BILL NUMBER: AB 2206 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 12, 2012
INTRODUCED BY Assembly Member Atkins
FEBRUARY 23, 2012
An act to amend Section 14132.275 of the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 2206, as amended, Atkins. Medi-Cal: dual eligibles: pilot
projects.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services and
under which qualified low-income persons receive health care
benefits. The Medi-Cal program is, in part, governed and funded by
federal Medicaid provisions. Existing federal law provides for the
federal Medicare Program, which is a public health insurance program
for persons 65 years of age and older and specified persons with
disabilities who are under 65 years of age. Existing law, to the
extent that federal financial participation is available, and
pursuant to a demonstration project or waiver of federal law,
requires the department to establish pilot projects in up to 4
counties, to develop effective health care models to provide services
to persons who are dually eligible under both the Medi-Cal and
Medicare programs. Under existing law, the department may require
persons who are dually eligible to enroll in a Medi-Cal managed care
plan that is established or expanded as part of a pilot project.
Existing law also provides that a person who is eligible for the
California Program of All-Inclusive Care for the Elderly (PACE),
which provides specified long-term care services to qualified older
individuals, may select a PACE plan if one is available in that
county.
This bill would require, if a PACE plan is available, that the
plan be presented as an enrollment option in the same manner as
managed care health plans participating in the demonstration project
, included in enrollment materials, enrollment assistance
programs, and outreach programs related to the pilot project, and
made available to Medi-Cal beneficiaries whenever enrollment choices
and options are presented. This bill would authorize persons who
are enrolled in a PACE plan to continue to receive their Medi-Cal
and Medicare benefits through the PACE plan without having to
reselect the plan, and authorize persons who are eligible for the
PACE program to disenroll from a managed care health plan and enroll
in a PACE plan at any time to receive their benefits. This
bill would require managed care health plans to identify, in their
assessments of enrollees, and notify certain beneficiaries of their
potential eligibility for the PACE program. This bill would require
the department to seek flexibility for PACE plans to facilitate the
growth of the PACE program.
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 14132.275 of the Welfare and Institutions Code
is amended to read:
14132.275. (a) The department shall seek federal approval to
establish pilot projects described in this section pursuant to a
Medicare or a Medicaid demonstration project or waiver, or a
combination thereof. Under a Medicare demonstration, the department
may operate the Medicare component of a pilot project as a delegated
Medicare benefit administrator, and may enter into financing
arrangements with the federal Centers for Medicare and Medicaid
Services to share in any Medicare program savings generated by the
operation of any pilot project.
(b) After federal approval is obtained, the department shall
establish pilot projects that enable dual eligibles to receive a
continuum of services, and that maximize the coordination of benefits
between the Medi-Cal and Medicare programs and access to the
continuum of services needed. The purpose of the pilot projects is to
develop effective health care models that integrate services
authorized under the federal Medicaid Program (Title XIX of the
federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the
federal Medicare Program (Title XVIII of the federal Social Security
Act (42 U.S.C. Sec. 1395 et seq.)). These pilot projects may also
include additional services as approved through a demonstration
project or waiver, or a combination thereof.
(c) Not sooner than March 1, 2011, the The
department shall identify health care models that may be
included in a pilot project, shall develop a timeline and process for
selecting, financing, monitoring, and evaluating these pilot
projects, and shall provide this timeline and process to the
appropriate fiscal and policy committees of the Legislature. The
department may implement these pilot projects in phases.
(d) Goals for the pilot projects shall include all of the
following:
(1) Coordinating Medi-Cal benefits, Medicare benefits, or both,
across health care settings and improving continuity of acute care,
long-term care, and home- and community-based services.
(2) Coordinating access to acute and long-term care services for
dual eligibles.
(3) Maximizing the ability of dual eligibles to remain in their
homes and communities with appropriate services and supports in lieu
of institutional care.
(4) Increasing the availability of and access to home- and
community-based alternatives.
(e) Pilot projects shall be established in up to four counties,
and shall include at least one county that provides Medi-Cal services
via a two-plan model pursuant to Article 2.7 (commencing with
Section 14087.3) and at least one county that provides Medi-Cal
services under a county organized health system pursuant to Article
2.8 (commencing with Section 14087.5). In determining the counties in
which to establish a pilot project, the director shall consider the
following:
(1) Local support for integrating medical care, long-term care,
and home- and community-based services networks.
(2) A local stakeholder process that includes health plans,
providers, community programs, consumers, and other interested
stakeholders in the development, implementation, and continued
operation of the pilot project.
(f) The director may enter into exclusive or nonexclusive
contracts on a bid or negotiated basis and may amend existing managed
care contracts to provide or arrange for services provided under
this section. Contracts entered into or amended pursuant to this
section shall be exempt from the provisions of Chapter 2 (commencing
with Section 10290) of Part 2 of Division 2 of the Public Contract
Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of
Division 3 of Title 2 of the Government Code.
(g) Services under Section 14132.95 or 14132.952, or Article 7
(commencing with Section 12300) of Chapter 3, that are provided under
the pilot projects established by this section shall be provided
through direct hiring of personnel, contract, or establishment of a
public authority or nonprofit consortium, in accordance with, and
subject to, Section 12301.6 or 12302 or 12301.6
, as applicable.
(h) Notwithstanding any other provision of state law, the
department may require that dual eligibles be assigned as mandatory
enrollees into managed care plans established or expanded as part of
a pilot project established under this section. Mandatory enrollment
in managed care for dual eligibles shall be applicable to the
beneficiary's Medi-Cal benefits only. Dual eligibles shall have the
option to enroll in a Medicare Advantage special needs plan (SNP)
offered by the managed care plan established or expanded as part of a
pilot project established pursuant to subdivision (e). To the extent
that mandatory enrollment is required, any requirement of the
department and the health plans, and any requirement of continuity of
care protections for enrollees, as specified in Section 14182, shall
be applicable to this section. Dual eligibles shall have the option
to forgo receiving Medicare benefits under a pilot project. Nothing
in this section shall be interpreted to reduce benefits otherwise
available under the Medi-Cal program or the Medicare Program.
(i) For purposes of this section, a "dual eligible" means an
individual who is simultaneously eligible for full scope
full-scope benefits under Medi-Cal and the
federal Medicare Program.
(j) (1) Persons meeting requirements for the
Program of All-Inclusive Care for the Elderly (PACE) pursuant to
Chapter 8.75 (commencing with Section 14590), may select a PACE plan
if one is available in that county. If In
areas where a PACE plan is available, the PACE plan shall be
presented as an enrollment option in the same manner as managed
care health plans participating in the demonstration project ,
and shall be included in all enrollment materials,
enrollment assistance programs, and outreach programs related to the
pilot project, and shall be made available to beneficiaries whenever
enrollment choices and options are presented. Persons who choose
a PACE plan shall remain in fee-for-service Medi-Cal and Medicare
and shall not be assigned to a managed care health plan until they
are assessed for eligibility and determined not to be eligible for
the PACE plan. Persons enrolled in a PACE plan shall
receive all Medi-Cal and Medicare services from the PACE
plan.
(2) Persons who are already enrolled in a PACE plan at the time of
the enrollment period for the demonstration project shall remain in
and continue to receive their Medi-Cal and Medicare benefits through
the PACE plan, and shall not be provided with enrollment materials or
required to select the PACE plan to remain in the plan.
(3) Notwithstanding any enrollment lock-in that may apply to the
demonstration project for receipt of Medi-Cal or Medicare benefits,
persons who become eligible for the PACE program and are enrolled in
a managed care plan are authorized to disenroll from the plan and
enroll in a PACE plan at any time to receive their Medi-Cal and
Medicare benefits.
(4) Managed care health plans shall identify in their assessments
of enrollees that occur during the transition to managed care and at
regularly scheduled intervals beneficiaries who are 55 years of age
and older who are at risk of being placed in a nursing home. Managed
care health plans shall notify these beneficiaries of their potential
eligibility for the PACE program.
(5) The department shall seek, through waivers or other means,
flexibility for PACE plans to facilitate the growth of the PACE
program, including, but not limited to, the ability to use
alternative care settings and community-based physicians to provide
services, interdisciplinary teams that are based on the needs of each
beneficiary, and marketing materials and enrollment brokers in a
simplified manner to create awareness in the community of available
PACE plans.
(k) Notwithstanding Section 10231.5 of the Government Code, the
department shall conduct an evaluation to assess outcomes and the
experience of dual eligibles in these pilot projects and shall
provide a report to the Legislature after the first full year of
pilot operation, and annually thereafter. A report submitted to the
Legislature pursuant to this subdivision shall be submitted in
compliance with Section 9795 of the Government Code. The department
shall consult with stakeholders regarding the scope and structure of
the evaluation.
(l) This section shall be implemented only if and to the extent
that federal financial participation or funding is available to
establish these pilot projects.
(m) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific this section
and any applicable federal waivers and state plan amendments by means
of all-county letters, plan letters, plan or provider bulletins, or
similar instructions, without taking regulatory action. Prior to
issuing any letter or similar instrument authorized pursuant to this
section, the department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries. The department
shall notify the appropriate policy and fiscal committees of the
Legislature of its intent to issue instructions under this section at
least five days in advance of the issuance.