Amended in Senate March 28, 2016

Senate Bill No. 1401

Introduced by Senator McGuire

begin insert

(Coauthor: Assembly Member Dodd)

end insert

February 19, 2016

An act to add and repeal Section 14132.78 of the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 1401, as amended, McGuire. begin delete Home health care pilot projects. end delete begin insert Pediatric and Home Care Expansion Act. end insert

Existing law provides for the licensure and regulation of home health agencies by the State Department of Public Health. Existing law requires all private or public organizations that provide or arrange for skilled nursing services to patients in the home to obtain a home health agency license. Existing law also provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. Existing law provides that home health care services are covered Medi-Cal benefits, subject to utilization controls.

This bill would require the department, on or before January 1, 2017, to develop at least 3 regional pilot projects in counties located in designated areas of the state. The pilot projects would be targeted to increase access to in-home, private duty nursing care for children receiving Medi-Cal benefits who are eligible for in-home, shift nursing care begin delete services. end delete begin insert services and participate in specified programs. end insert The bill would require, for a period of at least begin delete 2 end delete begin insert 3 end insert years, an increased reimbursement rate for participating licensed home health agencies that are currently providing private duty nursing. The bill would require that the pilot project be implemented only to the extent that federal financial participation is available, and would require the department to submit any state plan amendment, waiver, or waiver amendment application necessary for federal approval.

This bill would authorize the begin delete department end delete begin insert department, in collaboration with home health agencies, end insert to establish reasonable provider eligibility standards and participation requirements and also would require the department, or an entity contracting with the department, to report to specified committees of the Legislature an evaluation of the effectiveness of the pilot projects, with input from specified stakeholders. The bill’s provisions would become inoperative on July 1, begin delete 2019, end delete begin insert 2020, end insert and would be repealed as of January 1, begin delete 2020. end delete begin insert 2021. end insert

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

The Legislature finds and declares all of the
following:

(a) Home care services provide a critical role in the care
continuum. begin delete Home end delete begin insert Medi-Cal certified home end insert health agencies work
with begin insert many pediatric end insert patients who have medically complex
conditions, are often permanently disabled, and require extended
or continuous care, including ventilation, tracheostomy, and enteral
feedings.

(b) These services allow begin insert pediatric end insert patients to receive care in
their homes and allow parents of begin delete disabled end delete begin insert medically fragile end insert children
to continue to work in their communities. Studies have shown that
home care is cost effective compared to care in an acute care or
long-term care setting.

(c) The state has a responsibility under Section 1902(a)(30)(A)
of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(30)(A))
to ensure that Medicaid payments are consistent with efficiency,
economy, and quality of care, and are sufficient to enlist enough
providers so that care and services are available under the state
plan at least to the extent that care and services are available to
the general population in the geographic area.

(d) Hundreds of pediatric Medi-Cal patients in need of home
health services may face significant barriers in accessing care.
According to a 2015 study by Leavitt Partners, Medi-Cal patients
have fewer options than patients with alternative payment sources
for the services of home health agencies. Nearly 20 percent of
Medi-Cal certified agencies reported having to cease to provide
services to an area they previously served. In addition, only 28
percent of the agencies surveyed reported the ability to provide
more than 75 percent of the skilled nursing hours that the state
approved for the patient and almost 60 percent of the agencies
reported that they are able to cover less than 25 percent of the
approved hours for their Medi-Cal patients.

(e) Overwhelming evidence suggests that many home health
agencies are shifting resources away from Medi-Cal patients,
thereby creating barriers to providing care to Medi-Cal’s most
medically fragile children. Factors that create these barriers include,
but are not limited to, out-of-date reimbursement methodologies,
difficulty recruiting nurses into the home health care sector because
of low-pay rates, competition for nursing staff from long-term care
facilities, and market exits by many certified agencies. These
factors appear to have resulted in home health agencies begin delete receiving end delete
declining referrals from hospitals, using informal waiting lists or
caps to manage patient caseload, and missed nursing shifts for the
families of qualified patients.

(f) In order to address access to in-home nursing care for
children, the State Department of Health Care Services shall
conduct pilot projects targeted to home care providers in counties
in at least three regions of the state: the San Francisco Bay area
counties, the Central Valley region, and the begin delete San Diego area. The
pilot projects will require the department to adopt an
incentive-based value payment for children who are receiving
skilled nursing care in the home and who are enrolled in the state’s
Medi-Cal EPSDT/IHO waiver programs. The value-based payment
model will reward providers that improve quality and lower costs,
through better outcomes. end delete begin insert County of Los Angeles. end insert

SEC. 2.  

Section 14132.78 is added to the Welfare and
Institutions Code, to read:

14132.78.  

(a)  begin delete (1) end delete begin delete   end delete begin delete On end delete begin insert This section shall be known, and may
be cited, as the Pediatric and Home Care Expansion Act. end insert

begin insert (b) end insert begin insert   end insert begin insert (1) end insert begin insert   end insert begin insert On end insert or before January 1, 2017, the department shall
establish at least three regional pilot projects, located in counties
in the San Francisco Bay area, the Central Valley, and the begin delete San
Diego area, end delete begin insert County of Los Angeles, end insert applicable to home health
agencies that treat children who receive skilled nursing services
through the Medi-Cal program.

(2) The pilot projects established pursuant to paragraph (1) shall
be targeted to increase access to in-home, private duty nursing
care for children receiving Medi-Cal benefits who are eligible for
in-home, shift nursing care begin delete services. end delete begin insert services and participate in
the In-Home Operations Waiver (IHO), the California Children’s
Services Program (CCS), or the Early Periodic Screening,
Diagnosis and Treatment Program (EPSDT). end insert The applicable
reimbursement rate for licensed home health agencies that are
currently providing private duty nursing care shall be 20 percent
above the Medi-Cal rate schedule as of July 1, 2015. The increased
reimbursement rate shall remain in effect for at least begin delete two end delete begin insert three end insert
years.

(3) This section shall be implemented only to the extent that
federal financial participation is available. The department shall
submit any necessary application to the federal Centers for
Medicare and Medicaid Services for a state plan amendment,
waiver, or amendment to a waiver to implement the pilot project
described in this section.

begin delete

(b)

end delete

begin insert (c) end insert  The department begin delete may end delete begin insert may, in collaboration with home health
agencies, end insert establish reasonable provider eligibility standards and
participation requirements for the pilot projects. begin insert Collaborating
home health agencies end insert begin insert shall include, but are not limited to, agencies end insert

begin insert in good standing with the State Department of Public Health,
agencies that are end insert begin insert participating in the Medi-Cal program, and
agencies that are accredited by the Accreditation Commission for
Health Care. end insert

begin delete

(c)

end delete

begin insert (d end insert begin insert ) end insert begin insert   end insert begin insert (1) end insert  No later than April 1, begin delete 2019, end delete begin insert 2020, end insert the department, or a
qualified academic institution or other entity with which the
department contracts, shall submit a report evaluating the
effectiveness of the pilot projects to the Senate Committee on
Health, the Assembly Committee on Health, the Senate Committee
on Budget and Fiscal Review, and the Assembly Committee on
Budget.

begin delete

(1)

end delete

begin insert (2 end insert begin insert ) end insert  In order to compare access to necessary and approved
services before and after the establishment of the pilot projects,
the department may request participating home health agencies to
report on key access to care indicators identified by the department,
the participating agencies, and referring hospitals. The key access
to care indicators shall include, but need not be limited to:

(A) The increase or decrease in hospital discharges to home
health agencies.

(B) The number of nursing hours filled, as compared to the
number of hours that have been approved.

(C) The number of available licensed home health agencies that
accept pediatric patients.

begin delete

(2)

end delete

begin insert (3) end insert  In evaluating the effectiveness of the pilot projects, the
department shall cooperate with, and consider input from, home
health agencies, consumer groups, hospitals, and other provider
associations.

begin insert

(4) For the purposes of paragraph (1) of subdivision (b), the
three regional pilot project areas shall, at a minimum, include the
following counties:

end insert begin insert

(A) The counties of Alameda, Contra Costa, Marin, Napa, San
Francisco, San Mateo, Santa Clara, Solano, and Sonoma in the
San Francisco Bay area.

end insert begin insert

(B) The counties of Fresno, Kern, Kings, Madera, Merced, San
Joaquin, Stanislaus, and Tulare in the Central Valley region.

end insert begin insert

(C) The County of Los Angeles.

end insert begin delete

(3)

end delete

begin insert ( end insert begin insert 5) end insert  A report submitted pursuant to begin insert this end insert subdivision shall be
submitted in compliance with Section 9795 of the Government
Code.

begin delete

(d)

end delete

begin insert (e) end insert  This section shall become inoperative on July 1, begin delete 2019, end delete begin insert 2020, end insert
and as of January 1, begin delete 2020, end delete begin insert 2021, end insert is repealed.