BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Deborah V. Ortiz, Chair
BILL NO: AB 2968
A
AUTHOR: Leno
B
AMENDED: May 23, 2006
HEARING DATE: June 21, 2006
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FISCAL: Appropriations
9
6
CONSULTANT:
8
Vazquez / ak
SUBJECT
Medi-Cal: community-living support benefit
SUMMARY
This bill requires the Department of Health Services (DHS)
to develop and implement a program to provide a
community-living support benefit (benefit), as specified,
for Medi-Cal beneficiaries who are residents of San
Francisco (SF) and would otherwise be homeless, living in
shelters, or institutionalized.
ABSTRACT
Existing law:
1.Provides for the Medi-Cal program, administered by DHS,
and under which qualified low-income persons receive
health care benefits, subject to applicable state and
federal laws.
2.Establishes the Residential Care Facilities for the
Elderly Act (RCFE) under which facilities licensed by
Department of Social Services (DSS) provide varying
levels of protective supervision, personal care, or
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health-related services to persons 60 years of age or
older, but also to persons under 60 years of age with
compatible needs.
3.Establishes the California Statewide Supportive Housing
Initiative Act (SHIA), which defines supportive housing
as housing for low-income adults with specified health
and mental health conditions, but also including families
with children, elderly persons, young adults aging out of
the foster care system, individuals exiting from
institutional settings, veterans, or homeless people.
Supportive housing for these purposes has no limit on
length of stay, is occupied by the target population, and
is linked to onsite or offsite services that assist the
tenant to retain the housing, improve his or her health
status, maximize their ability to live and, when
possible, to work, in the community.
This bill:
1.Makes a number of findings and declarations regarding
Medi-Cal eligible persons in community-based housing and
their link to either community-based or site-based
health-related or psychosocial services.
2.Requires DHS to develop and implement a program to
provide a community-living support program for Medi-Cal
beneficiaries, to the extent federal financial
participation is available, and requires DHS to submit
any waiver application, modification of any existing
waiver, or amendment to the state's Medicaid plan,
necessary to provide this benefit.
3.Requires the community-living support benefit to include
both of the following:
a. Reimbursement for an array of health-related and
psychosocial services provided or coordinated at
community-based housing sites, including but not
limited to, assisted living units, residential care
facilities for the elderly, publicly-funded senior and
disabled housing projects, or supportive housing sites
that serve chronically homeless individuals; and
b. Access to community-living support services
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provided or coordinated at the community-based housing
site, including but not limited, personal care and
health services, such as are required in a licensed
residential care facility for the elderly, and support
services, as defined in existing law relating to
supportive housing programs.
4.Requires that individuals be eligible for the benefit
established by this bill if they are Medi-Cal eligible
and a resident of SF who would otherwise be homeless,
living in shelters or institutionalized, and who meet one
or both of the following criteria:
a. DHS determines that he or she would benefit from
supportive housing as defined in the SHIA; and
b. DHS determines that he or she is eligible for
placement in a skilled nursing or intermediate care
facility.
5.Requires DHS to seek to maximize resources for
community-based housing by coordinating the
community-living support benefits with existing efforts
to coordinate care, improve health outcomes, and reduce
long-term care costs for the targeted population.
6.Requires, as a condition of implementation of the project
established in this bill, the Board of Supervisors of the
City and County of SF to adopt a resolution providing
county funds for use by the state to match federal
Medicaid funds for the project and for any costs
associated with implementing and monitoring the waiver.
7.Includes legislative findings stating that due to the
unique circumstances facing Medi-Cal recipients in the
City and County of SF, who are residing in
community-based housing, special legislation, rather than
a general statute, is necessary.
FISCAL IMPACT
According to the Assembly Appropriations Committee, no
state fiscal effect would result from the measure as its
provisions would only apply upon a request by SF using its
own funds to pay for waiver implementation, monitoring, and
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services.
BACKGROUND AND DISCUSSION
Purpose of this bill
According to the author, this bill is needed to allow SF
City and County to offer community-based alternatives to
residents of Laguna Honda Hospital (LHH) or those at risk
of institutionalization. The author points out that SF has
experience providing financial supplements to keep people
in community alternatives, such as RCFEs, and continues to
do so. However, according to the sponsors, the Mayor of SF
and SF Department of Public Health, the need exceeds city
resources. This bill will provide access to a Medicaid
funded "wraparound" services, allowing SF to offer many
more SF residents a community alternative to admission to
LHH. The sponsors state that this bill will result in
bundling medical and support services, such as personal
care, case management, and mental health services together
in an all-inclusive rate, not unlike the nursing home rate.
According to the sponsors, SF currently pays an additional
$95 per day for Medi-Cal residents in LHH, and is willing
to continue to do that, but needs the flexibility to use
the combination of their contribution and Medi-Cal funds to
serve residents in the community instead of at LHH.
Medicaid and home and community-based services
The three ways that state Medicaid programs can provide
home and community-based services are through:
a. The home health benefit, a mandatory Medicaid
benefit that historically has emphasized skilled,
medically-oriented services in the home, but states
have the discretion to cover a number of therapeutic
services;
b. One of several optional state plan services,
including personal care, rehabilitation services,
private duty nursing, physical therapy, occupational
therapy, and transportation services; and
c. Home and community-based services waivers. Some of
California's Medi-Cal home and community-based
services include the In-Home Supportive Services
program, which is a state plan benefit, the Adult Day
Health Care Program, also a state plan benefit, the
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six 1915(C) waivers, including the AIDS waiver, the
developmentally disabled waiver, the In-Home Medical
Care waiver, the Nursing Facility A/B waiver, the
Nursing Facility Subacute waiver, and the Multipurpose
Senior Services Program waiver.
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Assisted Living Waiver Pilot Project (ALWPP)
AB 499 (Aroner, Chapter 557, Statutes of 2000), required
DHS to implement pilot projects to test the efficacy of
assisted living as a new Medi-Cal waiver benefit. This
Medicaid home and community-based services waiver program
will serve eligible residents in both licensed RCFEs and in
publicly subsidized housing settings. A key goal of the
pilot project is to enable low-income, Medi-Cal eligible
recipients, who would otherwise require inpatient nursing
facility services, to remain in or relocate to community
settings. The waiver has been approved by the Centers for
Medicare and Medicaid Services and will serve elderly
individuals or individuals with disabilities who meet the
nursing facility level of care but who can be served
outside of a nursing facility. To participate in the
ALWPP, beneficiaries must have full-scope Medi-Cal
eligibility, without a share of cost, meet the skilled
nursing facility level of care, and be at least 21 years of
age. The Governor's 2006-07 Budget proposes six staff at
DHS and $1.2 million ($476,000 General Fund) for
implementation in the three counties of Sacramento, San
Joaquin and Los Angeles and is expected to serve 500-1,000
persons over three years.
Arguments in support
Proponents write that this bill would support alternatives
to institutionalization at LHH including residential care
facilities, residential care facilities for the elderly,
and the permanent supportive housing provided through the
City's Direct Access to Housing program. Access to these
alternatives would be expanded at no additional costs to
the state because beneficiaries are already eligible for
the services that would be made available to beneficiaries
in community-based settings through this benefit.
Proponents add that ensuring that individuals with chronic
and disabling health conditions receive services in the
least restrictive setting is a mandate on states
established by the 1999 Olmstead v. L.C. Supreme Court
decision. This bill is consistent with this goal and with
language in California's Olmstead Plan stating that it is a
priority to ensure "the availability of housing options
that can be augmented by supports that facilitate the full
inclusion of the person into the community."
Other previous legislation
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AB 468 (Yee, 2005) requires DHS to develop, and request
approval of, a federal Medicaid waiver for reimbursement
of similar services for Medi-Cal beneficiaries in
supportive housing facilities administered by a local
governmental entity. AB 468 was amended to deal with
school nutrition issues.
PRIOR ACTIONS
Assembly Floor: 76 - 1 Pass
Assembly Appropriations:14 - 2 Do Pass as Amended
Assembly Health: 12 - 0 Do Pass as Amended
POSITIONS
Support: San Francisco Mayor's Office (co-sponsor)
San Francisco Department of Public Health
(co-sponsor)
American Federation of State, County, & Municipal
Employees
California Association for Health Services at
Home
Independent Living Resource Center
On Lok Senior Health Services
Protection and Advocacy, Inc.
San Francisco Senior Centers, Inc.
Oppose:None received.