BILL NUMBER: AB 2266 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MAY 25, 2012
AMENDED IN ASSEMBLY APRIL 17, 2012
AMENDED IN ASSEMBLY MARCH 20, 2012
INTRODUCED BY Assembly Member Mitchell
( Principal coauthor: Assembly Member
Atkins )
( Coauthors: Assembly Members
Wieckowski and Williams )
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
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 and subject to the availability of specified
funding , to establish a program in at least 5
counties to provide health home services to frequent
hospital users, as prescribed. This If
federal matching funds are available, 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 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) offers an opportunity for California to address
complex, co-occurring, 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 the people who frequently use the emergency
department 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, 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, 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 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 to and sustaining people
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 case management in housing demonstrated
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 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 Homes for 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 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) (d) 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.
(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.
(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. "Chronic homelessness"
means the state of an adult whose conditions limit his or her
activities of daily living and who has experienced homelessness for
longer than a year or for four or more episodes over three years.
14127.1. (a) No later than January 1, 2014, the department shall
do all of the following:
(1) Design, with opportunity for public comment, a program to
provide enhanced health home services to 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) (e) 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 applications to the federal Centers
forMedicare for Medicare and Medicaid
Services for a state plan amendment under 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 to Low Income Health Program (LIHP)
enrollees , if applicable, in counties with Low
Income Health Programs (LIHPs) LIHPs willing to
match federal funds , to enrollees of the LIHP .
(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 and to the extent federal approval is obtained , 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 followthrough, related to risk factors,
with elements of a treatment plan, including lack of followthrough 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 that providers meet criteria
identified in subdivision (c) (e) in
each county designated.
(b) The department may designate providers working under a managed
care organization contract or as a fee-for-service provider.
(c) The department may develop a payment methodology other than a
fee-for-service payment, including a per member, per month payment to
designated providers.
(b)
( d) (1) Subject to federal approval
for receipt of the enhanced federal match , services provided
under the program established pursuant to this article shall include
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) Comprehensive and individualized intensive
face-to-face outreach, engagement, and case management.
(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 followup.
(D) Individual and family support, including authorized
representatives.
(E) Referral If relevant, referral to
other relevant community and social services
supports , including transportation to appointments needed to
manage health needs, connection to housing for participants who are
homeless or unstably housed, and peer and recovery support .
(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.
(I) Transportation to appointments needed to manage health needs.
(J) Peer and recovery support.
(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)
( e) 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.
(2) Demonstrated experience working with frequent hospital users,
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.
(4) The capacity and administrative infrastructure to participate
in the program, including the ability to meet requirements of federal
guidelines.
(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.
(6) Experience working with supportive or other permanent housing
providers.
(7) Support of Current partnership with
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.
(F) Identify appropriate funding sources for the nonfederal share
of costs of services to sustain program funding beyond the first
eight quarters of implementation of the program. Identifying sources
may include a plan to partner with managed care organizations,
counties, hospitals, private funders, or others.
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.
(b) This article shall not be construed to limit the department in
targeting additional populations or creating additional programs
under the Health Homes option.
(c) 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 this article through provider bulletins or
similar instructions, without taking regulatory action.
14127.4. (a) The If federal matching
funds are available, the department shall prepare, or contract
for the preparation of, an evaluation of the program identified in
this article. The department shall seek out and utilize only
private nonstate public funds or private
funds to fund the nonfederal share of costs of the
evaluation. The department, within 18 months after designated
providers have been selected and have begun to seek 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. (a) 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 to subdivision (a) of
Section 14127.1 , and only to the extent non-General Fund
moneys are available for use as the nonfederal share during the first
eight quarters of implementation .
(b) Except as provided in subdivision (c), this article shall be
implemented only if nonstate public funds or private funds are
available to fully fund the creation, implementation, administration,
and service costs during the first eight quarters of implementation,
and thereafter.
(c) Notwithstanding subdivision (b), if the department finds,
after the first eight quarters of implementation, that Medi-Cal costs
avoided by the participants of the program are adequate to fully
fund the program costs, the department may use state funds to fund
the program costs.
(d) The department may revise or terminate the enhanced health
home program any time after the first eight quarters of
implementation if the department finds that the program fails to
result in improved health outcomes or fails to decrease total
Medi-Cal costs, including managed care organization costs, if
applicable, for the population it is serving. The department may also
designate additional providers, with federal approval, or may remove
providers operating under the program if those providers are unable
to provide the nonfederal matching funds or do not meet the
department's guidelines.