BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1503
AUTHOR: Steinberg
AMENDED: April 9, 2012
HEARING DATE: April 25, 2012
CONSULTANT: Bain
SUBJECT : In-Home Supportive Services program.
SUMMARY : Requires the Director of the Department of Social
Services (DSS) and the Director of the Department of Health Care
Services (DHCS) to convene a stakeholder group to design a plan
for the integration of long-term services and supports (LTSS)
programs, and requires the plan to include specified components.
Existing law:
1.Establishes the county-administered In-Home Supportive
Services (IHSS) program, under which qualified aged, blind,
and disabled persons are provided with services to permit them
to remain in their own homes and avoid institutionalization.
2.Establishes a list of covered benefits under the Medi-Cal
program, which includes hospital services, prescription drugs,
physician services, skilled nursing facility (SNF) care, and
personal care services.
3.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, under which
DHCS can require that dual eligibles are assigned as mandatory
enrollees into Medi-Cal managed care plans.
This bill:
1. Requires the Director of DSS and the Director of DHCS to
Continued---
SB 1503 | Page 2
convene a stakeholder group to design a plan for the
integration of programs, and requires the plan to include
specified components.
2. Requires, prior to development of the plan, a process for
receiving and including consumer input to be established.
Requires the plan to do at least all of the following:
a. Build incentives into the health care delivery system so
that home- and community-based services become the first
option for long-term care, and specify that the purpose of
these incentives is to ensure that a person who is able to
receive long-term care at home receives it;
b. Adopt coordinated care models that integrate IHSS and
other LTSS programs, including SNF, to ensure that consumer
needs are met across the entire spectrum of care;
c. Specify that the overall intent of this integration is
to improve consumer health and well-being, and to maximize
the cost-effectiveness of health care delivery to
consumers;
d. Maintain the key social model components of the IHSS
program and refocus the health care delivery system to
SB 1503 | Page
3
include the social model as a primary component of
coordinated care delivery;
e. Maintain a consumer's right to hire, fire, and supervise
his or her home care provider or providers to the extent
the consumer is able;
f. Require that consumers who elect to be a part of an
integrated care plan are authorized to participate on their
own health care teams, and to be able to allow their home
care providers to also be a part of their health care
teams;
g. Ensure that home care providers have the tools they need
to help consumers manage chronic conditions and prevent
additional health care needs, including access to adequate
training based on the wants and needs of the consumer; and
h. Specify that county social workers continue to assess
and reassess consumers to determine their care needs and
the number of care hours they receive.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, SB 1503 is a
step toward ensuring we are prioritizing home- and
community-based services for our aged and disabled
Californians in an effort to improve their health and
well-being while maximizing the cost-effectiveness of our LTSS
programs as a whole. For far too long, the delivery of LTSS
SB 1503 | Page 4
programs have been fragmented and have not allowed for
sufficient care coordination between in-home, community-based,
and health facility providers. This has resulted in decreased
preventive efforts and increased health care costs and
avoidable hospitalizations and institutionalizations. We know
that programs like the IHSS program save lives and save the
state money, and it is time for us to include IHSS and other
home- and community-based services as equal players in our
conversations about appropriate, effective, and cost-saving
long term care. Additionally, this bill moves toward ensuring
our LTSS providers have the tools and training they need to be
as effective as possible in assisting their consumers and
keeping them safe and healthy at home.
2.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 fee-for-service
�FFS]).
First, the Administration proposal would expand the existing
four-county, dual-eligible demonstration project to up to 10
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 IHSS) 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.
This bill addresses the integration of LTSS programs into
Medi-Cal managed care. Major LTSS programs that are part of
Medi-Cal include IHSS, the Multi-Purpose Senior Services
Program, Community-Based Adult Services (CBAS will be taking
SB 1503 | Page
5
the place of the Adult Day Health Care Program), and SNFs.
LTSS programs are generally provided through Medi-Cal FFS,
while medical services, such as hospital and physician
services, are provided through Medicare or Medi-Cal managed
care.
One of the major LTSS programs is the IHSS program, which
provides in-home care for persons who cannot safely remain in
their own homes without such assistance. Under the IHSS
program, approximately 365,000 in-home care workers provide
care to approximately 445,000 recipients. In order to qualify
for IHSS, a recipient must be aged, blind, or disabled and in
most cases have income below the level necessary to qualify
for the Supplemental Security Income/State Supplementary
Program (SSI/SSP). County social workers perform an assessment
to determine the number of hours and types of service to
authorize an IHSS recipient to receive each month. Recipients
are eligible to receive up to 283 hours per month of
assistance with tasks such as bathing, housework, feeding, and
dressing. The recipient is responsible for hiring and
supervising a provider. IHSS is administered by DSS at the
state level.
3.Prior legislation. SB 208 (Steinberg), Chapter 714, Statutes
of 2010, requires DHCS to seek federal approval to establish
pilot projects in up to four counties under a Medicare or
Medicaid demonstration project or waiver (or a combination of
the two). The purpose of the pilot projects is to develop
effective health care models that integrate Medicare and
Medicaid services.
4.Policy issues. This bill is a vehicle for discussions
regarding the integration of LTSS programs (including IHSS)
into Medi-Cal managed care plans. There are several policy
choices associated with the integration of IHSS into Medi-Cal
managed care, including the following:
a. Selection of IHSS provider. IHSS consumers are
authorized to hire any individual who successfully
completes the statutory provider enrollment process, and
the IHSS consumer has the ability to direct their own care.
In addition, the IHSS consumer is the employer for purposes
of hiring and firing an IHSS provider. Policy issues
associated with integrating IHSS into Medi-Cal managed care
plans include whether the IHSS consumer continues to hire a
provider of his or her choice, and what role, if any,
health plans will have in restricting that choice (for
SB 1503 | Page 6
example, through establishing a network of IHSS providers).
The Administration's proposed trailer bill language (TBL)
requires IHSS recipients, as the employer, to continue to
allow the recipient to select, engage, direct, supervise,
schedule and terminate IHSS providers in accordance with
existing law.
b. IHSS provider wage negotiations. IHSS provider wages are
collectively bargained at the local level. One of the
policy issues with IHSS integration into Medi-Cal managed
care is whether this policy continues, shifts to the state,
or is negotiated with health plans. Currently, local
entities known as "Public Authorities" represent the
counties in IHSS provider wage negotiations. The
Administration's proposed TBL requires Medi-Cal managed
care plans to enter into a contract with the county IHSS
Public Authority or nonprofit consortium to perform
specified activities, one of which is engaging in
collective bargaining for the purposes of wages, hours, and
other terms and conditions of employment.
c. Administering IHSS provider payroll. Currently, the
state issues paychecks to IHSS providers. If IHSS is
integrated into Medi-Cal managed care, one of the issues is
which entity (the plan or the state) will pay IHSS
providers. The Administration's proposed TBL requires
Medi-Cal managed care plans to enter into a contract with
DSS, under which DSS would perform specified activities,
including paying wages to IHSS providers.
d. County role in assessments and hours. County social
workers currently perform assessments to determine the
numbers of hours of services an IHSS recipient is
authorized to receive each month. The Administration's
proposed TBL requires county agencies to continue the IHSS
assessment and authorization processes, including final
determinations of IHSS hours on behalf of the Medi-Cal
managed care health plans and in accordance with statutory
provisions for IHSS eligibility. In addition, health plans
can authorize additional home and community-based services,
including IHSS hours.
e. Grievance and appeal process. Existing law grants
applicants and recipients of public social services
programs (including IHSS) who are dissatisfied with any
action of the county department relating to his or her
application for or receipt of public social services to
file a request with DSS or DHCS for a state hearing. The
Administration's proposed TBL requires a grievance and
appeals process and other protections for IHSS consumers to
SB 1503 | Page
7
remain in place but does not specify that this process is
the same process contained in existing law.
f. County share of cost in IHSS. Counties currently have a
share of cost in the IHSS program. The IHSS program is
funded by a combination of state, county, and federal
funds. Currently, for the majority of IHSS costs, the
federal share is about 50 percent, the state share is 32.5
percent, and the counties pay about 17.5 percent. If IHSS
is integrated into Medi-Cal managed care, one of the policy
and fiscal issues is the continued role of counties in
having a share of the program's cost. For example, county
funding for the IHSS program could be increased if Medi-Cal
managed care plans can increase utilization of IHSS
services, and if counties continue to have a role in
setting wages and assessing hours for IHSS. The
Administration's proposal requires counties to continue to
participate in the non-federal share of IHSS costs, as
specified in existing law, equal to the amount that would
have been expended by the counties in the absence of the
Administration's Coordinated Care Initiative. This
expenditure level for each county is known as the County
IHSS Maintenance of Effort.
5.Support. This bill is jointly sponsored by United Domestic
Workers/American Federation of State, County and Municipal
Employers (UDW/AFSCME) Local 3930, California United Homecare
Workers (CUHW) and the Service Employees International Union
California (SEIU). UDW/AFSCME writes this bill would protect
the IHSS benefit as an entitlement and its key social model
components while providing fiscal incentives for home and
community-based care over more costly and less desirable
institutional care, while ensuring that home care providers
have the appropriate tools and training necessary to care for
California's most vulnerable population. UDW/AFSCME states
California's current system for delivering medical care and
LTSS programs, including IHSS, to seniors and people with
disabilities is fragmented. A lack of care coordination and
misaligned financial incentives often result in high rates of
avoidable hospitalization and institutionalization, hard to
navigate bureaucratic structures, and escalating costs.
UDW/AFSCME states there is a clear need to reduce
fragmentation, increase access to necessary services, and
create financial incentives that promote and prioritize home
and community-based care. This bill aims to address these
issues by integrating IHSS and other LTSS programs, including
SB 1503 | Page 8
SNF care, into a coordinated care model that ensures that
consumer needs are met across the entire spectrum of care.
CUHW writes in support that this bill is a prudent proposal to
coordinate multiple disjointed LTSS programs and provider
better long-term preventive health care to California's most
vulnerable seniors and persons living with disabilities.
SUPPORT AND OPPOSITION :
Support: California United Homecare Workers (co-sponsor)
Service Employees International Union California
(co-sponsor)
United Domestic Workers/American Federation of State,
County and Municipal
Employees Local 3930 (co-sponsor)
Oppose:None received.
-- END --