BILL ANALYSIS �
SB 1503
Page 1
Date of Hearing: June 26, 2012
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Jim Beall Jr., Chair
SB 1503 (Steinberg) - As Amended: April 9, 2012
SENATE VOTE : 25-13
SUBJECT : In-Home Supportive Services (IHSS) program
SUMMARY : Requires the Director of the Department of Social
Services (DSS) and Director of the Department of Health Care
Services (DHCS) to convene a stakeholder group to design a plan
for the integration of long-term care services and supports
(LTSS) programs, and requires the plan to include specified
components. Specifically, this bill :
1)Requires the Director of DSS and the Director of DHCS to
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
SB 1503
Page 2
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 skilled nursing care, 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
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;
SB 1503
Page 3
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.
EXISTING LAW
1)Establishes the county-administered 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
SB 1503
Page 4
DHCS can require that dual-eligibles are assigned as mandatory
enrollees into Medi-Cal managed care plans.
FISCAL EFFECT : Unknown
COMMENTS :
Need for this bill : According to the author, the current
delivery system of long-term services and supports for seniors
and people with disabilities is disjointed and unnecessarily
costly. Currently, a lack of care coordination between the
various in-home, community-based, and health facility providers
results in a lack of appropriate preventive care for many
seniors and people with disabilities, which increases rates of
avoidable hospitalization and institutionalization, as well as
more negative health outcomes over all. Without a coordinated
approach to meeting the long term care needs of our aged and
disabled populations moving forward, we will likely continue to
fuel fiscal incentives that keep people in restrictive care
settings while having to decrease funding for the vital home-
and community-based services that are saving the state money.
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.
The author states that:
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.
SB 1503
Page 5
For far too long, the delivery of LTSS has been
fragmented and has 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.
2012-13 Budget : The Governor's 2012-13 budget proposed 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.
At this writing, final actions on these proposals in the 2012-13
SB 1503
Page 6
Budget are pending.
Policy issues : There are several policy issue areas associated
with the integration of IHSS into Medi-Cal managed care,
including the following:
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 example, through establishing a network of
IHSS providers).
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.
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.
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.
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.
County share of cost in IHSS . Counties currently have a share
of cost in the IHSS program. The IHSS program is funded by a
SB 1503
Page 7
combination of state, county, and federal funds. Currently,
for the majority of IHSS costs, the federal share is about
50%, the state share is 32.5%, and the counties pay about
17.5%. 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.
This bill : 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 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.
According to the author, this bill aims to do the following:
Create a plan to integrate IHSS and other LTSS,
including skilled nursing care, into a coordinated care
model to ensure that consumer needs are met across the
entire spectrum of care.
Protect the IHSS benefit in its entirety, as well as the
key social model components of the IHSS program. This
includes, but is not limited to, consumers continuing to
self-direct their care with the ability to hire, fire, and
supervise their homecare providers.
Build fiscal incentives into the health care delivery
system that will make home and community-based services the
first option for long-term care. From hospital
pre-admission planning to discharge planning, to fewer and
shorter nursing home stays and ultimately avoiding
unnecessary hospitalizations, these incentives will
prioritize and provide access to appropriate long-term care
at home.
Ensure that homecare providers have the tools and
training they need to provide the best care and support
possible. For consumers who choose to be in an integrated
SB 1503
Page 8
care plan, their providers will be able to work with other
integrated care team personnel in order to maximize care
coordination and the effectiveness of preventative
treatment.
This bill would require the DHCS and DSS to establish a
stakeholder workgroup to develop a plan for the integration of
LTSS programs. Prior to development of the plan, this bill
would require the departments to establish a process for
receiving consumer input. Additionally, this bill provides a
general outline of provisions that should be included in the
LTSS integration plan.
Support : The United Domestic Workers/American Federation of
State, County and Municipal Employees Local 3930 (UDW/AFSCME),
one of this bill's sponsors, writes that 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.
The Services Employees International Union (SEIU California),
also a sponsor of this bill, says that this bill "is a vehicle
to enable the Legislature to develop a true coordinated care
system that uses the innate advantages of social model care
delivery to transform the way in which we deliver healthcare.
Coordinated care will result in fewer and shorter duration acute
care incidents and in higher consumer satisfaction."
Additionally, SEIU California says, this bill "provides a
mechanism through which California will be able to realign LTSS
financial incentives so that being healthy at home is the first
option in care delivery and that delivering 'the right care at
the right time in the right place' becomes a reality instead of
SB 1503
Page 9
a catch phrase."
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.
DOUBLE REFERRAL . This bill has been double-referred. Should
this bill pass out of this committee, it will be referred to the
Assembly Health Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
Service Employees International Union - California (SEIU
California) (sponsor)
United Domestic Workers/American Federation of State, County and
Municipal Employees
Local 3930 (UDW/AFSCME) (sponsor)
Epilepsy California
Opposition
None on file
Analysis Prepared by : Eric Gelber / HUM. S. / (916) 319-2089