified provisions of
the Public Contract Code and Department of General Services
(DGS) review.
11)Requires DHCS to seek any federal approval as necessary to
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implement Medi-Cal 2020, this bill and any changes to the STCs
as deemed necessary. Implements this only to the extent
federal financial participation (FFP) is available and is not
otherwise jeopardized.
12)Permits the DHCS director to modify any process or
methodology in this bill to the extent necessary to comply
with federal law or the STCs, but only if the modification is
consistent with the goals of this bill.
13)Requires the DHCS director develop a methodology by which
payments under Medi-Cal 2020 are reduced if the amount of FFP
is reduced due to the application of penalties in the STC, the
enforcement of the budget neutrality limit or other similar
occurrence.
14)Permits DHCS to claim FFP for expenditures associated with
designated state health programs (DSHP) identified in the
STCs.
15)Continues the continuously appropriated Demonstration DSH
Fund and Public Hospital Investment, Improvement and Incentive
Fund, and establishes the continuously appropriated Global
Payment Program Special Fund and the WPC Pilot Special Fund in
the State Treasury.
16)Requires DHCS to conduct or arrange to have conducted any
study, report, assessment, evaluation or other similar
demonstration project activity required under the STCs.
17)Requires DHCS to conduct or arrange to have conducted the
PRIME program evaluation, the DTI evaluation, the WPC pilot
program, and two evaluations of the GPP required by the STCs.
18)Would take effect immediately as an urgency statute
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, this bill is
needed to provide the statutory framework for implementation
of "Medi-Cal 2020." While the STCs outline the programmatic
and financing elements of Medi-Cal 2020, state law changes are
required, particularly related to hospital financing. This
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bill is needed to continue existing Medi-Cal FFS payments to
DPHs, to change how federal DSH funds are provided to DPHs
consistent with the STCs under the GPP, to continue DSH
payments to private and DMPHs, to implement the expanded
provisions of PRIME, to appropriate funds for the
waiver-related provisions, to enable data sharing as part of
WPC projects, and to codify the provisions of the STCs
establishing the DTI and the access assessments. In addition,
this bill would grant flexibility to DHCS to implement
Medi-Cal 2020 without using the regular contracting and
regulatory processes due to waiver timelines, and would
require notification to the Legislature regarding
waiver-related activities.
2)Federal Section 1115 Medicaid Waivers. Section 1115 of the
Social Security Act authorizes the federal Secretary of Health
and Human Services to allow states to receive federal Medicaid
matching funds without complying with all of the federal
Medicaid rules. Traditionally designed as research and
demonstration programs to test innovative program improvements
and to facilitate coverage expansions to populations not
otherwise eligible for Medicaid, waivers are also used to
allow states to change how services are delivered, and to
change how services are reimbursed. In addition, under Section
1115, states are allowed to use federal Medicaid funds in ways
that are not otherwise allowed under federal law and
regulation (referred to expenditure authority for "costs not
otherwise matchable" or CNOM).
Section 1115 waivers are approved at the discretion of the
Secretary of HHS through negotiations between a state and CMS
for projects that the Secretary determines promote Medicaid
program objectives. Section 1115 waivers are generally
approved for a five-year period and then must be renewed.
Although not required by statute or regulation, longstanding
federal administrative policy has required waivers to be
"budget neutral" for the federal government, meaning that
federal spending under a waiver must not be more than
projected federal spending in the state without the waiver.
3)California's 2010 Bridge to Reform Section 1115 Waiver.
California's 2010 Section 1115 "California Bridge to Reform
Demonstration" Waiver was a five-year demonstration of health
care reform initiatives that was projected to provide an
additional $10 billion in federal funds over the lifetime of
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the waiver. The waiver prepared the state for successful
implementation of health care reform through an early
expansion of Medicaid, and tested innovations in health care
support for safety net providers. The Bridge to Reform was a
five year waiver, which began November 1, 2010 and expired
October 31, 2015 (although parts were extended until December
31, 2015). California also operates its Medi-Cal managed care
delivery system under this federal waiver. The Bridge to
Reform Waiver enabled California to:
a) Implement an early expansion of Medicaid to low-income
adults without minor children under ACA through the Low
Income Health Program, which enrolled 650,000 individuals;
b) Require the mandatory enrollment of SPDs into Medi-Cal
managed care plans in specified counties;
c) Provide federal funding for delivery system reform and
uncompensated care in designated public hospital systems
(county and University of California hospitals) through the
DSRIP and SNCP;
d) Provided federal funding for DSHP; and,
e) Operate its Medi-Cal managed care program,
Community-Based Adult Services program, and seven county
Coordinated Care Initiative (under the Initiative,
individuals dually eligible for Medicare and Medi-Cal
receive their Medi-Cal and Medicare benefits through one
health plan), Drug Medi-Cal Organized Delivery Systems
(Drug Medi-Cal ODS), uncompensated care for Indian Health
Services, and full scope coverage of pregnant women with
incomes between 109-138% of the federal poverty level.
1)Medi-Cal 2020 waiver. On December 30, 2015, DHCS received CMS
approval of "California Medi-Cal 2020 Demonstration" (Medi-Cal
2020). The five year waiver begins January 1, 2016 and ends
December 31, 2020. Medi-Cal 2020 is anticipated to provide
$6.2 billion in federal funds over the five years of the
waiver. The details of Medi-Cal 2020 are in the 300+ page STCs
and related attachments agreed to by the state and CMS.
Federal funding by waiver program component is as follows:
PRIME $3.732 billion
Global Payment Program$236 million* and **
Dental Transformation Initiative$375 million
Designated State Health Programs$375 million
Whole Person Care $1.5 billion __
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Total $6.21 billion
* GPP does not include the DSH component of funding. DSH
funding over the 5 years of the waiver is projected to be
$10.830 billion total funds ($5.915 billion federal funds).
** For GPP, initial federal funding only accounts for the
first year of the GPP (DY 11) as funding in subsequent years
is based on a study on DPH uncompensated care.
In addition to the program areas and federal funding under
Medi-Cal 2020, the federal government waives specified federal
Medicaid provisions, including the following:
a) Freedom of Choice:
i. To enable California to require participants
to receive benefits through certain providers and to
permit California to require that individuals receive
benefits through managed care providers who could not
otherwise be required to enroll in managed care. No
waiver of freedom of choice is authorized for family
planning providers.
b) DSH requirements:
i. To exempt California from making DSH payments,
in accordance with federal Medicaid law to a hospital
which qualifies as a DSH during any year for which the
Public Health Care System with which the DSH is
affiliated receives payment pursuant to the GPP.
a) Statewideness:
i. To enable California to operate the
demonstration on a county-by-county basis and to
provide Medi-Cal managed care plans only in certain
geographic areas.
ii. To enable California to provide Drug Medi-Cal
ODS services to individuals on a geographically
limited basis.
iii. To enable California to authorize WPC pilots
and to provide WPC services to individuals on a
geographically limited basis.
iv. To enable California to authorize DTI program
pilots and to provide DTI services to individuals on a
geographically limited basis.
a) Amount, Duration, and Scope of Services and
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Comparability
i. To enable California to provide different
benefits for low-income pregnant women between 109% up
to and including 138% of the Federal Poverty Level, as
compared to other pregnant women in the same
eligibility group.
ii. To enable California to authorize WPC pilots
which may make available certain services, supports or
interventions to certain high-risk, vulnerable
populations targeted under an approved WPC pilot
program that are not otherwise available to all
beneficiaries in the same eligibility group.
iii. To enable California to provide certain
services, supports and other interventions to eligible
individuals with substance use disorders under the
Drug Medi-Cal ODS program that are not otherwise
available to all beneficiaries in the same eligibility
group.
iv. To enable California to provide certain
services, supports and other interventions to eligible
individuals under the DTI program that are not
otherwise available to all beneficiaries in the same
eligibility group.
1)DSH. Medicaid DSH payments are federally required Medicaid
payments that states make to hospitals that serve a high
proportion of Medicaid and other low-income patients. DSH
payments supplement regular Medicaid payments for hospital
services and are intended to improve the financial stability
of safety-net hospitals by offsetting uncompensated care costs
for Medicaid and uninsured patients. Each state's annual DSH
allotment is calculated by federal law. DSH payments are
limited by the annual federal DSH allotments to each state.
Because hospitals were anticipated to have reduced
uncompensated care as a result of the federal Affordable Care
Act (ACA), the ACA proposed to reduce federal DSH funds.
Beginning in federal fiscal year 2014, the ACA proposed to
dramatically decrease the amount of funding that will be
provided under both DSH programs, based on the premise that
the ACA coverage expansions will result in fewer individuals
receiving uncompensated care. Under the ACA, the federal
Secretary of DHHS is required to develop a methodology that
will reduce the DSH payments by $14.1 billion during the
period 2014 to 2019, pursuant to a schedule set out in the
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ACA. These reductions increase over time, and by 2019
represent an approximate 50% reduction over baseline
projections. These reductions have been delayed multiple times
and are currently scheduled to begin in FY 2018. California
anticipates receiving $1.2 billion in federal DSH funds in
2015-16.
Under this bill, and consistent with the previous legislation
implementing the 2010 waiver, DHCS will "run the DSH list" to
determine which hospitals are eligible for federal DSH funds.
In 2014-15, the threshold for DSH eligibility is a 40.3%
Medi-Cal utilization rate (MUR) or higher, or a low-income
utilization rate (county indigent, charity care and Medi-Cal)
of 25% (the 25% LIUR is in statute and applies each year while
the MUR varies year-to-year). In the 2014-15 fiscal year,
there were 140 hospitals that were DSH-eligible, plus 3 UC
hospitals (at UCSF and 2 at UCLA) that were made DSH-eligible
by statute implementing the waiver. Under existing law dating
back to 1994-95, the state had a "rake off" of DSH funds to
achieve budget savings. The current rake off amount in statute
is $85 million, but the "rake off" was suspended in the
legislation implementing the 2005 and 2010 waivers, and
continues to be suspended in this bill.
Private hospitals that are DSH eligible do not receive DSH
funds. Instead, they receive "virtual DSH" (also referred to
as "DSH replacement payments") which is the same amount of
funding they would have received from DSH funds, except the
additional funds are funded by state General Funds and
"regular" federal Medicaid matching funds (instead of being
funded from the capped federal DSH allotment). DMPHs receive
DSH funds, with the state GF providing the matching funds used
to draw down federal funds. These requirements apply in the
previous waiver and continue in this bill.
Under Medi-Cal 2020, the five UC DPHs will continue to receive
DSH funds as they did in the prior waiver, using CPEs to draw
down the funds for costs below 100% of their costs, and IGTs
to drawn down DSH funds for their amounts between 100-175% of
their costs. Consistent with the previous waiver, this bill
makes all UC hospitals DSH-eligible who might not otherwise be
DSH-eligible. The amount of DSH funds UC is eligible to
receive under this bill system wide is capped at between 26.2%
and 21.8% after amounts for DMPHs are made, depending upon the
state fiscal year. DHCS is required to consult with UC prior
SB 815 (Hernandez) Page 17 of ?
to making interim and final DSH payments, and to make any
adjustments to the payment distributions requested by UC so
long as the aggregate net effect of the adjustments is zero.
County DPHs will now longer receive DSH funds as they did in
the prior waiver. Instead, county DPHs will receive DSH funds
under the new GPP, described below.
2)GPP. The GPP is a new feature of Medi-Cal 2020. Under GPP, a
statewide pool of funding for the remaining uninsured would be
established by combining federal DSH funding (which is limited
to hospitals under federal law) for county DPHs and some level
of federal uncompensated care pool funding (the SNCP was a
funding component of the previous waiver for the uninsured).
Under the GPP, each individual public hospital system would
receive a "global budget" for the remaining uninsured from the
overall GPP pool based on annual threshold amount determined
through baseline analysis of historical/projected
volume/cost/mix of services to the uninsured. The GPP would
integrate and reform Medicaid DSH and uncompensated care pool
funding by moving away from a cost-based payment methodology
restricted to mostly hospital settings to a more "risk-based"
and/or "bundled" payment structure.
GPP would encourage public hospital systems to provide greater
primary and preventive services, as well as alternative
modalities such as phone visits, group visits, telemedicine,
and other electronic consultations with the goal of improving
the health of the remaining uninsured through coordination of
care. DHCS would establish individual public hospital "global
budgets" for remaining uninsured for each DPH from the overall
pool based on annual threshold amount determined through
baseline analysis of historical/projected volume/cost/mix of
services to the uninsured. Achievement of threshold service
targets would be done on a "points" system with a base level
of points required for each system to earn their full global
budget. The threshold amounts for each PHCS will initially be
constructed using the volume and cost of services occurring in
participating providers, and will use the most recent complete
state fiscal year data. Funding would be claimed on a
quarterly basis, with the DPHs providing the necessary IGTs
for the non-federal share. Partial funding would be available
based on partial achievement of the "points" target. Funding
for the GPP is expected to decline over the duration of the
waiver due to the scheduled reduction in federal DSH funds.
SB 815 (Hernandez) Page 18 of ?
The amount of funding for the prior SNCP is unknown after the
initial year and will be determined based on an assessment of
DPH uninsured costs. DHCS received approval for the GPP points
systems attachments to the STCs on March 21, 2016.
As a condition of participation in the GPP, each DPH or
affiliated governmental agency or entity, must agrees to
provide IGTs necessary to meet the nonfederal share
obligation. This bill establishes different IGT transfer
amounts for each DPH under a methodology agreed to by the
DPHs. The reason for the different IGT transfer amounts is to
take into account hospital systems with high Medi-Cal losses.
The GPP is for the uninsured and it allows for care in a
non-hospital setting. However, because the point system is for
care to the uninsured and it uses DSH funds (which, under
federal law, are for hospital Medi-Cal and uninsured
shortfalls), the point system would disadvantage hospitals
with heavy Medi-Cal hospital loses. The second reason for the
different IGFT transfer amounts is the single standardized
point system used in the GPP is regardless of cost variation
among DPHs, and it results in a disadvantage to DPH systems in
higher cost areas as DPHs in lower-cost areas could meet their
threshold by providing relatively fewer services than would
otherwise be required.
3)PRIME. PRIME is a continuation and expansion on the DSRIP from
the 2010 waiver aimed to improve the care delivery in public
hospital systems. PRIME participating entities consist of DPHs
and DMPHs. DMPHs did not receive funds from DSRIP under the
2010 waiver. There are 21 DPHs that operate 17 health and
hospital systems, with one system comprised of four hospitals
in Los Angeles County. DPHs are located in mostly urban areas
in Northern, Central and Southern California. These hospitals
range in size from approximately 160 to 600 beds. DPHs are
similar in that they are academic teaching centers providing a
broad range of inpatient and outpatient services including
specialty care. More than 50% of patients served across these
health and hospital systems are Medi-Cal beneficiaries or
uninsured. DPHs provide 30% of all hospital-based care to the
Medi-Cal population in the state and operate more than half of
the state's level one trauma centers and more than two-thirds
of its burn centers. There are 40 DMPHs spanning 19 counties
across California. DMPHs are heterogeneous, varying
significantly in size (from approximately three to 500 beds)
and in the range of services provided.
SB 815 (Hernandez) Page 19 of ?
PRIME entities can earn incentive payments based on the
achievement of specified benchmarks across various metrics In
addition, PRIME requires the achievement of set targets in
three domains (Outpatient Delivery System Transformation,
Targeted High-Risk or High Cost, Populations, Resource
Utilization Efficiency) for moving toward APM for DPHs over
the course of the Waiver. DPHs must participate in all three
domains, while DMPHs must participate in only one domain.
Within the first two domains, DPHs are required to participate
in certain elements (for example, integration of physical and
behavioral health, ambulatory care redesign for primary care
and specialty care). The non-federal share of funding for
PRIME will be provided by DPHs/DMPHs through IGTs. Reporting
and payments will be made on a semi-annual basis, and PRIME
entities can achieve partial payment for partial achievement.
Annual federal funding available by waiver demonstration year
(DY) for DPH and DMPHs is shown below:
DPHs DMPHs
DY 11 (Jan 2016 - June 2016) $700 million $100
million
DY 12 (July 2016 - June 2017) $700 million $100
million
DY 13 (July 2017 - June 2018) $700 million $100
million
DY 14 (July 2018 - June 2019) $630 million $90
million
DY 15 (July 2019 - June 2020) $535.5 million$76.5
million
5 Year Total $3.2 billion$466.6
million
A goal of the waiver is to move participating DPH PRIME
providers toward a value-based payment structure when
receiving payments for Medi-Cal managed care beneficiaries. A
new feature in Medi-Cal 2020 is the establishment of APM
targets for DPHs in the aggregate that, if not met, result in
financial penalties. The waiver establishes four ways for
payments to be counted towards the APM thresholds, and the
target percentages are based on the number of Medi-Cal managed
care beneficiaries assigned to DPHs where all of, or a portion
of, their care is paid for under a contracted APM:
SB 815 (Hernandez) Page 20 of ?
50% by January 2018 (DY 13)
55% by January 2019 (DY 14)
60% by end of waiver (DY 15)
Five % of DPH PRIME funding at risk in DY14 (July 2018-June
2019) and DY15 (July 2019-June 2020) is tied to the
achievement of the APM targets. The APM targets do not apply
to DMPHs.
4)DTI. The DTI is a new feature of Medi-Cal 2020. It is funded
at $750 million total funds ($375 million in federal funds)
generated from federal waiver funding drawn down for
Designated State Health Programs. Of this amount, $10 million
in total funds is contingent upon the state meeting statewide
metrics. DTI consists of four domain areas as follows:
a) Domain 1: Increase Preventive Services Utilization for
Children. The goal of this domain is to increase statewide
proportion of children ages 20 and under enrolled in
Medi-Cal who receive a preventive dental service by 10
percentage points over a five-year period (the 2014 rate
for children was 37.84%). Incentive payments will be made
annually to providers for utilization and provider
participation and will be used to determine the subsequent
year's threshold. Semi-annual incentive payments will be
made to dental provider service locations that provide
preventative services to an increased number of Medi-Cal
children, as compared to the DHCS-determined baseline.
Incentive payments will be made to the service office
locations for rendered preventive services once they have
met the DHCS-established goal. As of September 2015, there
were 5,370 service office locations in California that
participated in Denti-Cal.
b) Domain 2: Caries Risk Assessment and Disease Management.
The goal of this domain is to diagnose early childhood
caries (cavities) by utilizing Caries Risk Assessments
(CRA) to treat caries as a chronic disease for children
ages six and under. The CRA would be a model that
proactively prevents and mitigates oral disease through the
delivery of preventative services in lieu of more invasive
and costly procedures (restorative services). Children will
have treatment plans prescribed based on caries risk level.
DHCS will use a baseline year with statewide data for the
SB 815 (Hernandez) Page 21 of ?
most recent state fiscal year preceding implementation of
the domain. DHCS will track and report the following
measures:
i. Number of, and percentage change in,
restorative services;
ii. Number of, and percentage change in,
preventive dental services;
iii. Utilization of CRA CDT codes and reduction
of caries risk levels (not available in the baseline
year prior to the waiver implementation);
iv. Change in use of emergency rooms for
dental-related reasons among the targeted children
for this domain; and,
v. Change in number and proportion of
children receiving dental surgery under general
anesthesia.
Dentists must opt-in by completing a DHCS recognized
training program. Treatment plans and associated procedures
will be carried out as follows, over a 12 month period, as
follows:
i. "high risk" children will be authorized to
visit four times;
ii. "moderate risk" children will be
authorized to visit three times; and,
iii. "low risk" children will be authorized to
visit two times.
Incentive payments will be made to providers for successful
completion of caries treatment plan and improvement in
"elevated risk" levels.
a) Domain 3: Increase Continuity of Care. The goal of this
domain is to increase continuity of care for beneficiaries
ages 20 and under for two, three, four, five, and six
continuous periods. DHCS will establish a baseline year
will be based on data from the most recent complete state
fiscal year using claims data to determine the number of
beneficiaries who received an examination each year from
the same service office location for two, three, four,
five, and six year continuous periods. Incentive payments
will be available to service office locations that provide
examinations to an enrolled Medi-Cal child for two, three,
SB 815 (Hernandez) Page 22 of ?
four, five, and six continuous periods. The incentive
payment will be an annual flat payment for providing
continuity of care to the beneficiary.
b) Domain 4: Local Dental Pilot Programs (LDPPs). LDPPS
will address one or more of the three domains through
alternative programs, potentially using strategies focused
on rural areas including local case management initiatives
and education partnerships. DHCS will solicit proposals
once at the beginning of the demonstration and will review,
approve, and make payments for LDPPs in accordance with the
requirements stipulated in the waiver. A maximum of 15
LDPPs will be approved, and no more than 25% of the total
funding in the DTI pool can be used for LDPPs. The specific
strategies, target populations, payment methodologies, and
participating entities will be proposed by the entity
submitting the application for participation and included
in the submission to DHCS. Each pilot application must
designate a responsible county, Tribe, Indian Health
Program, UC or CSU campus as the entity that will
coordinate the pilot.
1)WPC. WPC is a new feature of Medi-Cal 2020. WPC is essentially
a grant program over the five years of the waiver. The
overarching goal of the WPC pilots is the coordination of
health, behavioral health, and social services, as applicable,
in a patient-centered manner with the goals of improved
beneficiary health and well-being through more efficient and
effective use of resources. WPC pilots will provide an option
to participating entities to receive support to integrate care
for beneficiaries who are high-risk and high-utilizers of
multiple systems and continue to have poor health outcomes.
WPC pilots will include collaboration between two or more
public entities (e.g. county mental health plans and local
housing authorities), at least one Medi-Cal managed care
health plan, and other community entities with the goal of
improving health outcomes for the WPC population. Program
strategies would include increasing integration, data sharing
and coordination among county agencies, health plans,
providers, and other entities within the participating county
or counties that serve high-risk, high-utilizing beneficiaries
and develop an infrastructure that will reduce inappropriate
emergency and inpatient utilization, increase coordination and
appropriate access to care and increase collaboration and
integration among the entities participating in the WPC Pilots
SB 815 (Hernandez) Page 23 of ?
over the long term. The WPC target populations, include, but
are not limited to individuals:
a) With repeated incidents of avoidable emergency use,
hospital admissions, or nursing facility placement;
b) With two or more chronic conditions;
c) With mental health and/or substance use disorders;
d) Who are currently experiencing homelessness; and/or,
e) Who are at risk of homelessness, including individuals
who will experience homelessness upon release from
institutions (e.g. hospital, skilled nursing facility,
rehabilitation facility, jail/prison, etc.)
To test interventions that achieve these improved health
outcomes and cost savings, WPC Pilots may focus on Medi-Cal
beneficiaries with a demonstrated medical need for housing and
supportive services. These Pilots would ensure that the
entities collaborating and participating in the Pilot would
include local housing authorities, community-based
organizations, and others serving the homeless population. WPC
pilots with a focus on housing may include interventions such
as tenancy-based care management services and county housing
pools.
Up to $300 million in federal funding is available annually
for WPC. No single WPC pilot will be awarded more than 30% of
total available funding unless additional funds are available
after all initial awards are made. The non-federal share of
funds used to draw down federal funding is through IGTs.
The STCs establish an early implementation schedule for WPC.
DHCS is required to publish a WPC pilot application process,
detailed timeliness and selection criteria by April 1, 2016,
or within 90 days following CMS approval of WPC Pilot
attachments, whichever is later. WPC lead entities must submit
WPC Pilot applications to DHCS by May 15, 2016, or 45 days
after DHCS issues the WPC Pilot application process (whichever
is later). DHCS must complete its review of the application
within 60 days of submission, and will respond to the WPC
Pilot Lead Entity in writing with any questions, concerns or
problems identified. Within 30 days after submission of final
responses to questions about the application, DHCS will take
action on the application and promptly notify the applicant
and CMS of that decision.
SB 815 (Hernandez) Page 24 of ?
1)Designated State Health Programs. This bill permits DHCS to
claim FFP for expenditures associated with DSHPs identified in
the STCs. The state was able to draw down federal funds in the
previous waivers to offset GF expenditures. The DSHPs in the
waiver are as follows:
a) California Children Services (CCS)
b) Genetically Handicapped Persons Program (GHPP)
c) Medically Indigent Adult Long Term Care (MIALTC)
d) Breast & Cervical Cancer Treatment Program (BCCTP)
e) AIDS Drug Assistance Program (ADAP)
f) Department of Developmental Services (DDS)
g) Prostate Cancer Treatment Program (PCTP)
h) Song Brown Health Care Workforce Training Program
i) Steven M. Thompson Physician Corp Loan Repayment Program
j) Mental Health Loan Assumption Program
Any FFP claimed is required to be used to offset applicable GF
expenditures. DSHP funds will be used to fund Dental
Transformation Initiative FFP claiming, not to exceed $375
million over five years.
1)Waiver required reports, assessments and analyses. The Waiver
also contains several independent analyses of the Medi-Cal
program and evaluations of the Waiver programs, including:
a) Medi-Cal Managed Care Access Assessment;
b) Uncompensated Care Assessments for California hospitals
(one due in 2016 and one due one in 2017);
c) GPP Evaluations (2 required);
d) PRIME Evaluation; and,
e) Report on CCS pilots
This bill requires DHCS to conduct or arrange to have
conducted any study, report, assessment, evaluation or other
similar demonstration project activity required under the
STCs, and grants DHCS expedited contracting authority by
allowing DHCS to enter into exclusive or nonexclusive
contracts or amend existing contracts on a bid or negotiated
basis, and by exempting these contracts from specified
provisions of the Public Contract Code and DGS review. This
bill codifies the one of the evaluations (the Medi-Cal Managed
Care Access Assessment).
SB 815 (Hernandez) Page 25 of ?
Two foundations are funding the 2016 uncompensated care
assessment, which is due May 15, 2016 and is focused on DPHs.
This report is significant in that it will be used by CMS to
determine the appropriate level of Uncompensated Care Pool
funding of those providers in years two through five of the
demonstration (this pool of funding and DSH are the two fund
sources for the GPP). This report will review the impact of
the uncompensated care pool on those providers who participate
in the uncompensated care pool with respect to: uncompensated
care provided, Medicaid provider payment rates, Medicaid
beneficiary access, and the role of managed care plans in
managing care. CMS will provide a formal determination of the
funding levels for demonstration years two through five within
60 days of receipt of the complete report.
1)The next waiver post-Medi-Cal 2020. The funding in this waiver
is reduced from the 2010 waiver. DHCS and the public hospitals
both report CMS' desire to standardize waivers across the
states and CMS' view that waiver funding should be reduced
and/or eliminated due to the coverage expansions enacted by
the federal ACA. The most recent waiver was approved the day
before the expiration of the prior waiver, which, because it
occurred when the Legislature was not in session, necessitated
legislation (SB 36 (Hernandez and De Leon), Chapter 759,
Statutes of 2015) allowing DHCS to continue the operation of,
and the authorities provided under the prior waiver. This bill
contains language similar to SB 36 allowing DHCS to extend the
hospital methodologies payment in this waiver consistent with
federal requirements and after consultation with affected
entities. In addition, this bill contains language authorizing
DHCS to work to develop successor payment methodologies that
would continue to support entities participating in Medi-Cal
2020 following its expiration that further the goals of this
bill and the STCs.
2)Related legislation. AB 1568 (Bonta and Atkins) is identical
to this bill. AB 1568 is scheduled to be heard in the Assembly
Health Committee on April 26, 2016.
3)Prior legislation.
a) SB 36 (Hernandez and De Leon, Chapter 759, Statutes of
2015) authorized DHCS to request one or more temporary
waiver extensions to continue the operation of, and the
authorities provided under, the current "California Bridge
to Reform Demonstration," the state's Section 1115 Medicaid
SB 815 (Hernandez) Page 26 of ?
waiver. Requires DHCS to extend and apply the existing
hospital payment methodologies and allocations on a state
fiscal year, annual, partial year, or other basis, to the
extent permitted under any approved temporary waiver
extension, an approved subsequent waiver, or as otherwise
permitted under federal Medicaid law.
b) AB 1066 (John A. Pérez, Chapter 86, Statutes of 2011),
made further statutory changes to implement the Bridge to
Reform for funding DPHs. AB 1066 continued the FFS
cost-based reimbursement for DPHs, with those hospitals
providing the required federal match using their own funds
through CPEs. In addition, AB 1066 established under the
waiver a new distribution methodology for DSH and SNCP
funds to DPHs, as specified.
c) AB 342 (John A. Pérez, Chapter 723, Statutes of 2010),
enacted the LIHP to provide health care benefits to
uninsured adults up to 200% of the FPL, at county option
through a Medi-Cal waiver demonstration project.
d) SB 208 (Steinberg, Chapter 714, Statutes of 2010),
implemented provisions of the 2010 Section 1115 waiver
including establishing the Public Hospital Investment,
Improvement and Incentive Fund (known as DRSIP) consisting
of IGTs from counties or other specified governmental
entities, to be matched with federal funds and to be used
for investment, improvement and incentive payments for DPHs
and the affiliated governmental entities (counties and UC);
authorized DHCS to require the mandatory enrollment of SPDs
in a Medi-Cal managed care plan commencing on the later of
either June 1, 2011, or obtaining federal approval; and
requires DHCS to implement pilot projects to provide
coordinated care to children in CCS and to persons who are
dually eligible for Medi-Cal and Medicare.
e) SB 1100 (Perata, Chapter 560, Statutes of 2005), enacted
the statutory framework for implementing a five-year waiver
of federal Medicaid requirements that provides federal
Medicaid funding under the terms of the waiver to pay DPHs,
private, and district hospitals for services provided to
Medi-Cal and uninsured patients.
4)Support. This bill is supported by hospitals and consumer and
labor groups, which write in support of the $6.2 billion in
SB 815 (Hernandez) Page 27 of ?
federal funds and the new waiver funding components, including
PRIME, GPP and WPC. Public and district hospitals write in
support of PRIME, arguing the incentive funding provided by
PRIME will provide opportunity for public hospitals to put
into place needed programs to allow California to continue its
drive toward quality, improved outcomes and accountability in
safety net systems. The California Association of Public
Hospitals and Health Systems (CAPH) writes in support that
this bill will leverage California's coverage expansion with
significant payment reforms and delivery system improvements
for public health care systems.
Western Center on Law & Poverty (WCLP) writes in support and
requests amendments on the following: (a) that the access
assessment include a geographic assessment of the network that
examines how far patients have to go to access core
specialists and what transportation assistance and support the
plans provide to get patients to remote providers, and an
amendment to report languages spoken by the provider's office;
(b) to require DHCS to issue a final proposed point system for
the GPP to stakeholder for comments before finalizing it; (c)
to clarify that GPP systems may determine the scope, type and
extent to which services are available to the extent they are
consistent with the STCs but also to require that a patient's
services needs are met; (d) to make mandatory (instead of
optional) the WPC strategies of increasing access to housing
and supportive services for serving the homeless population;
and (e) to include a requirement that DHCS share such guidance
issued by DHCS with stakeholders prior to issuing it and
provide a chance for input.
5)Policy issues.
a) Need for urgency bill. This bill contains an urgency
clause. DHCS has indicated it would like to have this bill
enacted by June 2016 as several aspects of the work DHCS is
required to conduct under the Medi-Cal 2020 waiver cannot
be started or fully implemented without legislative
authority. For example, the waiver-required access
assessment must be conducted by the DHCS External Quality
Review organization. A contract amendment with this entity
is needed to do so, and this bill contains the authority so
DHCS can move forward on this assessment. In addition,
DHCS requires other contracting resources for other
evaluations and technical assistance, which cannot occur
until DHCS has the legislative authority, and a delay in
SB 815 (Hernandez) Page 28 of ?
DHCS' ability to contract impedes and delays DHCS' ability
to implement the various components of the waiver.
Finally, DHCS indicates that, although it believes the
waiver extension legislation from last year provided DHCS
the ability to make payments under GPP and PRIME, it is
possible that that interpretation could be challenged and
without this payment authority, DPHs would have severe cash
flow issues.
b) Contracting obligation on DPHs. Under the PRIME
provisions of the STCs and this bill, DPHs are required to
contract with at least one Medi-Cal managed care plan in
the service area where the plan operates using an APM
methodology as part of their APM methodology by January 1,
2018. If a DPH system is unable to meet the requirement and
can demonstrate that it has made a good faith effort to
contract with a Medi-Cal managed care plan in the service
area that it operates in or a gap in contracting period
occurs, DHCS has the discretion to waive this requirement.
One of the issues faced by patients in Medi-Cal managed care
plans is UC hospitals do not always contract with Medi-Cal
managed care plans, or they limit their contracting to
tertiary services or to letters of agreement for individual
patients. The contracting obligation in this bill and the
STCs is narrow in that the requirement that DPHs contract
only applies to one plan, and is limited to the service
area where they operate. However, this narrow waiver
requirement effectively means UC hospitals in urban
locations (UC hospitals are in San Diego, Irvine, San
Francisco, Sacramento and Los Angeles) may not be
accessible to patients served by patients enrolled in the
other Medi-Cal plan in two-plan model counties, or to
beneficiaries in rural or inland Medi-Cal managed care
plans. Medi-Cal 2020 provides a benefit to UC hospitals in
that it continues to make two of their hospitals (UCSF and
UCLA) DSH-eligible who would not otherwise be DSH eligible,
as shown below:
DSH Medicaid DSH
Low-Income
Utilization Rate
Utilization Rate
Minimum DSH Eligibility 40.3%*25%
SB 815 (Hernandez) Page 29 of ?
UCLA/Ronald Reagan 20.8% 10.8%
UCLA/Santa Monica 12.8% 13%
UCSF 26% 16.1%
*For 2014-15
In addition, Medi-Cal 2020 enables UC to receive cost-based
reimbursement in FFS Medi-Cal, and by making federal
funding available for quality improvement through PRIME.
However, UC also puts up the state match (through CPEs and
IGTs) to draw down federal Medicaid funds, which saves the
state GF, and UC argues it has sicker patient population
because of the specialized services it provides, and UC
uses its hospitals to help support its medical schools due
to insufficient state support. Should the requirement that
DPHs contract with Medi-Cal managed care plans be applied
more broadly beyond one Medi-Cal managed care plan in that
plan's area to include the other Medi-Cal managed care plan
in the county and Medi-Cal managed care plans serving
patients in inland and rural areas who use UC hospitals for
specialized care?
SUPPORT AND OPPOSITION :
Support: Antelope Valley Hospital
Association of California Healthcare Districts
Bear Valley Community Healthcare District
California Association of Public Hospitals
California Hospital Association
California Primary Care Association
California State Association of Counties
California State Council of the Service Employees
International Union
Coalinga Regional Medical Center
County Health Executives Association of California
County of San Bernardino
District Hospital Leadership Forum
El Camino Hospital
Health Access California
Kern Valley Healthcare District
Mammoth Hospital
Marin General Hospital
Mayers Memorial District Hospital
Northern Inyo Hospital
Oak Valley Hospital District
Palo Verde Hospital
SB 815 (Hernandez) Page 30 of ?
Palomar Health
Pioneers Memorial Healthcare District
Plumas District Hospitals
Salinas Valley Memorial Healthcare System
San Bernardino Mountains Community Hospital District
San Gorgonio Memorial Hospital
Santa Clara County Board of Supervisors
San Joaquin General Hospital
Seneca Healthcare District
Tahoe Forest Hospital District
Tri-City Medical Center
University of California
Urban Counties of California
Ventura County Board of Supervisors
Washington Hospital Healthcare System
Western Center on Law & Poverty
Oppose: None received
-- END --