BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: SB 815 --------------------------------------------------------------- |AUTHOR: |Hernandez and De Leon | |---------------+-----------------------------------------------| |VERSION: |April 11, 2016 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |April 27, 2016 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Scott Bain | --------------------------------------------------------------- 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) SB 815 (Hernandez) Page 2 of ? 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 SB 815 (Hernandez) Page 3 of ? 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. SB 815 (Hernandez) Page 4 of ? 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. SB 815 (Hernandez) Page 5 of ? 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. SB 815 (Hernandez) Page 6 of ? 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 SB 815 (Hernandez) Page 7 of ? 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 SB 815 (Hernandez) Page 8 of ? 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 SB 815 (Hernandez) Page 9 of ? 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. SB 815 (Hernandez) Page 10 of ? 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 SB 815 (Hernandez) Page 11 of ? 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 SB 815 (Hernandez) Page 12 of ? 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 SB 815 (Hernandez) Page 13 of ? 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 __ SB 815 (Hernandez) Page 14 of ? 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 SB 815 (Hernandez) Page 15 of ? 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 SB 815 (Hernandez) Page 16 of ? 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 --