BILL NUMBER: AB 2266 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 17, 2012
AMENDED IN ASSEMBLY MARCH 20, 2012
INTRODUCED BY Assembly Member Mitchell
FEBRUARY 24, 2012
An act to add Article 3.9 (commencing with Section 14127) to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 2266, as amended, Mitchell. Medi-Cal: Enhanced
Health Homes for Enrollees Frequent Hospital
Users with Chronic Conditions.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
The Medi-Cal program is, in part, governed and funded by federal
Medicaid Program provisions. Existing federal law authorizes a state,
subject to federal approval of a state plan amendment, to offer
health home services, as defined, to eligible individuals with
chronic conditions.
This bill would require the department, upon approval of a state
plan amendment, to establish a program in at least 5 counties to
provide health home services to frequent hospital users
of health services , as defined
prescribed . This bill would require the department
to prepare, or contract for the preparation of, an evaluation of the
program, and to complete the evaluation and submit a report to the
appropriate policy and fiscal committees of the Legislature within
18 months after designated providers have been selected
and have begun to seek payment.
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. The Legislature finds and declares all of the
following:
(a) The Health Home Homes for
Enrollees with Chronic Conditions option (Health Homes option)
under Section 2703 of the federal Patient Protection and
Affordable Care Act (Affordable Care Act) (42 U.S.C. Sec.
1396w-4) is offers an opportunity for
California to address the needs of people who frequently use
emergency departments for reasons that could have been avoided with
earlier or primary care, as well as the overlapping population of
people experiencing chronic homelessness complex,
cooccurring, chronic, and disabling health conditions, as well as
social determinants of poor health outcomes and high costs among
Medi-Cal beneficiaries .
(b) Almost half of frequent the people who
frequently use the emergency department users
for reasons that could have been avoided with earlier
or primary care are homeless. People who are
chronically homeless are vulnerable to frequent hospitalization.
Frequent users who are homeless face significant difficulties
accessing regular or preventive care and complying with treatment
protocols with , having no place to
store medications, an inability to adhere to a healthy diet or
maintain appropriate hygiene, frequent victimization, and a lack of
rest to recover from illness. Homeless Medi-Cal enrollees will, in
fact, continue to use costly acute care services and actually
increase their inpatient days, even if receiving medical home
services to reduce their return to the hospital.
(c) Increasingly, health providers are partnering with community
behavioral health, social services or
, and housing providers to offer a person-centered
interdisciplinary system of care that includes intensive
paraprofessional care coordination or case management , often in
supportive housing . Programs that offer intensive and
comprehensive care coordination to frequent emergency
department hospital users integrate primary care,
behavioral health care, and social services, and facilitate
coordination of care among health systems, making this model an ideal
health home that fosters a "whole person" orientation.
(d) Data show that programs providing intensive case
management and care coordination, including connecting
homeless to and sustaining people to
in housing, decrease Medicaid costs within a
year by reducing avoidable emergency department visits, hospital
admissions, and readmissions . A randomized study of
chronically homeless frequent users receiving intensive care
coordination case management in housing
demonstrated that every 100 participants experienced 270
fewer hospitalizations, 116 fewer emergency department visits, and
2,000 fewer nursing home days decreases in hospital
admission rates of 46 percent, hospital days of 46 percent, and
emergency department visits of 36 percent after 18 months of
intervention, compared to a control group receiving usual care
. Medi-Cal beneficiaries participating in foundation-funded frequent
user programs experienced reductions in Medi-Cal hospital
costs of three thousand eight hundred forty-one dollars
($3,841) per beneficiary after one year and seven thousand five
hundred nineteen dollars ($7,519) per beneficiary per year after two
years, while drastically improving clinical outcomes.
(e) Additionally, the Massachusetts Office of Medicaid, as another
example, reported that its Medicaid Program offering intensive
interdisciplinary services and connecting chronically homeless
individuals to housing reduced Medicaid costs by 67 percent for a
total cost decrease of nine thousand eight hundred ten dollars
($9,810) per resident, even when considering the costs of housing.
(f) Federal guidelines allow the state to access enhanced federal
matching rates under the Health Homes option for multiple target
populations to achieve more than one policy goal.
SEC. 2. Article 3.9 (commencing with Section 14127) is added to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, to read:
Article 3.9. Enhanced Health Home
Homes for Enrollees Frequent
Hospital Users with Chronic Conditions
14127. For the purposes of this article, the following
definitions shall apply:
(a) "Department" means the State Department of Health Care
Services.
(b) "Eligible program" means a team comprised of a nonprofit
organization or entity, including a private hospital, a public
hospital or county, a community clinic, and social service providers,
that elects to participate in the program pursuant to this article
and that meets the criteria described in federal guidelines. For the
purposes of this article, "eligible program" shall include health
home teams that incorporate social service providers.
(b) "Eligible individual" means an individual who meets the
criteria defined by the department consistent with subdivision (c) of
Section 14127.1 for eligibility for enhanced health home services
identified in subdivision (b) of Section 14127.2.
(c) "Enhanced health home" means a designated provider, such as a
physician, clinical practice or clinical group practice, rural health
clinic, community health center, community mental health center,
home health agency, or any other entity or provider, operating or
proposing to operate in coordination with a team of health care
professionals, such as physicians, nurse care coordinators,
nutritionists, social workers, behavioral health professionals, and
paraprofessionals, that satisfies all of the following:
(1) Meets the criteria described in federal guidelines.
(2) Offers a whole person approach.
(3) Coordinates or proposes to coordinate services for all of the
needs of eligible individuals.
(4) Elects to participate in the program pursuant to this article.
(5) Offers services in a range of settings, including the eligible
individual's home.
(c)
(d) "Federal guidelines" means all federal statutory
guidance, and all regulatory and policy guidelines issued by the
federal Centers for Medicare and Medicaid Services regarding the
Health Homes for Enrollees with Chronic Conditions option under
Section 2703 of the federal Patient Protection and Affordable Care
Act (42 U.S.C. Sec. 1396w-4), including the State Medicaid Director
Letter issued on November 16, 2010.
(d) "Frequent user of health services" means an adult who has
undergone emergency department treatment on five or more occasions in
the past 12 months or on eight or more occasions in the last 24
months, who would benefit from the provision of multidisciplinary
services, and who has two or more of the following risk factors:
(1) On one or more occasions within the last 24 months, the
individual was diagnosed with two or more chronic conditions that
require management of symptoms, medications, health care, or changes
in lifestyle or risk-related behaviors. These conditions may include
specific conditions the department identifies based on data collected
pursuant to Section 14127.1.
(2) On one or more occasions within the last 24 months, the
individual was diagnosed, or, in the judgment of an emergency
department physician, would likely be diagnosed, if provided a mental
assessment, with an Axis I or Axis II mental disorder identified in
the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition.
(3) On one or more occasions within the last 24 months, the
individual was diagnosed, or, in the judgment of an emergency
department physician, would likely be diagnosed, if provided an
assessment, with a substance use disorder, including substance
dependence and substance use problems, that interferes with the
individual's health or appropriate utilization of health services.
(4) The individual is homeless.
(e) "Homeless" has the same meaning as that term is defined in
Section 91.5 of Title 24 of the Code of Federal Regulations. An
adult is "chronically homeless" if he or she has a disability and has
experienced homelessness for longer than a year, or for four or more
episodes over three years.
(f) "Stakeholders" includes, but is not limited to, the Frequent
Users of Health Services Initiative program participants, other
frequent user programs the department selects, the Corporation for
Supportive Housing, the California Mental Health Directors
Association, community clinic representatives, the California
Hospital Association or the California Association of Public
Hospitals, and representatives from other disciplines that represent
the needs of frequent users of health services.
14127.1. (a) No later than July 1, 2013
January 1, 2014 , the department shall do all of the following:
(1) Collect data to determine conditions that are most prevalent
among frequent users of health services, as defined in subdivision
(d) of Section 14127, whose high costs could be avoided with more
appropriate care.
(2)
( 1) Design, in consultation with
stakeholders with opportunity for public comment
, a program to provide enhanced health home services to
frequent users of health care services
persons at high risk of avoidable and frequent use of hospital
services due to complex cooccurring health and behavioral
health conditions .
(2) Upon a request for proposals process, select providers in
accordance with subdivision (c) of Section 14127.2, as designated
providers working in coordination with health care providers under
the Health Homes option state plan amendment.
(3) Submit any necessary application
applications to the federal Centers of
for Medicare and Medicaid Services for a state plan amendment
under Section 2703 of the federal Patient Protection and
Affordable Care Act (42 U.S.C. Sec. 1396w-4), the Health Homes for
Enrollees with Chronic Conditions option, the Health
Homes option to provide enhanced health home
services to Medi-Cal beneficiaries , to newly eligible Medi-Cal
beneficiaries upon Medicaid expansion under the Affordable Care Act,
and Low Income Health Program (LIHP) ,
if applicable, in counties with Low Income
Health Programs (LIHPs) willing to match federal funds, to
enrollees who are frequent users of health services
of the LIHP .
(b) The department shall commence implementation of a program in
accordance with the Health Homes for Enrollees with Chronic
Conditions option (42 U.S.C. Sec. 1396w-4) on the first day of the
third month following the month in which federal approval of the
state plan amendment sought pursuant to subdivision (a) is received.
(c) The program established pursuant to this article shall provide
services to Medi-Cal beneficiaries in addition to an individual's
existing Medi-Cal benefits, and, in counties with LIHPs that are
willing to provide state matching funds, to enrollees of the LIHP
implemented through California's Bridge to Reform Section 1115(a)
Medicaid Demonstration, and shall be designed to reduce a
participating individual's use of hospital emergency departments when
more effective care, including primary, specialty, and social
services, can be provided in less costly settings.
(b) The program established pursuant to this article shall provide
services to Medi-Cal beneficiaries, to newly enrolled Medi-Cal
beneficiaries upon implementation of Medicaid expansion under the
Affordable Care Act, and, if applicable, in counties with a LIHP
established under California's Bridge to Reform Section 1115(a)
Medicaid Demonstration implemented on November 1, 2010, willing to
match federal funds, to enrollees of the LIHP. The program
established pursuant to this article shall be designed to reduce a
participating individual's avoidable use of hospitals when more
effective care, including primary and specialty care, and social
services, can be provided in less costly settings.
(c) The department shall seek, to the extent permitted by federal
law, to define the population of eligible individuals experiencing
both of the following:
(1) Two or more of the following current diagnoses:
(A) Mental health disorders identified by the department as
prevalent among frequent hospital users.
(B) Substance abuse or substance dependence disorders.
(C) Chronic or life-threatening medical conditions identified by
the department as prevalent among frequent hospital users.
(D) Significant cognitive impairments associated with traumatic
brain injury, dementia, or other causes.
(2) Two or more of the following indicators of severity:
(A) Frequent inpatient hospital admissions, including long-term
hospitalization for medical, psychiatric, or substance abuse related
conditions.
(B) Excessive use of crisis or emergency services or inpatient
hospital care with failed linkages to primary care or behavioral
health care.
(C) Chronic homelessness.
(D) History of inadequate follow-through, related to risk factors,
with elements of a treatment plan, including lack of follow through
in taking medications, following a crisis plan, or achieving stable
housing.
(E) Two or more episodes of use of detoxification services.
(F) Medication resistance due to intolerable side effects, or
illness interfering with consistent self-management of medications.
(G) Self-harm or threats of harm to others.
(H) Evidence of significant complications in health conditions.
14127.2. (a) In accordance with federal guidelines, the state may
limit the availability of services geographically, but shall
select designated providers to implement the program in at
least five counties; provided , however, that
providers meet federal criteria identified in
subdivision (c) in each county designated. Providers
may include nonlicensed professional or paraprofessional staff,
including social workers.
(b) (1) Services Subject to federal
approval, services provided under the program established
pursuant to this article shall include , but need not be
limited to, individual, multidisciplinary services and
supports available for eligible individuals to decrease
hospitalizations and crisis episodes, reduce medical risks, and
increase functioning to achieve and maintain rehabilitative,
resiliency, and recovery goals. At least 60 percent of the services
shall be provided in natural settings, including services
delivered in an eligible individual's home. Services shall consist of
all of the following:
(A) Individualized Comprehensive and
individualized intensive face-to-face outreach, care
coordination, engagement, and case management.
(B) Money management services and education.
(B) Care coordination and health promotion, including connection
to medical, mental health, and substance abuse care.
(C) Comprehensive transitional care from inpatient to other
settings, including appropriate follow-up.
(D) Individual and family support, including authorized
representatives.
(E) Referral to other relevant community and social services
supports.
(F) Health information technology to identify eligible individuals
and link services, if feasible and appropriate.
(G) Prevention and therapeutic interventions to facilitate
stabilization.
(H) Illness self-management.
(C)
( I) Transportation to appointments
needed to manage health needs .
(D) Life skills training.
(E)
( J) Peer and recovery support.
(F) Prevocational and vocational services.
(G) Employment support services.
(H)
( K) Housing location and tenancy
support services for participants who are homeless or unstably
housed.
(2) Beneficiaries may require less intensive services or graduate
completely from the program upon stabilization.
(c) The selection of the eligible programs shall be based on
criteria that shall be developed by the department pursuant to
federal guidelines and in consultation with stakeholders. The
criteria for participation as a program shall include at least all of
the following:
(c) The department shall select designated providers operating
with a team of health care professionals that have all of the
following:
(1) A designated lead provider that is a community clinic, a
provider of mental health services pursuant to the Adult and Older
Adult Mental Health System of Care Act (Part 3 (commencing with
Section 5800) of Division 5), or a hospital.
(1)
( 2) Demonstrated experience working with
the frequent hospital users of
health services population , with documentation of
experience reducing emergency department visits and hospital
inpatient days among the population served .
(3) Demonstrated experience working with people experiencing
chronic homelessness.
(2)
( 4) The capacity and administrative
infrastructure to participate in the program, including the ability
to meet requirements of federal guidelines identified in the
State Medicaid Director letter dated November 16, 2010, regarding
Health Homes for Enrollees with Chronic Conditions .
(3)
( 5) Documented ability to provide or to
link clients with appropriate community-based services, including
intensive individualized face-to-face care coordination, primary
care, specialty care, mental health treatment, substance abuse
treatment, peer and recovery support, permanent or transitional
housing, and transportation , money management,
prevocational and vocational services, and employment support
.
(4) A plan to offer services to a point-in-time caseload of at
least 100 clients on a voluntary basis.
(6) Experience working with supportive or other permanent housing
providers.
(5)
( 7) Support of essential community
hospitals, particularly the hospital or hospitals serving a high
proportion of Medi-Cal patients, such as disproportionate share
hospitals.
(8) A viable plan, with roles identified among providers of the
enhanced health home, to do all of the following:
(A) Reach out to and engage frequent hospital users and
chronically homeless eligible individuals.
(B) Connect eligible individuals who are homeless or experiencing
housing instability to permanent housing, including supportive
housing.
(C) Ensure eligible individuals receive whatever integrated
services are needed to access and maintain health stability,
including medical, mental health, and substance abuse care and social
services to address social determinants of health.
(D) Track, maintain, and provide outcome data to the evaluator
described in Section 14127.4.
(E) Identify appropriate funding sources for the nonfederal share
of costs of services for the first eight quarters of implementation
of the program.
14127.3. (a) The state shall provide for the nonfederal share of
costs for services provided to individuals under this article.
(b)
14127.3. (a) This section shall not be
construed to preclude local entities, health plans, or foundations
from contributing the nonfederal share of costs for services provided
under this program.
(c)
( b) This article shall not be construed to
limit the department in targeting additional populations or creating
additional programs under the Health Homes for Enrollees
with Chronic Conditions option.
14127.4. (a) The department shall prepare, or contract for the
preparation of, an evaluation of the frequent users
program identified in this article . The
department shall seek out and utilize only private funds to fund the
evaluation. The department, within 18 months after programs
designated providers have been selected and have
begun to seek reimbursement payment ,
shall complete the evaluation and submit a report to the appropriate
policy and fiscal committees of the Legislature.
(b) The requirement for submitting the report imposed under
subdivision (a) is inoperative four years after the date the report
is due, pursuant to Section 10231.5 of the Government Code.
14127.5. This article shall be implemented only if federal
financial participation is available and the federal Centers for
Medicare and Medicaid Services approves the state plan amendment
sought pursuant Section 14427.1 14127.1
, and only to the extent nonstate funds
non-General Fund moneys are available for use as the nonfederal
share during the first eight quarters of implementation.