BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1401
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|AUTHOR: |McGuire |
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|VERSION: |March 28, 2016 |
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|HEARING DATE: |April 13, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Pediatric and Home Care Expansion Act
SUMMARY : Requires the Department of Health Care Services to develop at
least 3 regional pilot projects in counties located in the San
Francisco Bay Area, the Central Valley and Los Angeles County to
increase access for children receiving Medi-Cal or California
Children's Services Program benefits who are eligible for
in-home, shift nursing care services by increasing private duty
nursing reimbursement rates by 20% for participating licensed
home health agencies. Sunsets the provisions of this bill on
July 1, 2020.
Existing law:
1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes Early and Periodic Diagnosis, Screening and
Treatment (EPSDT) for any individual under 21 years of age,
consistent with federal Medicaid requirements. Home health
care services are covered Medi-Cal benefits, subject to
utilization controls.
3)Establishes the California Childrens Services (CCS) Program to
provide specified medical care and therapy services to
children with CCS-eligible conditions. CCS eligible conditions
are generally described in regulation and include severe
genetic diseases, chronic medical conditions, infectious
diseases producing major sequelae, and traumatic injuries.
This bill:
1)Requires DHCS, on or before January 1, 2017, to establish at
SB 1401 (McGuire) Page 2 of ?
least three regional pilot projects, located in counties in
the San Francisco Bay area, the Central Valley, and the County
of Los Angeles, applicable to home health agencies that treat
children who receive skilled nursing services through the
Medi-Cal program.
2)Requires the three regional pilot project areas, at a minimum,
to include the following counties:
a) San Francisco Bay Area (Alameda, Contra Costa, Marin,
Napa, San Francisco, San Mateo, Santa Clara, Solano, and
Sonoma Counties);
b) Central Valley region (Fresno, Kern, Kings, Madera,
Merced, San Joaquin, Stanislaus, and Tulare Counties);
and,
c) Los Angeles County.
3)Requires the pilot projects to 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 and participate in the In-Home Operations Waiver
(IHO), CCS, or EPSDT.
4)Increases the applicable reimbursement rate for licensed home
health agencies that are currently providing private duty
nursing care by 20% above the Medi-Cal rate schedule in effect
as of July 1, 2015. Requires this increased reimbursement rate
to remain in effect for at least three years.
5)Implements this bill only to the extent that federal financial
participation is available. Requires DHCS to 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.
6)Permits DHCS, in collaboration with home health agencies, to
establish reasonable provider eligibility standards and
participation requirements for the pilot projects. Requires
collaborating home health agencies to include, but are not
limited to, agencies in good standing with the 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.
7)Requires, no later than April 1, 2020, DHCS, or a qualified
academic institution or other entity with which DHCS
contracts, to submit a report evaluating the effectiveness of
SB 1401 (McGuire) Page 3 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.
8)Permits DHCS, in order to compare access to necessary and
approved services before and after the establishment of the
pilot projects, to request participating home health agencies
to report on key access to care indicators identified by DHCS,
the participating agencies, and referring hospitals. Requires
the key access to care indicators to 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; and,
c) The number of available licensed home health agencies
that accept pediatric patients.
9)Requires DHCS, in evaluating the effectiveness of the pilot
projects, to cooperate with, and consider input from, home
health agencies, consumer groups, hospitals, and other
provider associations.
10)Makes legislative findings and declarations regarding home
care services, the pediatric patients served by home health
agencies, federal Medicaid law regarding reimbursement,
barriers to home health services, the reduction in home health
services to Medi-Cal patients.
11)Sunsets this bill on July 1, 2020, and repeals its provisions
January 1, 2021.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, there are almost
5,000 children statewide with severe long term, complex and
catastrophic health needs eligible for Medi-Cal in-home
nursing care. Most of these children are medically fragile,
permanently disabled, are on continuous life support or
require life-sustaining equipment such as ventilators and
feeding tubes. In-home skilled nursing care allows these
children to be safely discharged from expensive ICU-level
hospital care back into their homes at a fraction of the cost
to the state. In the last decade, Californians have seen
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growing barriers to accessing care. Factors such as
out-of-date reimbursement rates and difficulty recruiting
nurses with a unique combination of skills have resulted in
waiting lists and in some counties, no in-home care options.
Typically, medically fragile children are being treated in
expensive neonatal or pediatric intensive care units but can
come home if the appropriate care is available. Without the
access to skilled in-home nursing, the state is unnecessarily
spending limited resources and preventing children from being
at home with their families. This bill provide a targeted
Medi-Cal rate increase paid to eligible licensed home health
agencies for private duty nursing services provided to
children in three regional pilot areas that are currently
facing access to care challenges.
2)Background on Medi-Cal coverage of home health services.
Medi-Cal coverage of home health agency services is outlined
in its manual of criteria. In order for a patient to be
eligible to receive home health agency services, the patient
must have a medical condition requiring skilled care so as to
prevent further disability and/or promote improvement, and the
patient's medical condition for which services are being
prescribed must be reasonably responsive to the prescribed
service. Home health services are authorized only after being
prescribed by a physician as to the extent and duration of the
services and in accordance with a written treatment plan. The
treatment plan must be reviewed by a physician every 60 days.
The treatment plan must include a need for one or more covered
services such as skilled nursing care, physical therapy,
occupational therapy, speech therapy, medical social worker,
home health aide, and appropriate medical supplies. Medi-Cal
covers home health agency services in the following two
general situations:
a) During the convalescent phase of post-hospital or
institutional discharge or during the convalescent phase
following an acute episode or exacerbation of an illness
of a homebound patient; and,
b) When a homebound patient can be maintained at home in
lieu of institutional placement with skilled nursing or
other care.
Home health agency rates were reduced by 1% in 2009 but home
health agencies were not subject to the 10% rate reduction
required by AB 97 (Committee on Budget, Chapter 3, Statutes of
2011), because of potential access concerns. Home health
agency rates were last increased in 2001.
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1)Study on home health access for Medi-Cal patients. A 2015
study by Leavitt Partners funded by Maxim Healthcare Services
(a home health agency) entitled "Analysis of California Home
Health Care: Decreasing Access for Medi-Cal Patients" found
that while total capacity of the home health care market is
growing, services available for Medi-Cal patients have
remained stagnant since 2002. The report states significant
growth in new Medi-Cal enrollees and lack of growth in
agencies willing to provide services to enrollees suggests a
substantial access-to-care gap materializing between Medi-Cal
patients and non-Medi-Cal patients for home health services.
Key findings from the report are as follows:
a) That the Medi-Cal population has grown by 39% in seven
years (1.8 million more people), while the number of home
health visits provided to Medi-Cal patients has stayed
relatively stable during the same time period;
An increasing percentage of home health agencies are not
treating Medi-Cal patients (22% in 2002 to 56% in 2013);
b) Home health agencies are significantly more likely to
immediately accept new patients if they are privately
insured than if they are on Medi-Cal;
c) 60% of all the agencies treating Medi-Cal patients are
only able to provide 0 to 25% of the approved hours to
Medi-Cal patients;
d) 17% of all agencies have a cap on the number of
Medi-Cal patients they will accept; and,
e) By 2018, only four in 10 Medi-Cal certified agencies
will actually accept Medi-Cal patients in a given year.
The report concluded that the movement of home health agencies
away from providing services to Medi-Cal suggests three
important conclusions:
a) Growth in the home health care market has not
increased access to care for Medi-Cal patients as might
have been expected;
b) When entering the home health market, new agencies are
less likely to provide
services to Medi-Cal patients; and,
c) Access-to-care problems are exacerbated for certain
sub-populations, such as high-needs pediatric patients.
1)Support. This bill is supported by home health agencies and
children's specialty providers. Maxim Healthcare Services
(Maxim) writes in support that children throughout the state
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with severe medical conditions are eligible for in-home
nursing services through Medi-Cal, but the current fee
schedule causes access problems for in-home nursing services
as inadequate reimbursement rates to licensed home health
agencies restrict their ability to recruit and retain nurses
for this medically fragile pediatric population. When in-home
nursing services are not readily available, these children are
treated in expensive hospital neonatal or pediatric intensive
care units longer than necessary or they are being discharged
to family members without trained nurses available to assist
these families. A likely result of the poor access is longer
hospital admissions days or readmissions due to the lack of
nursing care available in the community. Maxim states this
bill addresses this urgent problem by establishing a pilot
project in three geographic areas where home health agency
Medi-Cal reimbursement rates are increased by 20%. To provide
accountability for the rate increase, this bill requires data
to be reported to the Legislature on the effectiveness of the
pilot by assessing the number of nursing hours provided and
Medi-Cal savings through moving children from hospital stays
and to care in their homes. Maxim concludes that, without an
increase in reimbursement rates, the access gap to home health
agency service will continue to grow, as fewer home health
agencies are willing to accept Medi-Cal patients, which will
result in increased wait times for those seeking in-home
nursing services and higher state costs as these patients
remain in acute care hospitals.
SUPPORT AND OPPOSITION :
Support: American Academy of Pediatrics, California
California Association for Health Services at Home
California Children's Hospital Association
Children's Specialty Care Coalition
Premier Health
Maxim Healthcare Services
An individual
Oppose: None received
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