BILL ANALYSIS
Senate Appropriations Committee Fiscal Summary
Senator Christine Kehoe, Chair
998 (Liu and Alquist)
Hearing Date: 5/3/2010 Amended: 4/20/2010
Consultant: Katie Johnson Policy Vote: Health 6-3
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BILL SUMMARY: SB 998 would require the Department of Health
Care Services (DHCS) to work with stakeholders to develop or
identify a long-term care assessment tool for use in case
management. It would also require counties to establish a
long-term care case management program for persons who are
Medi-Cal recipients or enrolled in both Medi-Cal and Medicare
and residing in, applying for admission to, or at imminent risk
of being placed in a long-term health care facility.
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Fiscal Impact (in thousands)
Major Provisions 2010-11 2011-12 2012-13 Fund
Stakeholder process to likely hundreds of thousands
annuallyGeneral/*
develop or select long-term Federal
care assessment tool; ongoing
program oversight
Development and likely hundreds of
thousandsGeneral/**
procurement of long-term to millions of dollars Federal
care assessment tool
Implementation of county likely millions of dollars
depending General/***
case management program on the number of case
managersFederal
Increased long-term care likely millions of dollars
annually General/***
facility staff reimbursement Federal
Increased reimbursement and unknown, but likely in the
General/*
utilization of home and millions to billions of dollarsFederal
community based services
Potential long-term unknown, to the extent that
program General/*
cost avoidance cost is contained and avoided byFederal
treating people in a more cost-
effective setting
*In general, costs would be shared 50 percent General Fund and
50 percent federal funds for all staff work
**If system procurement is necessary, costs could be shared 10
percent General Fund and 90 percent federal funds
***Costs could be shared 25 percent General Fund and 75 percent
federal funds
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STAFF COMMENTS: This bill meets the criteria for referral to the
Suspense File.
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SB 998 (Liu and Alquist)
This bill would create a county-based, comprehensive long-term
care program that would provide an assessment of an individual's
long-term care services needs and ongoing case management to
ensure that the individual would have every opportunity to
reside at home or in another community-based setting instead of
in a long-term care facility. Individuals who are Medi-Cal
recipients or enrolled in both Medi-Cal and Medicare, also known
as dual eligibles, and residing in, applying for admission to,
or at imminent risk of being placed in a long-term health care
facility would be eligible for the program. California has over
1 million dual eligibles and thousands more seniors and persons
with disabilities who are Medi-Cal enrollees. It is unknown
exactly how many people could be eligible for these transition
and case management services.
Major provisions in this bill with which a cost would likely be
associated are:
1) Department of Health Care Services (DHCS) initial and
ongoing staff costs to develop a uniform long-term care
services assessment in collaboration with stakeholders no
later than July 1, 2012, likely in the hundreds of
thousands of dollars through July 1, 2012;
2) DHCS administration to ensure that case management
programs maximize federal financial participation, provide
assistance to counties as they implement and administer the
case management program, and to contract directly with
nonprofit organizations or departments in counties that
choose not to administer their own case management program,
likely in the hundreds of thousands of dollars annually and
ongoing;
3) County case managers' and assessment workers' salaries
and administrative costs to implement and maintain the
required county case management programs. Assuming at least
1 case manager per county at $100,000 each, $5.8 million;
4) The hardware and software costs of developing an
assessment tool;
5) Increased Medi-Cal reimbursement for home and community
based service providers, unknown, but likely in the
millions and potentially billions of dollars;
6) Potential increased Medi-Cal costs or savings if the
stakeholders recommend and the Legislature approves a
revision of the long-term care treatment authorization
request (TAR) process;
7) Increase in Medi-Cal reimbursement to long-term care
facilities to inform residents and to contact case
managers, likely in the millions of dollars.
8) Initial and likely minor ongoing staff and data
collection and storage costs for the Office of Statewide
Health Planning and Development (OSHPD);
9) Increased staffing costs to the Department of Finance
(DOF) to develop baseline long-term care expenditures and
savings estimates;
10) Potential increased costs, offset by licensing
fees, to the Department of Public Health (CDPH) and
Department of Social Services (DSS) which license long-term
care facilities;
11) An unknown, but likely increase to In Home
Supportive Services (IHSS) program costs to the extent case
managers identify a need;
12) Increase in staffing to DSS to provide
oversight to any changes in the IHSS program administration
and assessment tool.
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SB 998 (Liu and Alquist)
Potential Future Program Cost Avoidance
This bill specifically directs the Department of Finance (DOF)
to estimate savings realized from placing individuals who would
otherwise be placed in or transferred to a licensed long-term
health care facility in a home or in a less restrictive
environment. To the extent that projected program costs of
serving beneficiaries in long-term care facilities is shown to
be more than actual program expenditures, there could be
significant cost avoidance.
Existing State Home and Community-Based Programs
Within California, the Departments of Aging (CDA), Health Care
Services (DHCS), Developmental Services (DDS), Mental Health
(DMH), Rehabilitation (DOR), Social Services (DSS), and Veterans
Affairs (DVA) each directly administer long-term care programs
such as Money Follows the Person (MFP), Program of All-Inclusive
Care for the Elderly (PACE), In-Home Supportive Services (IHSS),
and a DDS Home and Community Based Services waiver for Medi-Cal
eligible people with developmental disabilities. Many of these
programs conduct their own separate assessments and have
different eligibility requirements, limits on caseload, and
different streams of federal, state, and local funding.
It appears that this bill would attempt to streamline the
process of the procurement of services for eligible individuals.
Although it could be possible that DHCS and counties, in
implementing this bill, could utilize and build upon current
programs, streams of funding, and service delivery systems, it
is unknown both operationally and fiscally how existing programs
would interface with this bill's required long-term care
assessment tool and case management program.
One example of an existing system of stakeholder involvement and
a consumer-centered assessment, plan, case management system,
and service procurement is the regional center system that
serves Californians diagnosed with developmental disabilities as
administered by DDS. DDS staff currently work with a group of
stakeholders termed the Budget Advisory Committee on an ongoing
basis. The regional center system is made up of 21 nonprofit
regional centers that contract with DDS to initially assess an
individual's needs, develop an individual plan that outlines the
local services that an individual may need to live in his/her
community, purchase those necessary services, and provide
ongoing case management to the individual.
DDS and DHCS jointly administer a Section 1915 (c) Home and
Community Based Services (HCBS) waiver. This waiver serves
Medi-Cal and regional center services eligible consumers who
meet the requirements for placement in an intermediate care
facility (ICF). As an alternative to placement to an ICF or
state developmental center, waiver beneficiaries receive an
array of home and community based services, such as home health,
respite, skilled nursing, and transportation, to enable them to
live in a placement outside of a long-term care facility. Waiver
enrollment is capped at 90,000 consumers for October 1, 2009, to
September 31, 2010, and is capped at 95,000 for October 1, 2010,
through September 31, 2011. Actual caseload is unknown. The DDS
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SB 998 (Liu and Alquist)
November 2009 Estimate estimates that the department will spend
approximately $1.9 billion total funds in FY 2010-2011 for staff
and purchase of services for the HCBS waiver. There is no cost
avoidance calculation.
This is meant only as an example of a system and the necessary
funding similar to the program required by this bill. These
funding estimates are based on regional center clients only.
This bill could include individuals eligible for regional center
services and would include those with a diverse array of
diagnoses and needs. Costs per individual served could vary
dramatically.