BILL ANALYSIS �
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THIRD READING
Bill No: AB 2206
Author: Atkins (D)
Amended: 8/6/12 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 7-0, 6/27/12
AYES: Hernandez, Harman, Alquist, Anderson, Blakeslee,
DeSaulnier, Rubio
NO VOTE RECORDED: De Le�n, Wolk
SENATE APPROPRIATIONS COMMITTEE : 7-0, 8/6/12
AYES: Kehoe, Walters, Alquist, Dutton, Lieu, Price,
Steinberg
ASSEMBLY FLOOR : 73-0, 5/10/12 (Consent) - See last page
for vote
SUBJECT : Medi-Cal: dual eligibles: pilot projects
SOURCE : CalPACE
DIGEST : This bill expands the ability of people who are
dually eligible for Medi-Cal and Medicare to enroll or
remain enrolled in Programs for the All-Inclusive Care for
the Elderly (PACE).
ANALYSIS :
Existing law:
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1. Establishes the Medi-Cal Program, administered by the
Department of Health Care Services (DHCS), to provide
comprehensive health care and long-term services and
supports (LTSS) to pregnant women, children, seniors,
and people with disabilities (SPDs).
2. Requires DHCS to seek federal approval to establish a
pilot program in up to four counties for Medi-Cal
beneficiaries who are dually eligible for Medicare and
Medi-Cal (dual eligibles), under which DHCS can require
that dual eligibles are assigned as mandatory enrollees
into Medi-Cal managed care plans.
3. Permits the Director of DHCS to establish PACE to
promote the development of community-based, risk-based
capitated, long-term care programs. Permits the Director
of DHCS to contract with up to 15 demonstration projects
to develop risk-based long-term care pilot programs
modeled upon On Lok Senior Health Services in San
Francisco.
4. Establishes the PACE program as a Medi-Cal benefit,
subject to utilization controls and eligibility criteria
that require that the beneficiary be certified as
eligible for nursing facility services based on Medi-Cal
criteria.
This bill provides that:
1. Individuals who are already enrolled in PACE at the time
of mandatory enrollment in managed care shall remain in
PACE and not be sent alternative enrollment information.
2. Individuals who become eligible for PACE and are
enrolled in a managed care plan are exempted from the
lock-in period and may disenroll from their manage care
plan and enroll in PACE.
3. Managed care plans are required to periodically assess
beneficiaries over 55 years of age who are at risk for
placement in a nursing home and notify them of their
potential eligibility for PACE.
Background
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PACE . PACE is a capitated benefit provided primarily to
certain Medi-Cal and Medicare beneficiaries that offers a
comprehensive service delivery system and integrates
Medicare and Medicaid financing. The program was modeled
after the acute and long-term care services of On Lok
Senior Health Services in San Francisco.
Participants must be at least 55 years old, live in the
PACE service area, and be certified as eligible for nursing
home care. Enrollment in PACE is voluntary. An
interdisciplinary team, consisting of professional and
paraprofessional staff, assesses participants' needs,
develops care plans, and delivers all services (including
acute care services and when necessary, nursing facility
services). The PACE service package must include all
Medicare and Medicaid covered services and other services
determined necessary by the interdisciplinary team for the
care of the PACE participant. PACE providers assume full
financial risk for participants' care without limits on
amount, duration, or scope of services.
Existing state law allows DHCS to contract with up to 15
PACE organizations. The Governor's 2012-13 May Revise
budget estimates average monthly enrollment in PACE
statewide to be 3,566 and projects total payments to PACE
plans of $175.4 million ($87.7 million General Fund). DHCS
indicates it currently has contracts with five PACE
organizations and six new PACE organizations will begin
operation in 2012-13.
Governor's Budget proposal . The Governor's 2012-13 Budget
proposes a Coordinated Care Initiative phased in over three
years with the goal of improving beneficiary health
outcomes and care quality while achieving substantial
savings from the rebalancing of care delivery away from
institutional settings and into people's homes and
communities. The proposal consists of three major
components: an expansion of mandatory enrollment of dual
eligibles into Medi-Cal managed care, an expansion of
geographic regions covered by Medi-Cal managed care, and an
expansion of the scope of services covered within a
Medi-Cal managed care plan (instead of FFS).
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The Administration's proposal would expand the existing
four-county, dual-eligible demonstration project to up to
eight counties in 2013, by an additional 20 counties in
2014, and statewide in 2015. Under these pilots,
dual-eligible individuals would be required to enroll in a
Medi-Cal managed care plan for Medi-Cal services (instead
of receiving services through FFS Medi-Cal), and would be
passively enrolled for Medicare services (meaning
individuals could "opt out" of managed care for Medicare
services). Second, the proposal requires LTSS programs
(including In Home Supportive Services) to be provided
through managed care plans, instead of through FFS. Third,
the proposal requires the geographic expansion of the
mandatory enrollment of individuals into Medi-Cal managed
care in the 28 counties that are still currently FFS.
Part of the Administration's proposal is a "lock-in" where
DHCS can require any beneficiary to remain enrolled in the
Medicare portion of the demonstration project on a
mandatory basis for six months from the date of enrollment.
After six months, a dual-eligible beneficiary can enroll
in a different demonstration site plan, a Medicare
Advantage plan, fee-for-service Medicare, PACE or AIDS
HealthCare Foundation (if the individual is HIV positive or
has been diagnosed with AIDS). Federal approval is
required for the Coordinated Care Initiative generally and
specifically for the Medicare lock-in provision.
The Administration's proposal to the Center for Medicare
and Medicaid Innovation entitled "Coordinated Care
Initiative: State Demonstration to Integrate Care for Dual
Eligible Individuals" was submitted in May 31, 2012,
following a 30-day public comment period. The proposal
describes the role of PACE in the Coordinated Care
Imitative. In demonstration areas where PACE is available,
PACE enrollees will not be passively enrolled in the
demonstration, and PACE will remain a clear enrollment
option for dual eligible beneficiaries that meet the PACE
enrollment criteria. Additionally, in counties where PACE
is available, several demonstration health plans will
coordinate closely with PACE to offer this option to
nursing-home eligible dual eligible beneficiaries who wish
to remain in the community. The enrollment process for the
Coordinated Care Initiative will include a special focus on
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enabling beneficiaries to obtain information about PACE and
how to access the program. Finally, the proposal states
that some health plans participating in the demonstration
have expressed interest in contracting with PACE providers,
to provide an additional option for members that meet the
criteria for enrollment in PACE. The proposal indicates
the state will work with the Centers for Medicare and
Medicaid Services to determine if any amendments to current
authority for PACE are needed for this contracting option.
Current PACE enrollment information process . PACE is not
currently part of the Health Care Options (HCO)
presentation process, under which Medi-Cal beneficiaries
are given enrollment information on their choice of
Medi-Cal managed care plans and a form to return indicating
their choice of plan. Currently, DHCS/HCO health plan
choice enrollment packets mailed to seniors and SPDs
include a PACE fact sheet for beneficiaries residing in the
PACE service area. The PACE documents, included in the HCO
health plan choice enrollment packet mailings, are approved
and mailed by DHCS.
DHCS' Long-Term Care Division facilitated a separate mailer
to SPDs regarding PACE. The mailer contained a cover
letter and fact sheet specific to the available PACE
organization. DHCS reviewed and approved the mailer
contents developed by each PACE organization. Printing,
stuffing and mailing was done by the Office of State
Publishing (OSP), and each PACE plan was billed by DHCS for
each month of the mailer to pay for system costs
(compiling, filtering, and transmitting address file to the
OSP) and OSP costs (printing, labor/supplies, and postage).
The PACE SPD mailer was set up to specifically mirror the
SPD-mandatory enrollment transition phased over the period
of one year by birth month. The PACE SPD mailer
discontinued at the end of one year phased-notification on
SPD-mandatory enrollment mailer (targeted to existing SPDs)
processed by the Medi-Cal Managed Care Division/HCO. The
last PACE SPD mailer went out in March 2012. DHCS
indicates that federal privacy law prohibits DHCS from
providing PACE plans with the contact information of
Medi-Cal beneficiaries.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
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Local: No
According to DHCS, as part of its implementation of the
Coordinated Care Initiative, it will be setting capitation
rates for PACE that are similar to those paid to managed
care plans for the provision of similar services to a
similar population. Therefore, DHCS indicates that
additional use of PACE by dual-eligibles should not
increase overall Medi-Cal costs.
SUPPORT : (Verified 6/27/12) (per Senate Health Committee
analysis - per the prior version of the bill)
CalPACE (source)
National Association of Social Workers, California Chapter
St. Paul's Homes and Services for the Aging
Western Center on Law & Poverty
ARGUMENTS IN SUPPORT : This bill is sponsored by CalPACE,
the statewide association of PACE programs, to ensure that
dual-eligible beneficiaries are able to access PACE
programs under the state's Coordinated Care Initiative.
This bill ensures that PACE is clearly presented as an
enrollment option for dual-eligible beneficiaries who will
be subject to mandatory enrollment in managed care under
the state's dual-eligibles demonstration program. It also
ensures that beneficiaries who meet PACE eligibility
criteria are informed about and can enroll in PACE when
their care needs reach that level.
CalPACE states that PACE is widely known as the gold
standard for providing integrated care, and research shows
that PACE programs achieve important outcomes for
beneficiaries, including reducing hospitalizations and
nursing home stays. To date, PACE programs have not been
included in the state's enrollment process and options for
beneficiaries who are subject to mandatory enrollment in
managed care plans. As a result, frail seniors who could
benefit from PACE programs are often not aware of the
program.
Western Center on Law & Poverty writes in support that PACE
programs are unique in that they already have experience in
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dealing with this vulnerable population, which is by
default, low-income, and elderly or disabled, but often
both. PACE programs have a proven track record in
delivering high-quality services that enhance participants'
quality of life, while also ensuring fiscal solvency by
reducing hospitalizations and nursing home stays.
ASSEMBLY FLOOR : 73-0, 5/10/12
AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Beall,
Bill Berryhill, Block, Blumenfield, Bonilla, Bradford,
Brownley, Buchanan, Butler, Charles Calderon, Campos,
Carter, Cedillo, Chesbro, Conway, Davis, Dickinson,
Donnelly, Eng, Feuer, Fong, Fuentes, Beth Gaines,
Galgiani, Garrick, Gatto, Gordon, Gorell, Grove, Hagman,
Halderman, Hall, Harkey, Hayashi, Roger Hern�ndez, Hill,
Huber, Hueso, Huffman, Jones, Knight, Lara, Logue, Bonnie
Lowenthal, Ma, Mansoor, Mendoza, Miller, Mitchell,
Monning, Morrell, Nestande, Nielsen, Pan, Perea,
Portantino, Silva, Skinner, Smyth, Solorio, Swanson,
Torres, Valadao, Wagner, Wieckowski, Williams, Yamada,
John A. P�rez
NO VOTE RECORDED: Cook, Fletcher, Furutani, Jeffries,
Norby, Olsen, V. Manuel P�rez
CTW:m 8/8/12 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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