BILL NUMBER: SB 586 CHAPTERED
BILL TEXT
CHAPTER 625
FILED WITH SECRETARY OF STATE SEPTEMBER 25, 2016
APPROVED BY GOVERNOR SEPTEMBER 25, 2016
PASSED THE SENATE AUGUST 29, 2016
PASSED THE ASSEMBLY AUGUST 23, 2016
AMENDED IN ASSEMBLY AUGUST 19, 2016
AMENDED IN ASSEMBLY AUGUST 2, 2016
AMENDED IN ASSEMBLY JUNE 30, 2016
AMENDED IN ASSEMBLY JUNE 8, 2016
AMENDED IN ASSEMBLY MAY 4, 2016
AMENDED IN SENATE APRIL 28, 2015
INTRODUCED BY Senator Hernandez
(Coauthors: Assembly Members Alejo, Bonta, Chávez, and Wood)
FEBRUARY 26, 2015
An act to amend Sections 123835 and 123850 of the Health and
Safety Code, and to amend Sections 14093.06, 14094.2, and 14094.3 of,
and to add Article 2.985 (commencing with Section 14094.4) to
Chapter 7 of Part 3 of Division 9 of, the Welfare and Institutions
Code, relating to children's services.
LEGISLATIVE COUNSEL'S DIGEST
SB 586, Hernandez. Children's services.
The California Children's Services (CCS) program is a statewide
program providing medically necessary services required by physically
handicapped children whose parents are unable to pay for those
services. The State Department of Health Care Services administers
the CCS program. Counties, based on population size, are also charged
with administering the program, either independently or jointly with
the department. The services covered by the CCS program include
expert diagnosis, medical treatment, surgical treatment, hospital
care, physical therapy, occupational therapy, special treatment,
materials, and the supply of appliances and their upkeep,
maintenance, and transportation. Funding for the program comes from
county, state, and federal sources. In order to be eligible for the
CCS program, an applicant must be under 21 years of age, have or be
suspected of having a condition covered by the program, and meet
certain financial eligibility standards established by the
department.
Existing law prohibits services covered by the CCS program from
being incorporated into a Medi-Cal managed care contract entered into
after August 1, 1994, until January 1, 2017, except with respect to
contracts entered into for county organized health systems or
Regional Health Authority in specified counties.
This bill would exempt contracts entered into under the Whole
Child Model program, described below, from that prohibition and would
extend to January 1, 2022, and until the evaluation required under
the Whole Child Model program has been completed, the termination of
the prohibition against CCS-covered services being incorporated in a
Medi-Cal managed care contract entered into after August 1, 1994.
The bill would authorize the department, no sooner than July 1,
2017, to establish a Whole Child Model program, under which managed
care plans served by a county organized health system or Regional
Health Authority in designated counties would provide CCS services to
Medi-Cal eligible CCS children and youth. The bill would limit the
number of managed care plans under a county organized health system
or Regional Health Authority that are eligible to participate in the
program. The bill would require the department to implement the
program, as specified, and would require a managed care plan to
obtain written approval from the department and establish a local
stakeholder process, as prescribed. The bill would prohibit the
department from approving the application of a managed care plan
until the Director of Health Care Services has verified the readiness
of the managed care plan to address the unique needs of CCS-eligible
beneficiaries, including, among other things, that the managed care
contractor demonstrates the availability of an appropriate provider
network to serve the needs of children and youth with CCS conditions
and complies with all CCS program guidelines.
The bill would prohibit the department from implementing the
program in any county until it has developed specific CCS monitoring
and oversight standards for managed care plans. The bill would
require the department to establish, through December 31, 2021, a
statewide Whole Child Model program stakeholder advisory group
comprised of specified stakeholders, including representatives from
health plans and family resource centers, or modify an existing
stakeholder advisory group and would require the department to
consult with the Whole Child Model program stakeholder advisory group
on the implementation of the program, as specified. The bill would
impose various requirements on a Medi-Cal managed care plan serving
children and youth with CCS-eligible conditions under the CCS
program, including, but not limited to, coordinating services, as
specified; providing appropriate access to care, services, and
information, including continuity of care requirements; and providing
for case management, care coordination, provider referral, and
service authorization services. The bill would require a Medi-Cal
managed care plan participating in the Whole Child Model program to
ensure provision of case management, care coordination, provider
referral, and service authorization services to children and youth,
as prescribed, but would authorize the department to waive this
requirement if the plan demonstrates that it cannot meet the
requirement because it would result in substantially increased
program costs, as specified. This bill would require a managed care
plan to provide a timely process for accepting and acting upon
complaints and grievances of CCS-eligible children and youth. The
bill would require a specified stakeholder process to address
proposed changes to CCS medical eligibility requirements. The bill
would require the department to contract with an independent entity
to conduct an evaluation to assess health plan performance and the
outcomes and the experience of CCS-eligible children and youth
participating in the program, and would require the department to
provide a report on the results of this evaluation to the Legislature
no later than January 1, 2021.
This bill would provide that its provisions are not intended to
permit any reduction in benefits or eligibility levels under the
existing CCS program. The bill would require the department, by July
1, 2020, to adopt regulations and, commencing July 1, 2018, would
require the department to provide a status report to the Legislature
until regulations have been adopted. The bill would authorize the
Director of Health Care Services to enter into exclusive or
nonexclusive contracts on a bid, nonbid, or negotiated basis and
amend existing managed care contracts to provide or arrange for
services provided under the bill.
By imposing new duties on counties with respect to the transition
and implementation of CCS program services, this bill would impose a
state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the
following:
(a) The California Children's Services (CCS) program is the nation'
s oldest Title V Maternal and Child Health Services Block Grant
program.
(b) The CCS program has provided critical access to specialized
medical care for California's most complex and fragile pediatric
patients since 1927.
(c) The strong standards and credentialing created under the CCS
program ensure that eligible children obtain care from experienced
providers with appropriate pediatric-specific expertise.
(d) CCS providers form a regional backbone for all specialty
pediatric care in California, benefiting children of every income
level and insurance status.
(e) Over the past 20 years, coordinated and integrated health care
delivery models have been shown to improve delivery of health care,
reduce costs, and improve outcomes.
(f) As California expanded the reach of integrated delivery
systems in Medi-Cal, CCS services were often excluded from managed
care arrangements in recognition of the specialty nature of CCS
services and the complicated health status of enrolled children.
(g) Accordingly, it is the intent of the Legislature to modernize
the CCS program, through development of the Whole Child Model,
focused on the unique needs of CCS-eligible children in counties
served by county organized health systems to accomplish the
following:
(1) Improve coordination and integration of services to meet the
needs of the whole child, not just address the CCS-eligible
condition.
(2) Retain CCS program standards to maintain access to
high-quality specialty care for eligible children.
(3) Support active participation by parents and families, who are
frequently the primary caregivers for CCS-eligible children.
(4) Establish specialized programs to manage and coordinate the
care of CCS-enrolled children.
(5) Ensure that children with CCS-eligible conditions receive care
in the most appropriate, least restrictive setting.
(6) Maintain existing patient-provider relationships, whenever
possible.
(h) It is further the intent of the Legislature to protect the
unique access to pediatric specialty services provided by CCS while
promoting modern organized delivery systems to meet the medical care
needs of eligible children.
(i) It is further the intent of the Legislature to continue the
pediatric specialty expertise and statewide network of CCS providers
by promoting contractual relationships between those providers and
managed care plans. Accordingly, it is the intent of the Legislature
that reimbursement under the Whole Child Model program be sufficient
to attract and retain these specialists in the CCS program.
SEC. 2. Section 123835 of the Health and Safety Code is amended to
read:
123835. (a) The department shall keep the California Children's
Services (CCS) program abreast of advances in medical science,
leading to the inclusion of other handicapping conditions and
services within the limits of and consistent with the most beneficial
use of funds appropriated for this purpose. With the approval of the
agency administrator the department may carry out pilot studies to
determine the need for, or the feasibility of, including other
handicapping conditions and services in the program within the limits
of available funds appropriated for the program.
(b) To the extent that any changes in CCS medical eligibility are
proposed by the department, there shall be a stakeholder process that
shall include both of the following:
(1) A draft of the proposed regulatory changes shall be shared
publicly at least 120 days prior to the filing of a regulatory
change. The proposed changes shall also be shared with the
appropriate policy and fiscal committees of the Legislature and
posted publicly on the department's Internet Web site.
(2) The department shall utilize existing stakeholder committees
to receive input and comments on any proposed changes and shall
provide written comments back after input is provided. This input may
be provided to all stakeholders, including, but not limited to,
advocates, clinical experts, associations, county CCS program
administrators, families, and CCS providers.
SEC. 3. Section 123850 of the Health and Safety Code is amended to
read:
123850. (a) The board of supervisors of each county shall
designate the county department of public health or the county
department of social welfare as the designated agency to administer
the California Children's Services (CCS) program. Counties with total
population under 200,000 persons may administer the county program
independently or jointly with the department. Counties with a total
population in excess of 200,000 persons shall administer the county
program independently. Except as otherwise provided in this article,
the director shall establish standards relating to the local
administration and minimum services to be offered by counties in the
conduct of the CCS program.
(b) (1) Upon a determination by the director that a Medi-Cal
managed care plan and participating county have met all of the State
Department of Health Care Services' readiness requirements, the
designated county agency and a Medi-Cal managed care health plan
serving the county, as determined by the director, shall provide for
the transition of CCS program services, except for services provided
pursuant to subdivision (c), into the Medi-Cal managed care health
plan contract in Whole Child Model counties pursuant to Article 2.985
(commencing with Section 14094.4) for children who are enrolled in
the Medi-Cal managed care plan and CCS. For children enrolled in a
Medi-Cal managed care plan and CCS in Whole Child Model counties
pursuant to Article 2.985 (commencing with Section 14094.4), the case
management, care coordination, provider referral, and service
authorization administrative functions of the CCS program shall then
be the responsibility of the Medi-Cal managed care health plan in
accordance with Section 14094.13 and a written transition plan
prepared by the designated county agency and the Medi-Cal managed
care health plan. The director shall provide an implementation date
for the transition and identify how the state shall continue to
fulfill the requirements set forth in Sections 123855, 123925, and
123960. CCS program eligibility determination shall remain the
responsibility of the designated county agency in accordance with the
provisions of this article.
(2) The case management, care coordination, provider referral, and
service authorization functions of the CCS program shall remain the
responsibility of the county for CCS beneficiaries exempt from
mandatory enrollment in the Medi-Cal managed care plan.
(c) The CCS Medical Therapy program shall remain responsible for
the provision of medically necessary occupational and physical
therapy services prescribed by the CCS Medical Therapy Unit
Conference Team Physician or the CCS-paneled physician who is
providing the medical direction for occupational and physical therapy
services.
(d) 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, interpret, or make specific this article,
Article 2.97 (commencing with Section 14093) and Article 2.985
(commencing with Section 14094.4) of Chapter 7 of Part 3 of Division
9 of the Welfare and Institutions Code, and any applicable federal
waivers and state plan amendments by means of all-county letters,
plan letters, CCS numbered letters, plan or provider bulletins, or
similar instructions, without taking regulatory action in order to
implement the Whole Child Model established pursuant to Article 2.985
(commencing with Section 14094.4). By July 1, 2020, the department
shall adopt regulations in accordance with the requirements of
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code. Commencing January 1, 2018, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the Government
Code, until regulations have been adopted.
SEC. 4. Section 14093.06 of the Welfare and Institutions Code is
amended to read:
14093.06. (a) When a managed care contractor that is authorized
to provide California Children's Services (CCS) covered services
pursuant to subdivision (a) of Section 14094.3 or Article 2.985
(commencing with Section 14094.4) expands a managed care plan's CCS
coverage area to other counties, the contractor shall comply with CCS
program standards including, but not limited to, referral of
newborns to the appropriate neonatal intensive care level, referral
of children requiring pediatric intensive care to CCS-approved
pediatric intensive care units, and referral of children with CCS
eligible conditions to CCS-approved inpatient facilities and special
care centers in accordance with subdivision (c) of Section 14093.05.
(b) The managed care contractor shall comply with CCS program
medical eligibility regulations. Questions regarding interpretation
of state CCS medical eligibility regulations, or disagreements
between the county CCS program and the managed care contractor
regarding interpretation of those regulations, shall be resolved by
the local CCS program, in consultation with the state CCS program.
The resolution determined by the CCS program shall be communicated in
writing to the managed care contractor.
(c) In following the treatment plan developed in accordance with
CCS program requirements, the managed care contractor shall ensure
the timely referral of children with special health care needs to
CCS-paneled providers who are board-certified in both pediatrics and
in the appropriate pediatric subspecialty.
(d) The managed care contractor shall report expenditures and
savings separately for CCS covered services and CCS eligible
children, in accordance with paragraph (1) of subdivision (d) of
Section 14093.05.
(e) All children who are enrolled with a managed care contractor
who are seeking CCS program benefits shall retain all rights to CCS
program appeals and fair hearings of denials of medical eligibility
or of service authorizations. Information regarding the number,
nature, and disposition of appeals and fair hearings shall be part of
an annual report to the Legislature on managed care contractor
compliance with CCS standards, regulations, and procedures. This
report shall be made available to the public.
(f) The department, in consultation with stakeholder groups, shall
develop unique pediatric plan performance standards and
measurements, including, but not limited to, the health outcomes of
children with special health care needs.
SEC. 5. Section 14094.2 of the Welfare and Institutions Code is
amended to read:
14094.2. (a) This article is not intended, and shall not be
interpreted, to permit any reduction in benefits or eligibility
levels under the CCS program. Any medically necessary service not
available under the managed care contracts authorized under this
article shall remain the responsibility of the state and county.
(b) (1) In Whole Child Model counties authorized pursuant to
Article 2.985 (commencing with Section 14094.4), in order to ensure
that CCS benefits are provided to enrollees with a CCS-eligible
condition according to CCS program standards, there shall be
oversight by the department for both services covered and not covered
by the managed care contract.
(2) In counties not listed in Section 14094.5, in order to ensure
that CCS benefits are provided to enrollees with a CCS-eligible
condition according to CCS program standards, there shall be
oversight by the department and local CCS program agencies for both
services covered and not covered by the managed care contract.
SEC. 6. Section 14094.3 of the Welfare and Institutions Code is
amended to read:
14094.3. (a) Notwithstanding this article or Section 14093.05 or
14094.1, CCS covered services shall not be incorporated into any
Medi-Cal managed care contract entered into after August 1, 1994,
pursuant to Article 2.7 (commencing with Section 14087.3), Article
2.8 (commencing with Section 14087.5), Article 2.9 (commencing with
Section 14088), Article 2.91 (commencing with Section 14089), Article
2.95 (commencing with Section 14092); or either Article 1
(commencing with Section 14200), or Article 7 (commencing with
Section 14490) of Chapter 8, until January 1, 2022, and until the
evaluation required pursuant to Section 14094.18 has been completed,
except for contracts entered into pursuant to the Whole Child Model
program, as described in Article 2.985 (commencing with Section
14094.4), or for county organized health systems or Regional Health
Authority in the Counties of San Mateo, Santa Barbara, Solano, Yolo,
Marin, and Napa.
(b) Notwithstanding any other provision of this chapter, providers
serving children under the CCS program who are enrolled with a
Medi-Cal managed care contractor but who are not enrolled in a pilot
project pursuant to subdivision (c) shall continue to submit billing
for CCS covered services on a fee-for-service basis until CCS covered
services are incorporated into the Medi-Cal managed care contracts
described in subdivision (a).
(c) (1) The department may authorize a pilot project in Solano
County in which reimbursement for conditions eligible under the CCS
program may be reimbursed on a capitated basis pursuant to Section
14093.05, and provided all CCS program's guidelines, standards, and
regulations are adhered to, and the CCS program's case management is
utilized.
(2) During the time period described in subdivision (a), the
department may approve, implement, and evaluate limited pilot
projects under the CCS program to test alternative managed care
models tailored to the special health care needs of children under
the CCS program. The pilot projects may include, but need not be
limited to, coverage of different geographic areas, focusing on
certain subpopulations, and the employment of different payment and
incentive models. Pilot project proposals from CCS program-approved
providers shall be given preference. All pilot projects shall utilize
CCS program-approved standards and providers pursuant to Section
14094.1.
(d) For purposes of this section, CCS covered services include all
program benefits administered by the program specified in Section
123840 of the Health and Safety Code regardless of the funding
source.
(e) This section shall not be construed to exclude or restrict
CCS-eligible children from enrollment with a managed care contractor,
or from receiving from the managed care contractor with which they
are enrolled primary and other health care unrelated to the treatment
of the CCS-eligible condition.
SEC. 7. Article 2.985 (commencing with Section 14094.4) is added
to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, to read:
Article 2.985. Whole Child Model Program
14094.4. For the purposes of this article, the following
definitions shall apply:
(a) "CCS provider" means any of the following:
(1) A medical provider that is paneled by the CCS program to treat
a CCS-eligible condition pursuant to Article 5 (commencing with
Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health
and Safety Code.
(2) A licensed acute care hospital approved by the CCS program to
treat a CCS-eligible condition.
(3) A special care center approved by the CCS program to treat a
CCS-eligible condition.
(b) "County organized health system" or "COHS" means:
(1) A county organized health system contracting with the
department to provide Medi-Cal services to beneficiaries pursuant to
Article 2.8 (commencing with Section 14087.5).
(2) A regional health authority.
(c) "Medi-Cal managed care plan" means a COHS.
14094.5. No sooner than July 1, 2017, the department may
establish a Whole Child Model program for Medi-Cal eligible CCS
children and youth enrolled in a managed care plan served by a county
organized health system or Regional Health Authority in the
following counties: Del Norte, Humboldt, Lake, Lassen, Marin,
Mendocino, Merced, Modoc, Monterey, Napa, Orange, San Luis Obispo,
San Mateo, Santa Barbara, Santa Cruz, Shasta, Siskiyou, Solano,
Sonoma, Trinity, and Yolo.
14094.6. The goals for the Whole Child Model program for children
and youth under 21 years of age who meet the eligibility
requirements of Section 123805 of the Health and Safety Code and are
enrolled in a managed care plan under a county organized health
system or Regional Health Authority shall include all of the
following:
(a) Improving the coordination of primary and preventive services
with specialty care services, medical therapy units, Early and
Periodic Screening, Diagnosis, and Treatment (EPSDT), long-term
services and supports (LTSS), regional center services, and home- and
community-based services using a child and youth and family-centered
approach.
(b) Maintaining or exceeding CCS program standards and specialty
care access, including access to appropriate subspecialties.
(c) Providing for the continuity of child and youth access to
expert, CCS dedicated case management and care coordination, provider
referrals, and service authorizations.
(d) Improving the transition of youth from CCS to adult Medi-Cal
managed systems of care through better coordination of medical and
nonmedical services and supports and improved access to appropriate
adult providers for youth who age out of CCS.
(e) Identifying, tracking, and evaluating the transition of
children and youth from CCS to the Whole Child Model program to
inform future CCS program improvements.
14094.65. This article shall not be construed to exclude or
restrict the specialty of neonatology from reimbursement under the
California Children's Services (CCS) program, subject to the program'
s existing or applicable prior authorization requirements or
utilization review. Neonatology shall be included in the CCS program.
14094.7. (a) No sooner than July 1, 2017, the department may
implement the Whole Child Model program established under this
section, pursuant to the criteria described in this article. The
director shall provide notice to the Legislature, the federal Centers
for Medicare and Medicaid Services, counties, CCS providers, and CCS
families when each managed care plan, including a transition plan
with the county CCS program, has been reviewed and certified as ready
to enroll children based on the criteria described in this article.
(b) Prior to the implementation of the Whole Child Model, the
department shall do all of the following:
(1) Develop specific CCS program monitoring and oversight
standards for managed care plans that are subject to this article,
including access monitoring, quality measures, and ongoing public
data reporting.
(2) Establish a stakeholder process pursuant to Section 14094.17.
(3) Consult with the statewide stakeholder advisory group
established pursuant to Section 14094.17 to develop and implement
robust monitoring processes to ensure that managed care plans are in
compliance with all of the provisions of this section. The department
shall monitor managed care plan compliance with the provisions of
this section on at least an annual basis and post CCS-specific
monitoring dashboards on its Internet Web site on at least an annual
basis.
(c) (1) In order to aid the transition of CCS services into
Medi-Cal managed care plans participating in the Whole Child Model
program, commencing January 1, 2017, and continuing through the
completion of the transition of CCS enrollees into the Whole Child
Model program, the department shall begin requesting and collecting
from Medi-Cal managed care plans information about each health plan's
provider network, including, but not limited to, the contracting
primary care, specialty care providers, and hospital facilities
contracting with the Medi-Cal managed care plan.
(2) The department shall analyze the existing Medi-Cal managed
care delivery system network and the CCS fee-for-service provider
networks to determine the overlap of the provider networks in each
county and shall furnish this information to the Medi-Cal managed
care plan.
(d) A managed care plan shall not be approved to participate in
the Whole Child Model program unless all of the following conditions
have been satisfied:
(1) The managed care plan has obtained written approval from the
director.
(2) The department has obtained any necessary federal approvals.
(3) The Medi-Cal managed care plan has established a local
stakeholder process with the meaningful engagement of a diverse group
of families that represent a range of conditions, disabilities, and
demographics, and local providers, including, but not limited to, the
parent centers, such as family resource centers, family empowerment
centers, and parent training and information centers, that support
families in the affected county.
(4) The director has verified the readiness of the managed care
plan to address the unique needs of CCS-eligible beneficiaries,
including, but not limited to, the requirements set forth in
subdivision (b) of Section 14087.48, subdivisions (b) to (f),
inclusive, of Section 14093.05, and all of the following:
(A) That the managed care contractor has demonstrated the
availability of an appropriate provider network to serve the needs of
children and youth with CCS conditions, including primary care
physicians, pediatric specialists and subspecialists, professional,
allied, and medical supportive personnel, licensed acute care
hospitals, and special care centers.
(B) That the Medi-Cal managed care plan has established and
maintains an updated and accessible listing of providers and their
specialties and subspecialties and makes it available to CCS-eligible
children and youth and their parents or guardians, at a minimum by
phone, written material, and Internet Web site.
(C) That the Medi-Cal managed care plan has entered into an
agreement with the county CCS program or the state, or both, for the
transition of CCS care coordination and service authorization and how
the plan will work with the CCS program to ensure continuity and
consistency of CCS program expertise for that role, in accordance
with this section.
(e) A Medi-Cal managed care plan, prior to implementation of the
Whole Child Model program, shall review historical CCS
fee-for-service utilization data for CCS-eligible children and youth
upon transition of CCS services to managed care plans so that the
managed care plans are better able to assist CCS-eligible children
and youth and prioritize assessment and care planning.
14094.9. (a) The department shall develop a memorandum of
understanding template, which shall be utilized by participating
counties and health plans, and which shall include, but not be
limited to, the standards relating to the local administration of,
and minimum services to be provided by, counties and Medi-Cal managed
care plans in the administration of the Whole Child Model program.
The department shall consult with counties and Medi-Cal managed care
plans in the development of the Whole Child Model program memorandum
of understanding template.
(b) The department shall provide written notice to the county
agency, as designated in Section 123850 of the Health and Safety
Code, of the calculation for determining the administrative
allocation to the county CCS program by means of county information
notice. The department shall consult with the Whole Child Model
program counties in determining the calculation for determining the
administrative allocation.
14094.10. (a) Each Medi-Cal managed care plan participating in
the Whole Child Model program shall establish an assessment process
that, at a minimum, does all of the following:
(1) Assesses each CCS child's or youth's risk level and needs by
performing a risk assessment process using means such as telephonic
or in-person communication, review of utilization and claims
processing data, or by other means as determined by the department.
(2) Assesses, in accordance with the transition agreement with the
county CCS program, the health care needs of CCS-eligible children
and youth and coordinates their CCS specialty services, Medi-Cal
primary care services and mild to moderate mental health services,
specialty mental health as appropriate through the county specialty
mental health plan, and Drug Medi-Cal services as appropriate through
county substance use disorder program, and regional center services
across all settings, including coordination of necessary services
within and, when necessary, outside of the managed care plan's
provider network.
(3) Follows timeframes for reassessment of risk and, if necessary,
circumstances or conditions that require redetermination of risk
level, which shall be set by the department.
(b) The risk assessment process shall be performed in accordance
with all applicable federal and state laws.
14094.11. A Medi-Cal managed care plan participating in the Whole
Child Model program shall meet all of the following requirements:
(a) Ensure that each CCS-eligible child or youth receives case
management, care coordination, provider referral, and service
authorization services from an employee or contractor of the plan who
has knowledge of, and receives adequate training on, the CCS
program, and who has clinical experience with the CCS population, or
clinical experience with pediatric patients with complex medical
conditions.
(b) Work with the state or county CCS program, as appropriate, to
ensure that, at a minimum, and in addition to other statutory and
contractual requirements, care coordination and care management
activities do all of the following:
(1) Reflect a CCS child or youth family-centered, outcome-based
approach to care planning.
(2) Ensure families have access to ongoing information, education,
and support so that they understand the care plan for their child or
youth and their role in the individual care process, the benefits of
mental health services, what self-determination means, and what
services might be available.
(3) Adhere to the CCS child's or youth's or the CCS child's or
youth's family's determination about the appropriate involvement of
his or her medical providers and caregivers, according to the federal
Health Insurance Portability and Accountability Act of 1996 (Public
Law 104-191).
(4) Include individual care plans for CCS-eligible children and
youth based on the results of the risk assessment process with a
particular focus on CCS specialty care.
(5) Consider
behavioral health needs of CCS-eligible children and youth and
coordinate those services as part of the CCS child's or youth's
individual care plan, when appropriate, and facilitate a CCS child's
or youth's ability to access appropriate community resources and
other agencies, including referrals, as necessary and appropriate,
for behavioral services, such as specialty mental health services and
substance use disorder services.
(6) Ensure that children and youth and their families have
appropriate access to transportation and other support services
necessary to receive treatment.
(c) Incorporate all of the following into the CCS child's or youth'
s plan of care:
(1) Access for families so that families know where to go for
ongoing information, education, and support in order that they
understand the goals, treatment plan, and course of care for their
child or youth and their role in the process, what it means to have
primary or specialty care for their child or youth, when it is time
to call a specialist, primary, urgent care, or emergency room, what
an interdisciplinary team is, and what the community resources are.
(2) A primary or specialty care physician who is the primary
clinician for the CCS-eligible child or youth and who provides core
clinical management functions.
(3) Care management and care coordination for the CCS-eligible
child or youth across the health care system, including transitions
among levels of care and interdisciplinary care teams.
(4) Provision of information about qualified professionals,
community resources, or other agencies for services or items outside
the scope of responsibility of the managed care plan.
(d) Use clinical data to identify CCS-eligible children or youth
at the care site with chronic illness or other significant health
issues.
(e) Arrange for timely preventive, acute, and chronic illness
treatment of CCS-eligible children or youth in the appropriate
setting.
14094.12. A Medi-Cal managed care plan serving children and youth
with CCS-eligible conditions under the CCS program shall do all of
the following:
(a) Coordinate with each regional center operating within the plan'
s service area to assist CCS-eligible children and youth with
developmental disabilities and their families in understanding and
accessing services and act as a central point of contact for
questions related to health care access and care concerns, and
problem resolution.
(b) Coordinate with the local CCS Medical Therapy Unit (MTU) to
ensure appropriate access to MTU services. The Medi-Cal managed care
plan shall enter into a memorandum of understanding or similar
agreement with the county regarding coordination of MTU services and
other non-MTU services provided by the plan.
(c) Ensure that families have access to ongoing information,
education, and support so they understand the care plan, course of
treatment, and expected outcomes for their child or youth, the
assessment process, what it means, their role in the process, and
what services their child or youth may be eligible for.
(d) Facilitate communication among a CCS child's or youth's health
care and personal care providers, including in-home supportive
services and behavioral health providers, when appropriate, with the
CCS-eligible child or youth, parent, or guardian.
(e) Facilitate timely access to primary care, specialty care,
pharmacy, and other health services provided by CCS providers and
facilities with clinical expertise in treating the enrollee's
specific CCS condition that are needed by the CCS child or youth,
including referrals to address any physical or cognitive
disabilities.
(f) Provide information for families about managed care processes
and how to navigate a health plan, including their rights to appeal
any service denials, and how to request continuity of care for
pharmacy, specialized durable medical equipment, and health care
providers pursuant to Section 14094.13.
(g) Establish a mechanism to provide information on how to access
local family resource centers or family empowerment centers.
(h) Provide that communication to, and services for, the
CCS-eligible children or youth and their families are available in
alternative formats that are culturally, linguistically, and
physically appropriate through means, including, but not limited to,
assistive listening systems, sign language interpreters, captioning,
written communication, plain language, and written translations in
the applicable Medi-Cal threshold languages.
(i) Provide that materials are available and provided to inform
CCS children and youth and their families of procedures for obtaining
CCS specialty services and Medi-Cal primary care and mental health
benefits, including grievance and appeals procedures that are offered
by the managed care plan or are available through the Medi-Cal
program.
(j) Identify and track children and youth with CCS-eligible
conditions for the duration of the child's or youth's participation
in the Whole Child Model program and for children and youth who age
into adult Medi-Cal systems and who continue to be enrolled in the
same Medi-Cal managed care plan for at least three years into
adulthood, to the extent feasible.
(k) (1) Comply with Medi-Cal due process requirements and provide
timely processes for accepting and acting upon complaints and
grievances, including procedures for appealing decisions regarding
coverage or benefits. The grievance process shall comply with Section
14450 of this code, and Sections 1368 and 1368.01 of the Health and
Safety Code and applicable federal law and regulations.
(2) Upon denial, denial of reauthorization, or termination of
services, a notice of action shall be sent to the CCS-eligible child
or youth, or person legally authorized to act on behalf of the child
or youth. The notice of action shall include information about the
option to file a Medi-Cal appeal and Medi-Cal due process rights.
(l) Comply with Section 1383.15 of the Health and Safety Code by
allowing a child or youth or the parent or guardian of a child or
youth to receive a second opinion from an appropriately qualified
health care professional.
14094.13. (a) Each Medi-Cal managed care plan shall establish and
maintain a process by which a CCS-eligible child or youth may
maintain access to CCS providers that the child or youth has an
existing relationship with for treatment of the child's or youth's
CCS condition for up to 12 months, under the following conditions:
(1) The CCS-eligible child or youth has seen the out-of-network
CCS provider for a nonemergency visit at least once during the 12
months immediately preceding the date the Medi-Cal managed care plan
assumed responsibility for the child's or youth's CCS care under the
Whole Child Model program.
(2) The CCS provider accepts the health plan's rate for the
service offered or the applicable Medi-Cal or CCS fee-for-service
rate, whichever is higher, unless the CCS provider enters into an
agreement on an alternative payment methodology mutually agreed to by
the CCS provider and the Medi-Cal managed care plan.
(3) The managed care plan confirms that the provider meets
applicable CCS standards and has no disqualifying quality of care
issues.
(4) The CCS provider provides treatment information to the
Medi-Cal managed care plan, to the extent authorized by the state and
federal patient privacy provisions.
(b) Each Medi-Cal managed care plan shall establish and maintain a
process by which a CCS-eligible child or youth may maintain access
to specialized or customized durable medical equipment providers for
up to 12 months under the conditions in paragraph (2):
(1) For the purposes of this subdivision, "specialized or
customized durable medical equipment" means durable medical equipment
that meets all of the following criteria:
(A) Is uniquely constructed from raw materials or substantially
modified from the base material solely for the full-time use of the
specific beneficiary according to a physician's description and
orders.
(B) Is made to order or adapted to meet the specific needs of the
beneficiary.
(C) Is uniquely constructed, adapted, or modified to permanently
preclude the use of the equipment by another individual, and is so
different from another item used for the same purpose that the two
items cannot be grouped together for pricing purposes.
(2) (A) The CCS-eligible child or youth has an ongoing
relationship with a durable medical equipment provider who has
previously provided specialized or customized equipment, such as
power wheelchairs, repairs, and replacement parts; prosthetic limbs;
customized orthotic devices; and individualized assistive technology.
This does not include generally available or noncustomized durable
medical equipment.
(B) The durable medical equipment provider shall accept the health
plan's rate for the service offered or the applicable Medi-Cal or
CCS fee-for-service rate, whichever is higher, unless the durable
medical equipment provider enters into an agreement on an alternative
payment methodology mutually agreed upon by the durable medical
equipment provider and the Medi-Cal managed care plan.
(C) The durable medical equipment provider provides information to
the Medi-Cal managed care plan as requested by the plan, to the
extent authorized by state and federal patient privacy provisions.
(3) The department may extend the continuity of care duration
period described in this subdivision for specialized or customized
durable medical equipment that is under warranty as specified by the
department.
(c) A managed care plan, at its discretion, may extend the
continuity of care period beyond the length of time specified in
subdivisions (a) and (b).
(d) (1) Each Medi-Cal managed care plan participating in the Whole
Child Model program shall comply with continuity of care
requirements in Section 1373.96 of the Health and Safety Code and
Section 14185 of this code.
(2) Each Medi-Cal managed care plan shall permit a CCS-eligible
child or youth transitioned into the Whole Child Model program to
continue use of any currently prescribed prescription drug that is
part of a prescribed therapy for the enrollee's CCS-eligible
condition or conditions immediately prior to the date of enrollment,
whether or not the prescription drug is covered by the plan, until
the Medi-Cal managed care plan and the child's or youth's prescribing
CCS provider has completed an assessment of the child or youth,
created a treatment plan, and agrees with the Medi-Cal managed care
plan that the particular prescription drug is no longer medically
necessary, or the prescription drug is no longer prescribed by the
enrollee's CCS provider.
(e) Each Medi-Cal managed care plan participating in the Whole
Child Model program shall ensure that children and youth are provided
expert case management, care coordination, service authorization,
and provider referral services. Each plan shall meet this requirement
by, at the request of the child, youth, or his or her parent or
guardian, allowing the child or youth to continue to receive case
management and care coordination from his or her public health nurse.
This election shall be made within 90 days of the transition of CCS
services into the Medi-Cal managed care plan. A plan shall meet this
requirement by either or both of the following:
(1) By entering into a memorandum of understanding with the county
for case management and care coordination services to the child.
(2) By entering into a memorandum of understanding with the county
for case management, care coordination, provider referral, and
service authorization to all or some Whole Child Model program
participants.
(f) At least 60 days before the transition of CCS services to the
Medi-Cal managed care plan, a written notice shall be provided to all
CCS children and youth whose CCS care will become the responsibility
of the plan explaining their right to continue receiving case
management and care coordination services pursuant to subdivision
(e), including a written explanation of the process for that
election. A reminder notification shall be sent 30 days prior to the
start of the transition.
(g) In the event the county public health nurse leaves the CCS
program or is no longer available to provide the services requested
under this section, the Medi-Cal managed care plan shall transition
the care coordination and case management of a child or youth to an
employee or contractor of the plan who has received adequate training
on the CCS program and who has clinical experience with the CCS
population or pediatric patients with complex medical conditions.
(h) The department may waive the requirement of subdivision (e) if
the Medi-Cal managed care plan demonstrates that it cannot meet the
requirement because it would result in substantially increased
program costs compared to the existing CCS program allocation as
provided by the department through the annual Budget Act. The
department shall confirm the information provided by the Medi-Cal
managed care plan and meet with the county, affected labor
organizations, and the plan in an attempt to reach a mutually
agreeable contracting arrangement that fulfills the requirements of
this section while also ensuring that the arrangement is not in
excess of the current county program allocation.
(i) (1) A family or caregiver of a child or youth may appeal the
continuity of care limitation in subdivision (a) to the director or
his or her designee. When determining whether or not to grant the
appeal, the director or his or her designee shall consider all of the
following:
(A) Whether the noncontracting CCS provider has any relevant
clinical experience or unique expertise that available contracting
CCS providers do not have.
(B) If the noncontracting CCS provider is a special care center,
whether or not any of the available contracting CCS providers is a
special care center of the same type.
(C) The length of the ongoing relationship between the CCS
provider and the child or youth.
(D) The proximity of the noncontracting CCS provider to the child'
s or youth's home as compared to the proximity of the contracting CCS
provider being put forth by the plan.
(2) The opinion of the director or his or her designee shall be
final and binding upon the plan.
(j) This section shall not preclude the right of the CCS child or
youth to appeal or be eligible for a fair hearing regarding the
extension of a continuity of care period.
(k) Each Medi-Cal managed care plan participating in the Whole
Child Model program shall notify the CCS child or youth, in writing,
60 days prior to the end of his or her authorized continuity of care
period. The notice shall explain the right to petition the plan for
an extension of the continuity of care period, the criteria the plan
will use to evaluate the petition, and the appeals process if the
plan denies the petition.
14094.14. (a) Each Medi-Cal managed care plan participating in
the Whole Child Model program shall provide a mechanism for a
CCS-eligible child's and youth's parent or caregiver to request a
specialist or clinic as a primary care provider.
(b) A CCS specialist or clinic may serve as a primary care
provider if the specialist or clinic agrees to serve in a primary
care provider role and is qualified to treat the required range of
CCS-eligible conditions of the CCS child or youth.
14094.15. A Medi-Cal managed care plan shall meet all of the
following requirements:
(a) Use all current and applicable CCS program guidelines,
including CCS program regulations, CCS numbered letters, and CCS
program information notices in developing criteria for use by the
plan's chief medical officer or the equivalent and other care
management staff.
(b) In cases in which applicable CCS clinical guidelines do not
exist, use evidence-based guidelines or treatment protocols that are
medically appropriate given the child's CCS-eligible condition.
(c) Utilize only CCS providers to treat CCS conditions in any
circumstance in which the child's CCS-eligible condition requires
treatment from the provider types in paragraph (1), (2), or (3) of
subdivision (a) of Section 14094.4, except a plan may use an
out-of-state provider if an in-state CCS provider does not possess
the clinical expertise to appropriately treat the CCS condition of
the child or youth.
(d) Utilize a provider dispute resolution process that meets the
standards established under Section 1371.38 of the Health and Safety
Code.
14094.16. (a) The department shall pay any managed care plan
participating in the Whole Child Model program a separate,
actuarially sound rate specifically for CCS children and youth, to
the extent that an actuarially sound rate can be developed for the
managed care plan's CCS population. When contracting with managed
care plans, the department may allow the use of risk corridors or
other methods to appropriately mitigate a plan's risk for this
population. If services are already established in the rate of a
Medi-Cal managed care plan prior to January 1, 2016, the department
shall not be required to create a separate rate for the Whole Child
Model program.
(b) Medi-Cal managed care plans shall pay physician and surgeon
provider services at rates that are equal to or exceed the applicable
CCS fee-for-service rates, unless the physician and surgeon enters
into an agreement on an alternative payment methodology mutually
agreed to by the physician and surgeon and the Medi-Cal managed care
plan
14094.17. (a) A Medi-Cal managed care plan participating in the
Whole Child Model program shall create and maintain a clinical
advisory committee composed of the managed care contractor's chief
medical officer or the equivalent, the county CCS medical director,
and at least four CCS-paneled providers to advise on clinical issues
relating to CCS conditions, including treatment authorization
guidelines, and serve as clinical advisers on other clinical issues
relating to CCS conditions.
(b) (1) Each Medi-Cal managed care plan participating in the Whole
Child Model program shall establish a family advisory group for CCS
families.
(2) Family representatives who serve on this advisory group may
receive a reasonable per diem payment to enable in-person
participation in the advisory group. A plan may conduct family
advisory group meetings by teleconference or through other similar
electronic means to facilitate family participation in the advisory
group.
(3) A representative of this local group shall be invited to serve
on the department's statewide stakeholder advisory group established
pursuant to subdivision (c).
(c) (1) The department shall establish a statewide Whole Child
Model program stakeholder advisory group, or modify an existing Whole
Child Model program stakeholder advisory group, comprised of
representatives of CCS providers, county CCS program administrators,
health plans, family resource centers, regional centers, labor
organizations, CCS case managers, CCS MTUs, and representatives from
family advisory groups established pursuant to subdivision (b).
Participation on the statewide stakeholder advisory group shall be
voluntary, and members are not eligible for travel or other per diem
payments.
(2) The department shall consult with the stakeholder advisory
group on the implementation of the Whole Child Model program and
shall consider the recommendations of the stakeholder advisory group
in developing the monitoring processes and outcome measures by which
the plans participating in the Whole Child Model program shall be
monitored and evaluated.
(3) The statewide Whole Child Model program stakeholder advisory
group established under this section shall terminate December 31,
2021.
14094.18. (a) (1) The department shall contract with an
independent entity that has experience in performing robust program
evaluations to conduct an evaluation to assess Medi-Cal managed care
plan performance and the outcomes and the experience of CCS-eligible
children and youth participating in the Whole Child Model program,
including access to primary and specialty care, and youth transitions
from Whole Child Model program to adult Medi-Cal coverage.
(2) The department shall provide a report on the results of this
evaluation required pursuant to this section to the Legislature by no
later than January 1, 2021. A report submitted to the Legislature
pursuant to this subdivision shall be submitted in compliance with
Section 9795 of the Government Code.
(b) The evaluation required by this section, at a minimum, shall
evaluate the performance of the plans participating in the Whole
Child Model program as compared to the performance of the CCS program
prior to the implementation of the Whole Child Model program in
those same counties. The evaluation shall evaluate whether the
inclusion of CCS services in a managed care delivery system improves
access to care, quality of care, and the patient experience by
analyzing all of the following, and when possible, disaggregating the
results, based on the child's or youth's race, ethnicity, and
primary language spoken at home:
(1) Access to specialty and primary care, and in particular,
utilization of CCS-paneled providers.
(2) The type and location of CCS services and the extent to which
CCS services are provided in-network compared to out of network.
(3) Utilization rates of inpatient admissions, outpatient
services, durable medical equipment, behavioral health services, home
health, pharmacy, and other ancillary services.
(4) Patient and family satisfaction.
(5) Appeals and grievances, including the number of petitions to
the plan to extend the continuity of care period for durable medical
equipment and CCS providers, the results of those appeals, whether
any subsequent appeals were made to the department, and the results
of those appeals to the department.
(6) Authorization of CCS-eligible services.
(7) Network and provider participation, including participation of
pediatricians, pediatric specialists, and pediatric subspecialists,
by specialty and subspecialty.
(8) The ability of a child or youth who ages out of CCS and
remains in the same Medi-Cal managed care plan to retain his or her
existing providers, to the extent possible or known.
(c) The evaluation required by this section shall also evaluate
managed care plans participating in the Whole Child Model program as
compared to the CCS program in counties where CCS services are not
incorporated into managed care, and collect appropriate data to
evaluate all of the following:
(1) The rate of new CCS enrollment in each county.
(2) The percentage of CCS-eligible children and youth with a
diagnosis requiring a referral to a CCS special care center who have
been seen by a CCS special care center.
(3) The percentage of CCS children and youth discharged from a
hospital who had at least one followup contact or visit within 28
days after discharge.
(4) Appeals and grievances.
(d) The department shall consult with stakeholders, including, but
not limited to, the Whole Child Model program stakeholder advisory
group, regarding the scope and structure of the review.
14094.19. This article is not intended, and shall not be
interpreted, to permit any reduction in benefits or eligibility
levels under the CCS program.
14094.20. (a) Notwithstanding Chapter 3.5 (commencing with
Section 11340) of Part 1 of Division 3 of Title 2 of the Government
Code, the department, without taking regulatory action, shall
implement, interpret, or make specific this article, Article 2.97
(commencing with Section 14093), Article 2.98 (commencing with
Section 14094), and any applicable federal waivers and state plan
amendments by means of all-county letters, plan letters, CCS numbered
letters, plan or provider bulletins, or similar instructions until
the time regulations are adopted. By July 1, 2020, the department
shall adopt regulations in accordance with the requirements of
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code. Commencing July 1, 2018, the
department shall provide a status report to the Legislature on a
semiannual basis, in compliance with Section 9795 of the Government
Code, until regulations have been adopted.
(b) The director may enter into exclusive or nonexclusive
contracts on a bid, nonbid, or negotiated basis and may amend
existing managed care contracts to provide or arrange for services
provided under this article. Contracts entered into or amended
pursuant to this section shall be exempt from the provisions of
Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of
the Public Contract Code and Chapter 6 (commencing with Section
14825) of Part 5.5 of Division 3 of Title 2 of the Government Code,
and shall be exempt from the review and approval of any division of
the Department of General Services.
SEC. 8. If the Commission on State Mandates determines that this
act contains costs mandated by the state, reimbursement to local
agencies and school districts for those costs shall be made pursuant
to Part 7 (commencing with Section 17500) of Division 4 of Title 2 of
the Government Code.