BILL NUMBER: SB 1401 AMENDED
BILL TEXT
AMENDED IN SENATE MARCH 28, 2016
INTRODUCED BY Senator McGuire
( Coauthor: Assembly Member
Dodd )
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. Home health care pilot
projects. Pediatric and Home Care Expansion Act.
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 services.
services and participate in specified programs. The bill would
require, for a period of at least 2 3
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 department
department, in collaboration with home health agencies, 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, 2019,
2020, and would be repealed as of January 1,
2020. 2021.
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. Home Medi-Cal certified home
health agencies work with many pediatric 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 pediatric patients to receive
care in their homes and allow parents of disabled
medically fragile 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 receiving
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 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. County of Los Angeles.
SEC. 2. Section 14132.78 is added to the Welfare and Institutions
Code, to read:
14132.78. (a) (1)
On This section shall be known, and may be cited, as
the Pediatric and Home Care Expansion Act.
(b) (1) On
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 San Diego
area, County of Los Angeles, 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 services.
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). 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 two
three 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.
(b)
(c) The department may may, in
collab oration with home health agencies, establish
reasonable provider eligibility standards and participation
requirements for the pilot projects. Collaborating home health
agencies shall include, but are not limited to, agencies
in good standing with the State Department of Public
Health, agencies that are participating in the Medi-Cal
program, and agencies that are accredited by the Accreditation
Commission for Health Care.
(c)
(d ) (1) No later than
April 1, 2019, 2020, 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.
(1)
(2 ) 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.
(2)
(3) 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.
(4) For the purposes of paragraph (1) of subdivision (b), the
three regional pilot project areas shall, at a minimum, include the
following counties:
(A) The counties of Alameda, Contra Costa, Marin, Napa, San
Francisco, San Mateo, Santa Clara, Solano, and Sonoma in the San
Francisco Bay area.
(B) The counties of Fresno, Kern, Kings, Madera, Merced, San
Joaquin, Stanislaus, and Tulare in the Central Valley region.
(C) The County of Los Angeles.
(3)
( 5) A report submitted pursuant to
this subdivision shall be submitted in compliance with Section
9795 of the Government Code.
(d)
(e) This section shall become inoperative on July 1,
2019, 2020, and as of January 1,
2020, 2021, is repealed.