BILL ANALYSIS �
SB 1503
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Date of Hearing: July 3, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 1503 (Steinberg) - As Amended: April 9, 2012
SENATE VOTE : 25-13
SUBJECT : In-Home Supportive Services 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
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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 that care;
b) Adopt coordinated care models that integrate In-Home
Supportive Services (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;
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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 the Medi-Cal Program, administered by DHCS, to
provide comprehensive health care services and long-term care
to pregnant women, children, and people who are aged, blind,
and disabled. Services are reimbursed through fee-for-service
(FFS), capitated payments to managed care plans, County
Organized Health Systems (COHS), or other contractual
arrangements.
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3)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.
4)Authorizes DHCS to contract, on a bid or nonbid basis, with
any qualified individual, organization, or entity to provide
services to, arrange for, or case manage, the care of Medi-Cal
beneficiaries. Defines a Medi-Cal managed care (MCMC) plan as
any entity that enters into one of several types of contracts
with DHCS including COHS, geographic managed care (GMC) plans
and Local Initiatives.
5)Requires DHCS to implement mandatory enrollment of most women,
children and Seniors and Persons with Disabilities (SPDs), who
are not also eligible for Medicare, into a MCMC plan in any
county with a COHS, two-plan model or GMC.
6)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 MCMC plans.
FISCAL EFFECT : According to the Senate Appropriations
Committee, the fiscal effect of this bill is absorbable costs to
convene the stakeholder group and develop plans. DSS and DHCS
have already initiated an extensive stakeholder group to
consider issues relating to the integration of long-term
services and supports pursuant to the dual-eligible
demonstration project. The requirements of this bill should be
absorbable within those efforts.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, the current
delivery system of LTSS for SPDs 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 SPDs, which increases rates of avoidable
hospitalizations 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
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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.
2)BACKGROUND . This bill addresses the integration of LTSS
programs into MCMC. 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.
Traditionally, LTSS programs were provided through Medi-Cal
FFS, while medical services, such as hospital and physician
services, are provided through Medicare or MCMC.
According to the author, this bill aims to do the following:
a) Create a plan to integrate IHSS and other LTSS,
including SNFs, into a coordinated care model to ensure
that consumer needs are met across the entire spectrum of
care;
b) 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;
c) Build fiscal incentives into the health care delivery
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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;
d) 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
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; and,
e) Require 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 DHCS and DSS 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.
3)DUAL ELIGIBLES AND SPDs . About 1.9 million SPDs are enrolled
in Medi-Cal. Of the SPDs enrolled in Medi-Cal, about 1.2
million are also enrolled in Medicare, the federal program
that provides health care services to qualifying persons aged
65 and over and persons with disabilities. The SPDs who are
enrolled in both Medi-Cal and Medicare are known as dual
eligibles. The SPDs who are not enrolled in Medicare, also
known as Medi-Cal-only SPDs, typically have not met the
24-month disability waiting period or the minimum work
requirements necessary to qualify for Medicare. National
studies have found that dual eligibles are more likely than
other Medicare beneficiaries in their age group to suffer
cognitive impairment from conditions such as Alzheimer's
disease or dementia. They are also more likely to require
assistance with activities of daily living, such as moving,
bathing, dressing, eating, and toileting. They may be unable
to fully care for themselves, and may require LTSS in
institutional (typically, nursing home) or home and
community-based settings. Dual eligibles often suffer from
multiple chronic illnesses, such as diabetes, pulmonary
disease, and hypertension at higher rates than Medi-Cal-only
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beneficiaries. While dual eligible represent only 15% of all
Medi-Cal beneficiaries, they account for 27% ($2.4 billion) of
annual Medi-Cal General Fund spending on medical and LTSS
provided outside of managed care.
Medi-Cal pays for LTSS for dual eligible in both institutional
and community settings. According to the Legislative Analyst
Office, nursing home care is by far the greatest cost driver
for the dual eligible population. In 2007-08, dual eligibles
accounted for nearly 80% of $2.1 billion in Medi-Cal General
Fund spending on nursing home care. Dual eligibles also make
up the majority of spending on home and community based LTSS.
For example, they represent about 85% of beneficiaries using
the IHSS program. They may also use case management services
administered by the state Department of Aging and many
behavioral health services provided by the counties.
4)COORDINATED CARE INITIATIVE. SB 208 (Steinberg), Chapter 714,
Statutes of 2010, established demonstration projects in up to
four counties under which dual eligible beneficiaries would be
enrolled into coordinated systems responsible for all Medicare
and Medi-Cal benefits, as well as LTSS and behavioral health
services.
In January, the Governor's proposed 2012-13 budget increased the
number of demonstration sites to 10. The proposal would have
allowed DHCS to expand the demonstration by an additional 20
counties in 2014 and statewide in 2015. This Coordinated Care
Initiative (CCI) would have required all full-benefit dual
eligible beneficiaries residing in a demonstration county to
enroll in the demonstration. DHCS would have the authority to
require a beneficiary, upon enrollment into a demonstration
site, to remain in the plan for a period of six months from
the time of initial enrollment. During the six-month
enrollment period the beneficiary may continue to receive
services from an out-of-network Medicare provider for primary
and specialty care services, as specified. After the six
month period, beneficiaries would have an opportunity to opt
out of enrollment in the demonstration for their Medicare
benefits only. They would remain mandatorily enrolled in a
MCMC plan for their Medi-Cal benefits including IHSS.
In the May Revision, the Administration proposed the following
changes to the CCI:
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a) Implementation date . In response to stakeholder
feedback that more time is needed to prepare for
enrollment, the May Revision proposed to move the
implementation date from January 1, 2013 to March 1, 2013.
Enrollment would be phased in throughout the rest of 2013.
b) Demonstration Counties . The number of counties proposed
for demonstration implementation in 2013 has been reduced
from 10 to eight. The Administration had suspended work on
launching the demonstration in Contra Costa and Sacramento
counties for 2013, but intended to include those counties
in the second year expansion.
c) Mandatory MCMC Enrollment . The May Revision limited
dual eligible mandatory enrollment in MCMC in 2013 to only
the eight counties where the duals demonstration is
implemented. Previously, the CCI proposed mandatory MCMC
for wrap-around Medi-Cal services in all managed care
counties in 2013.
d) LTSS . The May Revision indicated the Administration's
intention to eventually transition IHSS collective
bargaining from the local government level to the state.
5)FINAL BUDGET ACTIONS . The 2012-13 Budget, as passed by the
Legislature and signed by the Governor includes a modified
version of the Administration's CCI proposal to expand the
dual demonstration projects and to coordinate and integrate
LTSS, including IHSS. The provisions as modified by the
Legislature are contained in SB 1008 (Committee on Budget and
Fiscal Review), Chapter 33, Statutes of 2012, and SB 1036
(Committee on Budget), Chapter 45, Statutes of 2012, both of
which passed the Legislature and were signed by the Governor
on June 27, 2012. The major provisions relating to LTSS are
as follows:
a) Implementation of the demonstration project in up to
eight counties, not to begin sooner than March 1, 2013 and
requires DHCS consult with the Legislature, federal
government, and stakeholders when determining the
implementation date;
b) Legislative intent for the demonstration project to
expand statewide within three years of the start of the
demonstration project and requires that expansion beyond
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the initial eight counties is contingent upon statutory
authorization and a subsequent budget appropriation;
c) States intent to promote a system that is both
sustainable and person- and family-centered by providing
dual eligible beneficiaries with timely access to
appropriate, coordinated health care services and community
resources that enable them to attain or maintain personal
health goals;
d) Requires dual beneficiaries to be enrolled into a
demonstration site unless the beneficiary makes an
affirmative choice to opt out of enrollment or is enrolled
in the Program of All-Inclusive Care for the Elderly or an
AIDS Healthcare Foundation plan as specified, or is
otherwise exempt;
e) Allows dual beneficiaries who opt out of enrollment in a
demonstration site to choose to remain enrolled in FFS
Medicare or a Medicare Advantage plan for their Medicare
benefits, but shall be mandatorily enrolled into a MCMC
health plan, with exceptions;
f) Allows, to the extent federal approval is obtained, DHCS
to require that any beneficiary, to remain enrolled in the
Medicare portion of the demonstration project on a
mandatory basis for six months from the date of initial
enrollment. Includes continuity of care provisions;
g) Specifies exemptions from enrollment in the dual
demonstration project;
h) Allows beneficiaries who have been diagnosed with
HIV/AIDS to opt out of the demonstration project at the
beginning of any month;
i) Requires that in the 2013 calendar year, beneficiaries
in Medicare Advantage and Medicare Advantage Special Needs
Plans D plans to be exempt from mandatory enrollment in the
demonstration project, but may voluntarily choose to enroll
in the demonstration project;
j) Requires that Medi-Cal beneficiaries who have dual
eligibility in Medi-Cal and Medicare Programs be assigned
as mandatory enrollees into new or existing MCMC health
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plans for their Medi-Cal benefits in counties participating
in the dual demonstration projects only, with specified
exemptions;
aa) Requires that, no sooner than March 1, 2013, all
Medi-Cal LTSS services, as defined, shall be services that
are covered under managed care plan contracts and shall be
available only through managed care plans to beneficiaries
residing in counties participating in the dual
demonstration counties only;
bb) Establishes the California In-Home Supportive Services
Authority (Statewide Authority) and would deem the
authority a joint powers authority and a separate public
entity. Requires the Statewide Authority to be the entity
authorized to meet and confer in good faith regarding
wages, benefits, and other terms and conditions of
employment with representatives of recognized employee
organizations for any individual provider who is employed
by a recipient of IHSS;
cc) Establishes the IHSS Employer-Employee Relations Act
(Act) for the purpose of resolving disputes regarding
wages, benefits, and other terms and conditions of
employment between the Statewide Authority, and recognized
employee organizations. Under the Act, the Statewide
Authority would be deemed to be the employer of record, for
purposes of collective bargaining, of individual providers
of IHSS in each county, upon implementation by a county.
Pursuant to the Act, employees would have the right to
form, join, and participate in the activities of employee
organizations for the purpose of representation on all
matters within the scope of representation;
dd) Protects the rights of IHSS recipients to hire, fire,
direct, schedule, and supervise their own IHSS provider(s)
and control their own care in accordance with existing law;
ee) Establishes a required county Maintenance of Effort
level of funding for IHSS, with specified adjustments in
future years, in order to stabilize the county share of
cost for the program.
ff) Provides that beneficiaries who are not mandatorily
enrolled in managed care pursuant to current law exemptions
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or specified new exemptions are not required to receive
LTSS, other than CBAS, through a managed care plan;
gg) Requires that no sooner than March 1, 2013, or on the
date that any necessary federal approvals or waivers are
obtained, whichever is later, nursing facility services and
subacute facility services shall be Medi-Cal benefits
available only through managed care plans in counties
participating in the dual demonstration project;
hh) Establishes plan and DHCS readiness standards,
beneficiary notifications, an assessment process, network
adequacy, performance, and quality measures;
ii) Requires DHCS ensure that managed care plans perform
care coordination and care management activities, that
managed care plans address medical and social needs, and
that managed care plans provide a grievance and appeal
process;
jj) Requires that in the event DHCS has not received, by
February 1, 2013, federal approval, or notification
indicating pending approval, of a mutual rate setting
process, shared federal savings as defined, and a six-month
enrollment period in the dual demonstration project, then
effective March 1, 2013, the provisions of the dual
demonstration project, enrollment of dual beneficiaries
into MCMC, and LTSS integration become inoperative; and,
aaa) Creates a 13-member consumer advisory committee at the
state level to provide ongoing advice and recommendations
regarding the IHSS program. Provides that at least 50% of
the membership of the advisory committee shall be
individuals who are current or past consumers of personal
assistance services paid for through public or private
funds or as current consumers of services under this
article. Membership will include current or former
providers and individuals who represent organizations that
advocate for SPDs.
6)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
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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 SPDs 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 a catch phrase."
7)PRIOR LEGISLATION . SB 208 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 (Medi-Cal in California)
services.
8)DOUBLE REFERRAL . This bill is double referred. It passed out
of the Assembly Human Services Committee by a vote of 4-1 on
June 26, 2012.
9)POLICY CONCERN . In light of the recent passage of the budget
trailer bills enacting the dual demonstration expansion and
integration of LTSS, including IHSS, most of the issues
proposed to be considered by the stakeholder group created by
this bill have been resolved. The author may wish to explain
the continued need for this bill.
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REGISTERED SUPPORT / OPPOSITION :
Support
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 : Marjorie Swartz / HEALTH / (916)
319-2097