BILL NUMBER: AB 1076 AMENDED
BILL TEXT
AMENDED IN SENATE JULY 23, 2009
AMENDED IN ASSEMBLY JUNE 1, 2009
AMENDED IN ASSEMBLY MAY 5, 2009
INTRODUCED BY Assembly Member Jones
( Principal coauthor: Senator
Alquist )
FEBRUARY 27, 2009
An act to amend Sections 14132.27 and 14133.10 of the Welfare and
Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 1076, as amended, Jones. Medi-Cal.
Existing law establishes the Medi-Cal program, administered by the
State Department of Health Care Services, under which basic health
care services are provided to qualified low-income persons.
Existing law requires the department to apply for a waiver of
federal law to test the efficacy of providing a disease management
benefit, as described, to specified beneficiaries under the Medi-Cal
program. Existing law permits the director, in undertaking this
program, to enter into contracts for the purpose of directly
providing specified services.
This bill would add the designation of a primary care provider as
a patient's medical home to the list of components that a disease
management benefit would include for purposes of the waiver. The
bill would also specify that this component only apply to a contract
entered into or renewed by the director after January 1, 2010.
Existing law authorizes the director, in conducting Medi-Cal acute
care inpatient hospital utilization controls, to establish a program
of aggressive case management of elective, nonemergency acute care
hospital admissions.
This bill would, if the director has established a program of
aggressive case management, require the director, on or after July 1,
2010, to expand the program to include Medi-Cal beneficiaries who
meet prescribed conditions. The bill would specify that the
expansion wo uld only be implemented to the extent that
funds are appropriated by the Legislature, or are otherwise made
available, for that purpose.
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. Section 14132.27 of the Welfare and Institutions Code
is amended to read:
14132.27. (a) (1) The department shall apply for a waiver of
federal law pursuant to Section 1396n of Title 42 of the United
States Code to test the efficacy of providing a disease management
benefit to beneficiaries under the Medi-Cal program. A disease
management benefit shall include, but not be limited to, the use of
evidence-based practice guidelines, the designation of a primary care
provider as a patient's medical home, supporting adherence to care
plans, and providing patient education, monitoring, and healthy
lifestyle changes.
(2) The waiver developed pursuant to this section shall be known
as the Disease Management Waiver. The department shall submit any
necessary waiver applications or modifications to the Medicaid State
Plan to the federal Centers for Medicare and Medicaid Services to
implement the Disease Management Waiver, and shall implement the
waiver only to the extent federal financial participation is
available.
(b) The Disease Management Waiver shall be designed to provide
eligible individuals with a range of services that enable them to
remain in the least restrictive and most homelike environment while
receiving the medical care necessary to protect their health and
well-being. Services provided pursuant to this waiver program shall
include only those not otherwise available under the state plan, and
may include, but are not limited to, medication management,
coordination with a primary care provider, use of evidence-based
practice guidelines, supporting adherence to a plan of care, patient
education, communication and collaboration among providers, and
process and outcome measures. Coverage for those services shall be
limited by the terms, conditions, and duration of the federal waiver.
(c) Eligibility for the Disease Management Waiver shall be limited
to those persons who are eligible for the Medi-Cal program as aged,
blind, and disabled persons or those persons over 21 years of age who
are not enrolled in a Medi-Cal managed care plan, or eligible for
the federal Medicare program, and who are determined by the
department to be at risk of, or diagnosed with, select chronic
diseases, including, but not limited to, advanced atherosclerotic
disease syndromes, congestive heart failure, and diabetes.
Eligibility shall be based on the individual's medical diagnosis and
prognosis, and other criteria, as specified in the waiver.
(d) The Disease Management Waiver shall test the effectiveness of
providing a Medi-Cal disease management benefit. The department shall
evaluate the effectiveness of the Disease Management Waiver.
(1) The evaluation shall include, but not be limited to,
participant satisfaction, health and safety, the quality of life of
the participant receiving the disease management benefit, and
demonstration of the cost neutrality of the Disease Management Waiver
as specified in federal guidelines.
(2) The evaluation shall estimate the projected savings, if any,
in the budgets of state and local governments if the Disease
Management Waiver was expanded statewide.
(3) The evaluation shall be submitted to the appropriate policy
and fiscal committees of the Legislature on or before January 1,
2008.
(e) The department shall limit the number of participants in the
Disease Management Waiver during the initial three years of its
operation to a number that will be statistically significant for
purposes of the waiver evaluation and that meets any requirements of
the federal government, including a request to waive statewide
implementation requirements for the waiver during the initial years
of evaluation.
(f) In undertaking this Disease Management Waiver, the director
may enter into contracts for the purpose of directly providing
Disease Management Waiver services. The requirement that the
disease management benefit includes the designation of a primary care
provider as a patient's medical home, pursuant to paragraph (1) of
subdivision (a), shall only apply to a contract entered into or
renewed after January 1, 2010.
(g) The department shall seek all federal waivers necessary to
allow for federal financial participation under this section.
(h) The Disease Management Waiver shall be developed and
implemented only to the extent that funds are appropriated or
otherwise available for that purpose.
(i) The department shall not implement this section if any of the
following apply:
(1) The department's application for federal funds under the
Disease Management Waiver is not accepted.
(2) Federal funding for the waiver ceases to be available.
SEC. 2. Section 14133.10 of the Welfare and Institutions Code is
amended to read:
14133.10. (a) Where it is expected to be cost-effective, the
director may, in conducting Medi-Cal acute care inpatient hospital
utilization control, establish a program of aggressive case
management of elective, nonemergency acute care hospital admissions
for the purpose of reducing both the numbers and duration of acute
care hospital stays by Medi-Cal beneficiaries.
(b) In conducting the case management program, the department may
conduct daily reviews to determine the need for additional days of
inpatient care.
(c) In undertaking this case management program, the director may
enter into contracts, on a bid or nonbid basis, for the purposes of
obtaining the necessary expertise to train and educate utilization
control staff in case management concepts, principles and techniques,
identifying and recommend cost-effective therapies, services, and
technology as alternatives to elective acute care hospitalization or
to directly provide the case management and diversion services.
(d) (1) If the director has established a program of aggressive
case management pursuant to subdivision (a), the director shall, on
or after July 1, 2010, expand the program to include Medi-Cal
beneficiaries who meet all of the following conditions:
(A) The beneficiaries have two or more chronic conditions,
including substance abuse disorders and mental health conditions.
(B) The beneficiaries are not enrolled in a managed care plan.
(C) The beneficiaries are not eligible for the Medicare benefits.
(D) The beneficiaries have received emergency department services
on four or more occasions in the previous 12 months.
(E) The beneficiaries are currently seeking care for a condition
that could have been prevented with timely primary care access and
case management.
(2) Case management services provided pursuant to this subdivision
shall include, but not be limited to, coordinating services to
ensure continuity of care, establishing links to health care
professionals and community social services resources that would
assist in stabilizing the target population, and expediting the
authorization of medically necessary services.
(3) An expansion of the aggressive case management program
pursuant to this subdivision shall be implemented only to the extent
that funds are appropriated by the Legislature, or are otherwise made
available, for that purpose.
(e) In order to achieve maximum cost savings the Legislature
hereby determines that an expedited contract process for contracts
under this section is necessary. Therefore, contracts under this
article may be on a nonbid basis, and shall be exempt from the
provisions of Chapter 2 (commencing with Section 10290) of Part 2 of
Division 2 of the Public Contract Code. Contracts shall have no force
and effect unless approved by the Department of Finance.
(f) The department shall seek all federal waivers necessary to
allow for federal financial participation under this section.