AB 461: Coordinated Care Initiative.
- Session Year: 2015-2016
- House: Assembly
- Latest Version Date: 2015-08-13
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. Existing federal law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age.
Existing law requires the department to seek federal approval pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof, to establish a demonstration project that enables beneficiaries dually eligible for the Medi-Cal program and the Medicare Program to receive a continuum of services that maximizes access to, and coordination of, benefits between the programs. Existing law requires, with some exceptions, the department to enroll dual eligible beneficiaries into a managed care plan that is selected to participate in the demonstration project unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled in a specified managed care organization on or before June 1, 2013. Existing law excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is receiving services through a regional center or state developmental center. Existing law also excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is enrolled in a home- and community-based waiver except for persons enrolled in Multipurpose Senior Services Program services.
This bill would authorize a beneficiary receiving services through a regional center who resides in the County of San Mateo to participate voluntarily in the demonstration project if certain requirements are met.
This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Mateo.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. Existing federal law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age.
Existing law requires the department to seek federal approval pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof, to establish a demonstration project that enables beneficiaries dually eligible for the Medi-Cal program and the Medicare Program to receive a continuum of services that maximizes access to, and coordination of, benefits between the programs. Existing law requires, with some exceptions, the department to enroll dual eligible beneficiaries into a managed care plan that is selected to participate in the demonstration project unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled in a specified managed care organization on or before June 1, 2013. Existing law excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is receiving services through a regional center or state developmental center. Existing law also excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is enrolled in a home- and community-based waiver except for persons enrolled in Multipurpose Senior Services Program services.
This bill would authorize a beneficiary receiving services through a regional center who resides in the County of San Mateo to participate voluntarily in the demonstration project if certain requirements are met.
This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Mateo.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. Existing federal law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age.
Existing law requires the department to seek federal approval pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof, to establish a demonstration project that enables beneficiaries dually eligible for the Medi-Cal program and the Medicare Program to receive a continuum of services that maximizes access to, and coordination of, benefits between the programs. Existing law requires, with some exceptions, the department to enroll dual eligible beneficiaries into a managed care plan that is selected to participate in the demonstration project unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled in a specified managed care organization on or before June 1, 2013. Existing law excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is receiving services through a regional center or state developmental center. Existing law also excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is enrolled in a home- and community-based waiver except for persons enrolled in Multipurpose Senior Services Program services.
This bill would authorize a beneficiary receiving services through a regional center who resides in the County of San Mateo to participate voluntarily in the demonstration project if certain requirements are met.
This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Mateo.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. Existing federal law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age.
Existing law requires the department to seek federal approval pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof, to establish a demonstration project that enables beneficiaries dually eligible for the Medi-Cal program and the Medicare Program to receive a continuum of services that maximizes access to, and coordination of, benefits between the programs. Existing law requires, with some exceptions, the department to enroll dual eligible beneficiaries into a managed care plan that is selected to participate in the demonstration project unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled in a specified managed care organization on or before June 1, 2013. Existing law excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is receiving services through a regional center or state developmental center.
This bill would authorize a beneficiary receiving services through a regional center who resides in the County of San Mateo to participate voluntarily in the demonstration project if certain requirements are met.
This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Mateo.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. Existing federal law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age.
Existing law requires the department to seek federal approval pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof, to establish a demonstration project that enables beneficiaries dually eligible for the Medi-Cal program and the Medicare Program to receive a continuum of services that maximizes access to, and coordination of, benefits between the programs. Existing law requires, with some exceptions, the department to enroll dual eligible beneficiaries into a managed care plan that is selected to participate in the demonstration project unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled in a specified managed care organization on or before June 1, 2013. Existing law excludes a dual eligible beneficiary from enrollment in the demonstration project if, among other reasons, the beneficiary is receiving services through a regional center or state developmental center.
This bill would authorize a beneficiary receiving services through a regional center who resides in the County of San Mateo to participate voluntarily in the demonstration project if certain requirements are met.
This bill would make legislative findings and declarations as to the necessity of a special statute for the County of San Mateo.
(a)The department shall seek federal approval to establish the demonstration project described in this section pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof. Under a Medicare demonstration, the department may contract with the federal Centers for Medicare and Medicaid Services (CMS) and demonstration sites to operate the Medicare and Medicaid benefits in a demonstration project that is overseen by the state as a delegated Medicare benefit administrator, and may enter into financing arrangements with CMS to share in any Medicare program savings generated by the demonstration project.
(b)After federal approval is obtained, the department shall establish the demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports and behavioral health services, including mental health and substance use disorder treatment services. The purpose of the demonstration project is to integrate services authorized under the federal Medicaid Program (Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the federal Medicare Program (Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.)). The demonstration project may also include additional services as approved through a demonstration project or waiver, or a combination thereof.
(c)For purposes of this section, the following definitions shall apply:
(1)Behavioral health means Medi-Cal services provided pursuant to Section 51341 of Title 22 of the California Code of Regulations and Drug Medi-Cal substance abuse services provided pursuant to Section 51341.1 of Title 22 of the California Code of Regulations, and any mental health benefits available under the Medicare Program.
(2)Capitated payment model means an agreement entered into between CMS, the state, and a managed care health plan, in which the managed care health plan receives a capitation payment for the comprehensive, coordinated provision of Medi-Cal services and benefits under Medicare Part C (42 U.S.C. Sec. 1395w-21 et seq.) and Medicare Part D (42 U.S.C. Sec. 1395w-101 et seq.), and CMS shares the savings with the state from improved provision of Medi-Cal and Medicare services that reduces the cost of those services. Medi-Cal services include long-term services and supports as defined in Section 14186.1, behavioral health services, and any additional services offered by the demonstration site.
(3)Demonstration site means a managed care health plan that is selected to participate in the demonstration project under the capitated payment model.
(4)Dual eligible beneficiary means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) and Medicare Part B (42 U.S.C. Sec. 1395j et seq.) and is eligible for medical assistance under the Medi-Cal State Plan.
(d)No sooner than March 1, 2011, the department shall identify health care models that may be included in the demonstration project, shall develop a timeline and process for selecting, financing, monitoring, and evaluating the demonstration sites, and shall provide this timeline and process to the appropriate fiscal and policy committees of the Legislature. The department may implement these demonstration sites in phases.
(e)The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of any report submitted to CMS to meet the requirements under the demonstration project.
(f)Goals for the demonstration project shall include all of the following:
(1)Coordinate Medi-Cal and Medicare benefits across health care settings and improve the continuity of care across acute care, long-term care, behavioral health, including mental health and substance use disorder services, and home- and community-based services settings using a person-centered approach.
(2)Coordinate access to acute and long-term care services for dual eligible beneficiaries.
(3)Maximize the ability of dual eligible beneficiaries to remain in their homes and communities with appropriate services and supports in lieu of institutional care.
(4)Increase the availability of and access to home- and community-based services.
(5)Coordinate access to necessary and appropriate behavioral health services, including mental health and substance use disorder services.
(6)Improve the quality of care for dual eligible beneficiaries.
(7)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.
(g)No sooner than March 1, 2013, demonstration sites shall be established in up to eight counties, and shall include at least one county that provides Medi-Cal services via a two-plan model pursuant to Article 2.7 (commencing with Section 14087.3) and at least one county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5). The director shall consult with the Legislature, CMS, and stakeholders when determining the implementation date for this section. In determining the counties in which to establish a demonstration site, the director shall consider the following:
(1)Local support for integrating medical care, long-term care, and home- and community-based services networks.
(2)A local stakeholder process that includes health plans, providers, mental health representatives, community programs, consumers, designated representatives of in-home supportive services personnel, and other interested stakeholders in the development, implementation, and continued operation of the demonstration site.
(h)In developing the process for selecting, financing, monitoring, and evaluating the health care models for the demonstration project, the department shall enter into a memorandum of understanding with CMS. Upon completion, the memorandum of understanding shall be provided to the fiscal and appropriate policy committees of the Legislature and posted on the departments Internet Web site.
(i)The department shall negotiate the terms and conditions of the memorandum of understanding, which shall address, but are not limited to, the following:
(1)Reimbursement methods for a capitated payment model. Under the capitated payment model, the demonstration sites shall meet all of the following requirements:
(A)Have Medi-Cal managed care health plan and Medicare dual eligible-special needs plan contract experience, or evidence of the ability to meet these contracting requirements.
(B)Be in good financial standing and meet licensure requirements under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), except for county organized health system plans that are exempt from licensure pursuant to Section 14087.95.
(C)Meet quality measures, which may include Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set measures and other quality measures determined or developed by the department or CMS.
(D)Demonstrate a local stakeholder process that includes dual eligible beneficiaries, managed care health plans, providers, mental health representatives, county health and human services agencies, designated representatives of in-home supportive services personnel, and other interested stakeholders that advise and consult with the demonstration site in the development, implementation, and continued operation of the demonstration project.
(E)Pay providers reimbursement rates sufficient to maintain an adequate provider network and ensure access to care for beneficiaries.
(F)Follow final policy guidance determined by CMS and the department with regard to reimbursement rates for providers pursuant to paragraphs (4) to (7), inclusive, of subdivision (o).
(G)To the extent permitted under the demonstration, pay noncontracted hospitals prevailing Medicare fee-for-service rates for traditionally Medicare covered benefits and prevailing Medi-Cal fee-for-service rates for traditionally Medi-Cal covered benefits.
(2)Encounter data reporting requirements for both Medi-Cal and Medicare services provided to beneficiaries enrolling in the demonstration project.
(3)Quality assurance withholding from the demonstration site payment, to be paid only if quality measures developed as part of the memorandum of understanding and plan contracts are met.
(4)Provider network adequacy standards developed by the department and CMS, in consultation with the Department of Managed Health Care, the demonstration site, and stakeholders.
(5)Medicare and Medi-Cal appeals and hearing process.
(6)Unified marketing requirements and combined review process by the department and CMS.
(7)Combined quality management and consolidated reporting process by the department and CMS.
(8)Procedures related to combined federal and state contract management to ensure access, quality, program integrity, and financial solvency of the demonstration site.
(9)To the extent permissible under federal requirements, implementation of the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under Medi-Cal and the Medicare Program.
(10)(A)In consultation with the hospital industry, CMS approval to ensure that Medicare supplemental payments for direct graduate medical education and Medicare add-on payments, including indirect medical education and disproportionate share hospital adjustments continue to be made available to hospitals for services provided under the demonstration.
(B)The department shall seek CMS approval for CMS to continue these payments either outside the capitation rates or, if contained within the capitation rates, and to the extent permitted under the demonstration project, shall require demonstration sites to provide this reimbursement to hospitals.
(11)To the extent permitted under the demonstration project, the default rate for noncontracting providers of physician services shall be the prevailing Medicare fee schedule for services covered by the Medicare program and the prevailing Medi-Cal fee schedule for services covered by the Medi-Cal program.
(j)(1)The department shall comply with and enforce the terms and conditions of the memorandum of understanding with CMS, as specified in subdivision (i). To the extent that the terms and conditions do not address the specific selection, financing, monitoring, and evaluation criteria listed in subdivision (i), the department:
(A)Shall require the demonstration site to do all of the following:
(i)Comply with additional site readiness criteria specified by the department.
(ii)Comply with long-term services and supports requirements in accordance with Article 5.7 (commencing with Section 14186).
(iii)To the extent permissible under federal requirements, comply with the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under both Medi-Cal and the Medicare Program.
(iv)Comply with all transition of care requirements for Medicare Part D benefits as described in Chapters 6 and 14 of the Medicare Managed Care Manual, published by CMS, including transition timeframes, notices, and emergency supplies.
(B)May require the demonstration site to forgo charging premiums, coinsurance, copayments, and deductibles for Medicare Part C and Medicare Part D services.
(2)The department shall notify the Legislature within 30 days of the implementation of each provision in paragraph (1).
(k)The director may enter into exclusive or nonexclusive contracts on a bid or negotiated basis and may amend existing managed care contracts to provide or arrange for services provided under this section. 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.
(l)(1)(A)Except for the exemptions provided for in this section and in Section 14132.277, the department shall enroll dual eligible beneficiaries into a demonstration site unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled on or before June 1, 2013, in a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS or in any entity with a contract with the department pursuant to Chapter 8.75 (commencing with Section 14591).
(B)Dual eligible beneficiaries who opt out of enrollment into a demonstration site may choose to remain enrolled in fee-for-service Medicare or a Medicare Advantage plan for their Medicare benefits, but shall be mandatorily enrolled into a Medi-Cal managed care health plan pursuant to Section 14182.16, except as exempted under subdivision (c) of Section 14182.16.
(C)(i)Persons meeting requirements for the Program of All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section 14591) or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) of Chapter 7 to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS may select either of these managed care health plans for their Medicare and Medi-Cal benefits if one is available in that county.
(ii)In areas where a PACE plan is available, the PACE plan shall be presented as an enrollment option, included in all enrollment materials, enrollment assistance programs, and outreach programs related to the demonstration project, and made available to beneficiaries whenever enrollment choices and options are presented. Persons meeting the age qualifications for PACE and who choose PACE shall remain in the fee-for-service Medi-Cal and Medicare programs, and shall not be assigned to a managed care health plan for the lesser of 60 days or until they are assessed for eligibility for PACE and determined not to be eligible for a PACE plan. Persons enrolled in a PACE plan shall receive all Medicare and Medi-Cal services from the PACE program pursuant to the three-way agreement between the PACE program, the department, and the Centers for Medicare and Medicaid Services.
(2)To the extent that federal approval is obtained, the department may require that any beneficiary, upon enrollment in a demonstration site, remain enrolled in the Medicare portion of the demonstration project on a mandatory basis for six months from the date of initial enrollment. After the sixth month, a dual eligible beneficiary may elect to enroll in a different demonstration site, a different Medicare Advantage plan, fee-for-service Medicare, PACE, or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS, for his or her Medicare benefits.
(A)During the six-month mandatory enrollment in a demonstration site, a beneficiary may continue receiving services from an out-of-network Medicare provider for primary and specialty care services only if all of the following criteria are met:
(i)The dual eligible beneficiary demonstrates an existing relationship with the provider prior to enrollment in a demonstration site.
(ii)The provider is willing to accept payment from the demonstration site based on the current Medicare fee schedule.
(iii)The demonstration site would not otherwise exclude the provider from its provider network due to documented quality of care concerns.
(B)The department shall develop a process to inform providers and beneficiaries of the availability of continuity of services from an existing provider and ensure that the beneficiary continues to receive services without interruption.
(3)(A)Notwithstanding subparagraph (A) of paragraph (1), a dual eligible beneficiary shall be excluded from enrollment in the demonstration project if the beneficiary meets any of the following:
(i)The beneficiary has a prior diagnosis of end-stage renal disease. This clause shall not apply to beneficiaries diagnosed with end-stage renal disease subsequent to enrollment in the demonstration project. The director may, with stakeholder input and federal approval, authorize beneficiaries with a prior diagnosis of end-stage renal disease in specified counties to voluntarily enroll in the demonstration project.
(ii)The beneficiary has other health coverage, as defined in paragraph (5) of subdivision (b) of Section 14182.16.
(iii)The beneficiary is enrolled in a home- and community-based waiver that is a Medi-Cal benefit under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n et seq.), except for persons enrolled in Multipurpose Senior Services Program services or beneficiaries receiving services through a regional center who resides in the County of San Mateo.
(iv)The beneficiary is receiving services through a regional center or state developmental center. However, a beneficiary receiving services through a regional center who resides in the County of San Mateo, by making an affirmative choice to opt in, may voluntarily enroll in the demonstration project, upon receipt of all legal notifications required pursuant to this section and applicable federal requirements.
(v)The beneficiary resides in a geographic area or ZIP Code not included in managed care, as determined by the department and CMS.
(vi)The beneficiary resides in one of the Veterans Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code.
(B)(i)Beneficiaries who have been diagnosed with HIV/AIDS may opt out of the demonstration project at the beginning of any month. The State Department of Public Health may share relevant data relating to a beneficiarys enrollment in the AIDS Drug Assistance Program with the department, and the department may share relevant data relating to HIV-positive beneficiaries with the State Department of Public Health.
(ii)The information provided by the State Department of Public Health pursuant to this subparagraph shall not be further disclosed by the State Department of Health Care Services, and shall be subject to the confidentiality protections of subdivisions (d) and (e) of Section 121025 of the Health and Safety Code, except this information may be further disclosed as follows:
(I)To the person to whom the information pertains or the designated representative of that person.
(II)To the Office of AIDS within the State Department of Public Health.
(C)Beneficiaries who are Indians receiving Medi-Cal services in accordance with Section 55110 of Title 22 of the California Code of Regulations may opt out of the demonstration project at the beginning of any month.
(D)The department, with stakeholder input, may exempt specific categories of dual eligible beneficiaries from enrollment requirements in this section based on extraordinary medical needs of specific patient groups or to meet federal requirements.
(4)For the 2013 calendar year, the department shall offer federal Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) compliant contracts to existing Medicare Advantage Dual Special Needs Plans (D-SNP plans) to continue to provide Medicare benefits to their enrollees in their service areas as approved on January 1, 2012. In the 2013 calendar year, beneficiaries in Medicare Advantage and D-SNP plans shall be exempt from the enrollment provisions of subparagraph (A) of paragraph (1), but may voluntarily choose to enroll in the demonstration project. Enrollment into the demonstration projects managed care health plans shall be reassessed in 2014 depending on federal reauthorization of the D-SNP model and the departments assessment of the demonstration plans.
(5)For the 2013 calendar year, demonstration sites shall not offer to enroll dual eligible beneficiaries eligible for the demonstration project into the demonstration sites D-SNP.
(6)The department shall not terminate contracts in a demonstration site with a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive beneficiaries or who have been diagnosed with AIDS and with any entity with a contract pursuant to Chapter 8.75 (commencing with Section 14591), except as provided in the contract or pursuant to state or federal law.
(m)Notwithstanding Section 10231.5 of the Government Code, the department shall conduct an evaluation, in partnership with CMS, to assess outcomes and the experience of dual eligibles in these demonstration sites and shall provide a report to the Legislature after the first full year of demonstration operation, and annually thereafter. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code. The department shall consult with stakeholders regarding the scope and structure of the evaluation.
(n)This section shall be implemented only if and to the extent that federal financial participation or funding is available.
(o)It is the intent of the Legislature that:
(1)In order to maintain adequate provider networks, demonstration sites shall reimburse providers at rates sufficient to ensure access to care for beneficiaries.
(2)Savings under the demonstration project are intended to be achieved through shifts in utilization, and not through reduced reimbursement rates to providers.
(3)Reimbursement policies shall not prevent demonstration sites and providers from entering into payment arrangements that allow for the alignment of financial incentives and provide opportunities for shared risk and shared savings in order to promote appropriate utilization shifts, which encourage the use of home- and community-based services and quality of care for dual eligible beneficiaries enrolled in the demonstration sites.
(4)To the extent permitted under the demonstration project, and to the extent that a public entity voluntarily provides an intergovernmental transfer for this purpose, both of the following shall apply:
(A)The department shall work with CMS in ensuring that the capitation rates under the demonstration project are inclusive of funding currently provided through certified public expenditures supplemental payment programs that would otherwise be impacted by the demonstration project.
(B)Demonstration sites shall pay to a public entity voluntarily providing intergovernmental transfers that previously received reimbursement under a certified public expenditures supplemental payment program, rates that include the additional funding under the capitation rates that are funded by the public entitys intergovernmental transfer.
(5)The department shall work with CMS in developing other reimbursement policies and shall inform demonstration sites, providers, and the Legislature of the final policy guidance.
(6)The department shall seek approval from CMS to permit the provider payment requirements contained in subparagraph (G) of paragraph (1) and paragraphs (10) and (11) of subdivision (i), and Section 14132.276.
(7)Demonstration sites that contract with hospitals for hospital services on a fee-for-service basis that otherwise would have been traditionally Medicare services will achieve savings through utilization changes and not by paying hospitals at rates lower than prevailing Medicare fee-for-service rates.
(p)The department shall enter into an interagency agreement with the Department of Managed Health Care to perform some or all of the departments oversight and readiness review activities specified in this section. These activities may include providing consumer assistance to beneficiaries affected by this section and conducting financial audits, medical surveys, and a review of the adequacy of provider networks of the managed care health plans participating in this section. The interagency agreement shall be updated, as necessary, on an annual basis in order to maintain functional clarity regarding the roles and responsibilities of the Department of Managed Health Care and the department. The department shall not delegate its authority under this section as the single state Medicaid agency to the Department of Managed Health Care.
(q)(1)Beginning with the May Revision to the 201314 Governors Budget, and annually thereafter, the department shall report to the Legislature on the enrollment status, quality measures, and state costs of the actions taken pursuant to this section.
(2)(A)By January 1, 2013, or as soon thereafter as practicable, the department shall develop, in consultation with CMS and stakeholders, quality and fiscal measures for health plans to reflect the short- and long-term results of the implementation of this section. The department shall also develop quality thresholds and milestones for these measures. The department shall update these measures periodically to reflect changes in this program due to implementation factors and the structure and design of the benefits and services being coordinated by managed care health plans.
(B)The department shall require health plans to submit Medicare and Medi-Cal data to determine the results of these measures. If the department finds that a health plan is not in compliance with one or more of the measures set forth in this section, the health plan shall, within 60 days, submit a corrective action plan to the department for approval. The corrective action plan shall, at a minimum, include steps that the health plan shall take to improve its performance based on the standard or standards with which the health plan is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the health plan in order to avoid a sanction pursuant to Section 14304. Nothing in this subparagraph is intended to limit Section 14304.
(C)The department shall publish the results of these measures, including via posting on the departments Internet Web site, on a quarterly basis.
(r)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 section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance.
(s)This section shall be inoperative if the Coordinated Care Initiative becomes inoperative pursuant to Section 34 of the act that added this subdivision.
SEC. 2.The Legislature finds and declares that a special law is necessary and that a general law cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the unique circumstances regarding the availability of resources for dual eligible beneficiaries in the County of San Mateo.
(a)The department shall seek federal approval to establish the demonstration project described in this section pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof. Under a Medicare demonstration, the department may contract with the federal Centers for Medicare and Medicaid Services (CMS) and demonstration sites to operate the Medicare and Medicaid benefits in a demonstration project that is overseen by the state as a delegated Medicare benefit administrator, and may enter into financing arrangements with CMS to share in any Medicare program savings generated by the demonstration project.
(b)After federal approval is obtained, the department shall establish the demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports and behavioral health services, including mental health and substance use disorder treatment services. The purpose of the demonstration project is to integrate services authorized under the federal Medicaid Program (Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the federal Medicare Program (Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.)). The demonstration project may also include additional services as approved through a demonstration project or waiver, or a combination thereof.
(c)For purposes of this section, the following definitions shall apply:
(1)Behavioral health means Medi-Cal services provided pursuant to Section 51341 of Title 22 of the California Code of Regulations and Drug Medi-Cal substance abuse services provided pursuant to Section 51341.1 of Title 22 of the California Code of Regulations, and any mental health benefits available under the Medicare Program.
(2)Capitated payment model means an agreement entered into between CMS, the state, and a managed care health plan, in which the managed care health plan receives a capitation payment for the comprehensive, coordinated provision of Medi-Cal services and benefits under Medicare Part C (42 U.S.C. Sec. 1395w-21 et seq.) and Medicare Part D (42 U.S.C. Sec. 1395w-101 et seq.), and CMS shares the savings with the state from improved provision of Medi-Cal and Medicare services that reduces the cost of those services. Medi-Cal services include long-term services and supports as defined in Section 14186.1, behavioral health services, and any additional services offered by the demonstration site.
(3)Demonstration site means a managed care health plan that is selected to participate in the demonstration project under the capitated payment model.
(4)Dual eligible beneficiary means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) and Medicare Part B (42 U.S.C. Sec. 1395j et seq.) and is eligible for medical assistance under the Medi-Cal State Plan.
(d)No sooner than March 1, 2011, the department shall identify health care models that may be included in the demonstration project, shall develop a timeline and process for selecting, financing, monitoring, and evaluating the demonstration sites, and shall provide this timeline and process to the appropriate fiscal and policy committees of the Legislature. The department may implement these demonstration sites in phases.
(e)The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of any report submitted to CMS to meet the requirements under the demonstration project.
(f)Goals for the demonstration project shall include all of the following:
(1)Coordinate Medi-Cal and Medicare benefits across health care settings and improve the continuity of care across acute care, long-term care, behavioral health, including mental health and substance use disorder services, and home- and community-based services settings using a person-centered approach.
(2)Coordinate access to acute and long-term care services for dual eligible beneficiaries.
(3)Maximize the ability of dual eligible beneficiaries to remain in their homes and communities with appropriate services and supports in lieu of institutional care.
(4)Increase the availability of and access to home- and community-based services.
(5)Coordinate access to necessary and appropriate behavioral health services, including mental health and substance use disorder services.
(6)Improve the quality of care for dual eligible beneficiaries.
(7)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.
(g)No sooner than March 1, 2013, demonstration sites shall be established in up to eight counties, and shall include at least one county that provides Medi-Cal services via a two-plan model pursuant to Article 2.7 (commencing with Section 14087.3) and at least one county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5). The director shall consult with the Legislature, CMS, and stakeholders when determining the implementation date for this section. In determining the counties in which to establish a demonstration site, the director shall consider the following:
(1)Local support for integrating medical care, long-term care, and home- and community-based services networks.
(2)A local stakeholder process that includes health plans, providers, mental health representatives, community programs, consumers, designated representatives of in-home supportive services personnel, and other interested stakeholders in the development, implementation, and continued operation of the demonstration site.
(h)In developing the process for selecting, financing, monitoring, and evaluating the health care models for the demonstration project, the department shall enter into a memorandum of understanding with CMS. Upon completion, the memorandum of understanding shall be provided to the fiscal and appropriate policy committees of the Legislature and posted on the departments Internet Web site.
(i)The department shall negotiate the terms and conditions of the memorandum of understanding, which shall address, but are not limited to, the following:
(1)Reimbursement methods for a capitated payment model. Under the capitated payment model, the demonstration sites shall meet all of the following requirements:
(A)Have Medi-Cal managed care health plan and Medicare dual eligible-special needs plan contract experience, or evidence of the ability to meet these contracting requirements.
(B)Be in good financial standing and meet licensure requirements under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), except for county organized health system plans that are exempt from licensure pursuant to Section 14087.95.
(C)Meet quality measures, which may include Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set measures and other quality measures determined or developed by the department or CMS.
(D)Demonstrate a local stakeholder process that includes dual eligible beneficiaries, managed care health plans, providers, mental health representatives, county health and human services agencies, designated representatives of in-home supportive services personnel, and other interested stakeholders that advise and consult with the demonstration site in the development, implementation, and continued operation of the demonstration project.
(E)Pay providers reimbursement rates sufficient to maintain an adequate provider network and ensure access to care for beneficiaries.
(F)Follow final policy guidance determined by CMS and the department with regard to reimbursement rates for providers pursuant to paragraphs (4) to (7), inclusive, of subdivision (o).
(G)To the extent permitted under the demonstration, pay noncontracted hospitals prevailing Medicare fee-for-service rates for traditionally Medicare covered benefits and prevailing Medi-Cal fee-for-service rates for traditionally Medi-Cal covered benefits.
(2)Encounter data reporting requirements for both Medi-Cal and Medicare services provided to beneficiaries enrolling in the demonstration project.
(3)Quality assurance withholding from the demonstration site payment, to be paid only if quality measures developed as part of the memorandum of understanding and plan contracts are met.
(4)Provider network adequacy standards developed by the department and CMS, in consultation with the Department of Managed Health Care, the demonstration site, and stakeholders.
(5)Medicare and Medi-Cal appeals and hearing process.
(6)Unified marketing requirements and combined review process by the department and CMS.
(7)Combined quality management and consolidated reporting process by the department and CMS.
(8)Procedures related to combined federal and state contract management to ensure access, quality, program integrity, and financial solvency of the demonstration site.
(9)To the extent permissible under federal requirements, implementation of the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under Medi-Cal and the Medicare Program.
(10)(A)In consultation with the hospital industry, CMS approval to ensure that Medicare supplemental payments for direct graduate medical education and Medicare add-on payments, including indirect medical education and disproportionate share hospital adjustments continue to be made available to hospitals for services provided under the demonstration.
(B)The department shall seek CMS approval for CMS to continue these payments either outside the capitation rates or, if contained within the capitation rates, and to the extent permitted under the demonstration project, shall require demonstration sites to provide this reimbursement to hospitals.
(11)To the extent permitted under the demonstration project, the default rate for noncontracting providers of physician services shall be the prevailing Medicare fee schedule for services covered by the Medicare program and the prevailing Medi-Cal fee schedule for services covered by the Medi-Cal program.
(j)(1)The department shall comply with and enforce the terms and conditions of the memorandum of understanding with CMS, as specified in subdivision (i). To the extent that the terms and conditions do not address the specific selection, financing, monitoring, and evaluation criteria listed in subdivision (i), the department:
(A)Shall require the demonstration site to do all of the following:
(i)Comply with additional site readiness criteria specified by the department.
(ii)Comply with long-term services and supports requirements in accordance with Article 5.7 (commencing with Section 14186).
(iii)To the extent permissible under federal requirements, comply with the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under both Medi-Cal and the Medicare Program.
(iv)Comply with all transition of care requirements for Medicare Part D benefits as described in Chapters 6 and 14 of the Medicare Managed Care Manual, published by CMS, including transition timeframes, notices, and emergency supplies.
(B)May require the demonstration site to forgo charging premiums, coinsurance, copayments, and deductibles for Medicare Part C and Medicare Part D services.
(2)The department shall notify the Legislature within 30 days of the implementation of each provision in paragraph (1).
(k)The director may enter into exclusive or nonexclusive contracts on a bid or negotiated basis and may amend existing managed care contracts to provide or arrange for services provided under this section. 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.
(l)(1)(A)Except for the exemptions provided for in this section and in Section 14132.277, the department shall enroll dual eligible beneficiaries into a demonstration site unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled on or before June 1, 2013, in a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS or in any entity with a contract with the department pursuant to Chapter 8.75 (commencing with Section 14591).
(B)Dual eligible beneficiaries who opt out of enrollment into a demonstration site may choose to remain enrolled in fee-for-service Medicare or a Medicare Advantage plan for their Medicare benefits, but shall be mandatorily enrolled into a Medi-Cal managed care health plan pursuant to Section 14182.16, except as exempted under subdivision (c) of Section 14182.16.
(C)(i)Persons meeting requirements for the Program of All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section 14591) or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) of Chapter 7 to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS may select either of these managed care health plans for their Medicare and Medi-Cal benefits if one is available in that county.
(ii)In areas where a PACE plan is available, the PACE plan shall be presented as an enrollment option, included in all enrollment materials, enrollment assistance programs, and outreach programs related to the demonstration project, and made available to beneficiaries whenever enrollment choices and options are presented. Persons meeting the age qualifications for PACE and who choose PACE shall remain in the fee-for-service Medi-Cal and Medicare programs, and shall not be assigned to a managed care health plan for the lesser of 60 days or until they are assessed for eligibility for PACE and determined not to be eligible for a PACE plan. Persons enrolled in a PACE plan shall receive all Medicare and Medi-Cal services from the PACE program pursuant to the three-way agreement between the PACE program, the department, and the Centers for Medicare and Medicaid Services.
(2)To the extent that federal approval is obtained, the department may require that any beneficiary, upon enrollment in a demonstration site, remain enrolled in the Medicare portion of the demonstration project on a mandatory basis for six months from the date of initial enrollment. After the sixth month, a dual eligible beneficiary may elect to enroll in a different demonstration site, a different Medicare Advantage plan, fee-for-service Medicare, PACE, or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS, for his or her Medicare benefits.
(A)During the six-month mandatory enrollment in a demonstration site, a beneficiary may continue receiving services from an out-of-network Medicare provider for primary and specialty care services only if all of the following criteria are met:
(i)The dual eligible beneficiary demonstrates an existing relationship with the provider prior to enrollment in a demonstration site.
(ii)The provider is willing to accept payment from the demonstration site based on the current Medicare fee schedule.
(iii)The demonstration site would not otherwise exclude the provider from its provider network due to documented quality of care concerns.
(B)The department shall develop a process to inform providers and beneficiaries of the availability of continuity of services from an existing provider and ensure that the beneficiary continues to receive services without interruption.
(3)(A)Notwithstanding subparagraph (A) of paragraph (1), a dual eligible beneficiary shall be excluded from enrollment in the demonstration project if the beneficiary meets any of the following:
(i)The beneficiary has a prior diagnosis of end-stage renal disease. This clause shall not apply to beneficiaries diagnosed with end-stage renal disease subsequent to enrollment in the demonstration project. The director may, with stakeholder input and federal approval, authorize beneficiaries with a prior diagnosis of end-stage renal disease in specified counties to voluntarily enroll in the demonstration project.
(ii)The beneficiary has other health coverage, as defined in paragraph (5) of subdivision (b) of Section 14182.16.
(iii)The beneficiary is enrolled in a home- and community-based waiver that is a Medi-Cal benefit under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n et seq.), except for persons enrolled in Multipurpose Senior Services Program services or beneficiaries receiving services through a regional center who resides in the County of San Mateo.
(iv)The beneficiary is receiving services through a regional center or state developmental center. However, a beneficiary receiving services through a regional center who resides in the County of San Mateo, by making an affirmative choice to opt in, may voluntarily enroll in the demonstration project, upon receipt of all legal notifications required pursuant to this section and applicable federal requirements.
(v)The beneficiary resides in a geographic area or ZIP Code not included in managed care, as determined by the department and CMS.
(vi)The beneficiary resides in one of the Veterans Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code.
(B)(i)Beneficiaries who have been diagnosed with HIV/AIDS may opt out of the demonstration project at the beginning of any month. The State Department of Public Health may share relevant data relating to a beneficiarys enrollment in the AIDS Drug Assistance Program with the department, and the department may share relevant data relating to HIV-positive beneficiaries with the State Department of Public Health.
(ii)The information provided by the State Department of Public Health pursuant to this subparagraph shall not be further disclosed by the State Department of Health Care Services, and shall be subject to the confidentiality protections of subdivisions (d) and (e) of Section 121025 of the Health and Safety Code, except this information may be further disclosed as follows:
(I)To the person to whom the information pertains or the designated representative of that person.
(II)To the Office of AIDS within the State Department of Public Health.
(C)Beneficiaries who are Indians receiving Medi-Cal services in accordance with Section 55110 of Title 22 of the California Code of Regulations may opt out of the demonstration project at the beginning of any month.
(D)The department, with stakeholder input, may exempt specific categories of dual eligible beneficiaries from enrollment requirements in this section based on extraordinary medical needs of specific patient groups or to meet federal requirements.
(4)For the 2013 calendar year, the department shall offer federal Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) compliant contracts to existing Medicare Advantage Dual Special Needs Plans (D-SNP plans) to continue to provide Medicare benefits to their enrollees in their service areas as approved on January 1, 2012. In the 2013 calendar year, beneficiaries in Medicare Advantage and D-SNP plans shall be exempt from the enrollment provisions of subparagraph (A) of paragraph (1), but may voluntarily choose to enroll in the demonstration project. Enrollment into the demonstration projects managed care health plans shall be reassessed in 2014 depending on federal reauthorization of the D-SNP model and the departments assessment of the demonstration plans.
(5)For the 2013 calendar year, demonstration sites shall not offer to enroll dual eligible beneficiaries eligible for the demonstration project into the demonstration sites D-SNP.
(6)The department shall not terminate contracts in a demonstration site with a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive beneficiaries or who have been diagnosed with AIDS and with any entity with a contract pursuant to Chapter 8.75 (commencing with Section 14591), except as provided in the contract or pursuant to state or federal law.
(m)Notwithstanding Section 10231.5 of the Government Code, the department shall conduct an evaluation, in partnership with CMS, to assess outcomes and the experience of dual eligibles in these demonstration sites and shall provide a report to the Legislature after the first full year of demonstration operation, and annually thereafter. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code. The department shall consult with stakeholders regarding the scope and structure of the evaluation.
(n)This section shall be implemented only if and to the extent that federal financial participation or funding is available.
(o)It is the intent of the Legislature that:
(1)In order to maintain adequate provider networks, demonstration sites shall reimburse providers at rates sufficient to ensure access to care for beneficiaries.
(2)Savings under the demonstration project are intended to be achieved through shifts in utilization, and not through reduced reimbursement rates to providers.
(3)Reimbursement policies shall not prevent demonstration sites and providers from entering into payment arrangements that allow for the alignment of financial incentives and provide opportunities for shared risk and shared savings in order to promote appropriate utilization shifts, which encourage the use of home- and community-based services and quality of care for dual eligible beneficiaries enrolled in the demonstration sites.
(4)To the extent permitted under the demonstration project, and to the extent that a public entity voluntarily provides an intergovernmental transfer for this purpose, both of the following shall apply:
(A)The department shall work with CMS in ensuring that the capitation rates under the demonstration project are inclusive of funding currently provided through certified public expenditures supplemental payment programs that would otherwise be impacted by the demonstration project.
(B)Demonstration sites shall pay to a public entity voluntarily providing intergovernmental transfers that previously received reimbursement under a certified public expenditures supplemental payment program, rates that include the additional funding under the capitation rates that are funded by the public entitys intergovernmental transfer.
(5)The department shall work with CMS in developing other reimbursement policies and shall inform demonstration sites, providers, and the Legislature of the final policy guidance.
(6)The department shall seek approval from CMS to permit the provider payment requirements contained in subparagraph (G) of paragraph (1) and paragraphs (10) and (11) of subdivision (i), and Section 14132.276.
(7)Demonstration sites that contract with hospitals for hospital services on a fee-for-service basis that otherwise would have been traditionally Medicare services will achieve savings through utilization changes and not by paying hospitals at rates lower than prevailing Medicare fee-for-service rates.
(p)The department shall enter into an interagency agreement with the Department of Managed Health Care to perform some or all of the departments oversight and readiness review activities specified in this section. These activities may include providing consumer assistance to beneficiaries affected by this section and conducting financial audits, medical surveys, and a review of the adequacy of provider networks of the managed care health plans participating in this section. The interagency agreement shall be updated, as necessary, on an annual basis in order to maintain functional clarity regarding the roles and responsibilities of the Department of Managed Health Care and the department. The department shall not delegate its authority under this section as the single state Medicaid agency to the Department of Managed Health Care.
(q)(1)Beginning with the May Revision to the 201314 Governors Budget, and annually thereafter, the department shall report to the Legislature on the enrollment status, quality measures, and state costs of the actions taken pursuant to this section.
(2)(A)By January 1, 2013, or as soon thereafter as practicable, the department shall develop, in consultation with CMS and stakeholders, quality and fiscal measures for health plans to reflect the short- and long-term results of the implementation of this section. The department shall also develop quality thresholds and milestones for these measures. The department shall update these measures periodically to reflect changes in this program due to implementation factors and the structure and design of the benefits and services being coordinated by managed care health plans.
(B)The department shall require health plans to submit Medicare and Medi-Cal data to determine the results of these measures. If the department finds that a health plan is not in compliance with one or more of the measures set forth in this section, the health plan shall, within 60 days, submit a corrective action plan to the department for approval. The corrective action plan shall, at a minimum, include steps that the health plan shall take to improve its performance based on the standard or standards with which the health plan is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the health plan in order to avoid a sanction pursuant to Section 14304. Nothing in this subparagraph is intended to limit Section 14304.
(C)The department shall publish the results of these measures, including via posting on the departments Internet Web site, on a quarterly basis.
(r)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 section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance.
(s)This section shall be inoperative if the Coordinated Care Initiative becomes inoperative pursuant to Section 34 of the act that added this subdivision.
SEC. 2.The Legislature finds and declares that a special law is necessary and that a general law cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the unique circumstances regarding the availability of resources for dual eligible beneficiaries in the County of San Mateo.
(a)The department shall seek federal approval to establish the demonstration project described in this section pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof. Under a Medicare demonstration, the department may contract with the federal Centers for Medicare and Medicaid Services (CMS) and demonstration sites to operate the Medicare and Medicaid benefits in a demonstration project that is overseen by the state as a delegated Medicare benefit administrator, and may enter into financing arrangements with CMS to share in any Medicare program savings generated by the demonstration project.
(b)After federal approval is obtained, the department shall establish the demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports and behavioral health services, including mental health and substance use disorder treatment services. The purpose of the demonstration project is to integrate services authorized under the federal Medicaid Program (Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the federal Medicare Program (Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.)). The demonstration project may also include additional services as approved through a demonstration project or waiver, or a combination thereof.
(c)For purposes of this section, the following definitions shall apply:
(1)Behavioral health means Medi-Cal services provided pursuant to Section 51341 of Title 22 of the California Code of Regulations and Drug Medi-Cal substance abuse services provided pursuant to Section 51341.1 of Title 22 of the California Code of Regulations, and any mental health benefits available under the Medicare Program.
(2)Capitated payment model means an agreement entered into between CMS, the state, and a managed care health plan, in which the managed care health plan receives a capitation payment for the comprehensive, coordinated provision of Medi-Cal services and benefits under Medicare Part C (42 U.S.C. Sec. 1395w-21 et seq.) and Medicare Part D (42 U.S.C. Sec. 1395w-101 et seq.), and CMS shares the savings with the state from improved provision of Medi-Cal and Medicare services that reduces the cost of those services. Medi-Cal services include long-term services and supports as defined in Section 14186.1, behavioral health services, and any additional services offered by the demonstration site.
(3)Demonstration site means a managed care health plan that is selected to participate in the demonstration project under the capitated payment model.
(4)Dual eligible beneficiary means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) and Medicare Part B (42 U.S.C. Sec. 1395j et seq.) and is eligible for medical assistance under the Medi-Cal State Plan.
(d)No sooner than March 1, 2011, the department shall identify health care models that may be included in the demonstration project, shall develop a timeline and process for selecting, financing, monitoring, and evaluating the demonstration sites, and shall provide this timeline and process to the appropriate fiscal and policy committees of the Legislature. The department may implement these demonstration sites in phases.
(e)The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of any report submitted to CMS to meet the requirements under the demonstration project.
(f)Goals for the demonstration project shall include all of the following:
(1)Coordinate Medi-Cal and Medicare benefits across health care settings and improve the continuity of care across acute care, long-term care, behavioral health, including mental health and substance use disorder services, and home- and community-based services settings using a person-centered approach.
(2)Coordinate access to acute and long-term care services for dual eligible beneficiaries.
(3)Maximize the ability of dual eligible beneficiaries to remain in their homes and communities with appropriate services and supports in lieu of institutional care.
(4)Increase the availability of and access to home- and community-based services.
(5)Coordinate access to necessary and appropriate behavioral health services, including mental health and substance use disorder services.
(6)Improve the quality of care for dual eligible beneficiaries.
(7)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.
(g)No sooner than March 1, 2013, demonstration sites shall be established in up to eight counties, and shall include at least one county that provides Medi-Cal services via a two-plan model pursuant to Article 2.7 (commencing with Section 14087.3) and at least one county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5). The director shall consult with the Legislature, CMS, and stakeholders when determining the implementation date for this section. In determining the counties in which to establish a demonstration site, the director shall consider the following:
(1)Local support for integrating medical care, long-term care, and home- and community-based services networks.
(2)A local stakeholder process that includes health plans, providers, mental health representatives, community programs, consumers, designated representatives of in-home supportive services personnel, and other interested stakeholders in the development, implementation, and continued operation of the demonstration site.
(h)In developing the process for selecting, financing, monitoring, and evaluating the health care models for the demonstration project, the department shall enter into a memorandum of understanding with CMS. Upon completion, the memorandum of understanding shall be provided to the fiscal and appropriate policy committees of the Legislature and posted on the departments Internet Web site.
(i)The department shall negotiate the terms and conditions of the memorandum of understanding, which shall address, but are not limited to, the following:
(1)Reimbursement methods for a capitated payment model. Under the capitated payment model, the demonstration sites shall meet all of the following requirements:
(A)Have Medi-Cal managed care health plan and Medicare dual eligible-special needs plan contract experience, or evidence of the ability to meet these contracting requirements.
(B)Be in good financial standing and meet licensure requirements under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), except for county organized health system plans that are exempt from licensure pursuant to Section 14087.95.
(C)Meet quality measures, which may include Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set measures and other quality measures determined or developed by the department or CMS.
(D)Demonstrate a local stakeholder process that includes dual eligible beneficiaries, managed care health plans, providers, mental health representatives, county health and human services agencies, designated representatives of in-home supportive services personnel, and other interested stakeholders that advise and consult with the demonstration site in the development, implementation, and continued operation of the demonstration project.
(E)Pay providers reimbursement rates sufficient to maintain an adequate provider network and ensure access to care for beneficiaries.
(F)Follow final policy guidance determined by CMS and the department with regard to reimbursement rates for providers pursuant to paragraphs (4) to (7), inclusive, of subdivision (o).
(G)To the extent permitted under the demonstration, pay noncontracted hospitals prevailing Medicare fee-for-service rates for traditionally Medicare covered benefits and prevailing Medi-Cal fee-for-service rates for traditionally Medi-Cal covered benefits.
(2)Encounter data reporting requirements for both Medi-Cal and Medicare services provided to beneficiaries enrolling in the demonstration project.
(3)Quality assurance withholding from the demonstration site payment, to be paid only if quality measures developed as part of the memorandum of understanding and plan contracts are met.
(4)Provider network adequacy standards developed by the department and CMS, in consultation with the Department of Managed Health Care, the demonstration site, and stakeholders.
(5)Medicare and Medi-Cal appeals and hearing process.
(6)Unified marketing requirements and combined review process by the department and CMS.
(7)Combined quality management and consolidated reporting process by the department and CMS.
(8)Procedures related to combined federal and state contract management to ensure access, quality, program integrity, and financial solvency of the demonstration site.
(9)To the extent permissible under federal requirements, implementation of the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under Medi-Cal and the Medicare Program.
(10)(A)In consultation with the hospital industry, CMS approval to ensure that Medicare supplemental payments for direct graduate medical education and Medicare add-on payments, including indirect medical education and disproportionate share hospital adjustments continue to be made available to hospitals for services provided under the demonstration.
(B)The department shall seek CMS approval for CMS to continue these payments either outside the capitation rates or, if contained within the capitation rates, and to the extent permitted under the demonstration project, shall require demonstration sites to provide this reimbursement to hospitals.
(11)To the extent permitted under the demonstration project, the default rate for noncontracting providers of physician services shall be the prevailing Medicare fee schedule for services covered by the Medicare program and the prevailing Medi-Cal fee schedule for services covered by the Medi-Cal program.
(j)(1)The department shall comply with and enforce the terms and conditions of the memorandum of understanding with CMS, as specified in subdivision (i). To the extent that the terms and conditions do not address the specific selection, financing, monitoring, and evaluation criteria listed in subdivision (i), the department:
(A)Shall require the demonstration site to do all of the following:
(i)Comply with additional site readiness criteria specified by the department.
(ii)Comply with long-term services and supports requirements in accordance with Article 5.7 (commencing with Section 14186).
(iii)To the extent permissible under federal requirements, comply with the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under both Medi-Cal and the Medicare Program.
(iv)Comply with all transition of care requirements for Medicare Part D benefits as described in Chapters 6 and 14 of the Medicare Managed Care Manual, published by CMS, including transition timeframes, notices, and emergency supplies.
(B)May require the demonstration site to forgo charging premiums, coinsurance, copayments, and deductibles for Medicare Part C and Medicare Part D services.
(2)The department shall notify the Legislature within 30 days of the implementation of each provision in paragraph (1).
(k)The director may enter into exclusive or nonexclusive contracts on a bid or negotiated basis and may amend existing managed care contracts to provide or arrange for services provided under this section. 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.
(l)(1)(A)Except for the exemptions provided for in this section and in Section 14132.277, the department shall enroll dual eligible beneficiaries into a demonstration site unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled on or before June 1, 2013, in a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS or in any entity with a contract with the department pursuant to Chapter 8.75 (commencing with Section 14591).
(B)Dual eligible beneficiaries who opt out of enrollment into a demonstration site may choose to remain enrolled in fee-for-service Medicare or a Medicare Advantage plan for their Medicare benefits, but shall be mandatorily enrolled into a Medi-Cal managed care health plan pursuant to Section 14182.16, except as exempted under subdivision (c) of Section 14182.16.
(C)(i)Persons meeting requirements for the Program of All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section 14591) or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) of Chapter 7 to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS may select either of these managed care health plans for their Medicare and Medi-Cal benefits if one is available in that county.
(ii)In areas where a PACE plan is available, the PACE plan shall be presented as an enrollment option, included in all enrollment materials, enrollment assistance programs, and outreach programs related to the demonstration project, and made available to beneficiaries whenever enrollment choices and options are presented. Persons meeting the age qualifications for PACE and who choose PACE shall remain in the fee-for-service Medi-Cal and Medicare programs, and shall not be assigned to a managed care health plan for the lesser of 60 days or until they are assessed for eligibility for PACE and determined not to be eligible for a PACE plan. Persons enrolled in a PACE plan shall receive all Medicare and Medi-Cal services from the PACE program pursuant to the three-way agreement between the PACE program, the department, and the Centers for Medicare and Medicaid Services.
(2)To the extent that federal approval is obtained, the department may require that any beneficiary, upon enrollment in a demonstration site, remain enrolled in the Medicare portion of the demonstration project on a mandatory basis for six months from the date of initial enrollment. After the sixth month, a dual eligible beneficiary may elect to enroll in a different demonstration site, a different Medicare Advantage plan, fee-for-service Medicare, PACE, or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS, for his or her Medicare benefits.
(A)During the six-month mandatory enrollment in a demonstration site, a beneficiary may continue receiving services from an out-of-network Medicare provider for primary and specialty care services only if all of the following criteria are met:
(i)The dual eligible beneficiary demonstrates an existing relationship with the provider prior to enrollment in a demonstration site.
(ii)The provider is willing to accept payment from the demonstration site based on the current Medicare fee schedule.
(iii)The demonstration site would not otherwise exclude the provider from its provider network due to documented quality of care concerns.
(B)The department shall develop a process to inform providers and beneficiaries of the availability of continuity of services from an existing provider and ensure that the beneficiary continues to receive services without interruption.
(3)(A)Notwithstanding subparagraph (A) of paragraph (1), a dual eligible beneficiary shall be excluded from enrollment in the demonstration project if the beneficiary meets any of the following:
(i)The beneficiary has a prior diagnosis of end-stage renal disease. This clause shall not apply to beneficiaries diagnosed with end-stage renal disease subsequent to enrollment in the demonstration project. The director may, with stakeholder input and federal approval, authorize beneficiaries with a prior diagnosis of end-stage renal disease in specified counties to voluntarily enroll in the demonstration project.
(ii)The beneficiary has other health coverage, as defined in paragraph (5) of subdivision (b) of Section 14182.16.
(iii)The beneficiary is enrolled in a home- and community-based waiver that is a Medi-Cal benefit under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n et seq.), except for persons enrolled in Multipurpose Senior Services Program services. services or beneficiaries receiving services through a regional center who resides in the County of San Mateo.
(iv)The beneficiary is receiving services through a regional center or state developmental center. However, a beneficiary receiving services through a regional center who resides in the County of San Mateo, by making an affirmative choice to opt in, may voluntarily enroll in the demonstration project, upon receipt of all legal notifications required pursuant to this section and applicable federal requirements.
(v)The beneficiary resides in a geographic area or ZIP Code not included in managed care, as determined by the department and CMS.
(vi)The beneficiary resides in one of the Veterans Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code.
(B)(i)Beneficiaries who have been diagnosed with HIV/AIDS may opt out of the demonstration project at the beginning of any month. The State Department of Public Health may share relevant data relating to a beneficiarys enrollment in the AIDS Drug Assistance Program with the department, and the department may share relevant data relating to HIV-positive beneficiaries with the State Department of Public Health.
(ii)The information provided by the State Department of Public Health pursuant to this subparagraph shall not be further disclosed by the State Department of Health Care Services, and shall be subject to the confidentiality protections of subdivisions (d) and (e) of Section 121025 of the Health and Safety Code, except this information may be further disclosed as follows:
(I)To the person to whom the information pertains or the designated representative of that person.
(II)To the Office of AIDS within the State Department of Public Health.
(C)Beneficiaries who are Indians receiving Medi-Cal services in accordance with Section 55110 of Title 22 of the California Code of Regulations may opt out of the demonstration project at the beginning of any month.
(D)The department, with stakeholder input, may exempt specific categories of dual eligible beneficiaries from enrollment requirements in this section based on extraordinary medical needs of specific patient groups or to meet federal requirements.
(4)For the 2013 calendar year, the department shall offer federal Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) compliant contracts to existing Medicare Advantage Dual Special Needs Plans (D-SNP plans) to continue to provide Medicare benefits to their enrollees in their service areas as approved on January 1, 2012. In the 2013 calendar year, beneficiaries in Medicare Advantage and D-SNP plans shall be exempt from the enrollment provisions of subparagraph (A) of paragraph (1), but may voluntarily choose to enroll in the demonstration project. Enrollment into the demonstration projects managed care health plans shall be reassessed in 2014 depending on federal reauthorization of the D-SNP model and the departments assessment of the demonstration plans.
(5)For the 2013 calendar year, demonstration sites shall not offer to enroll dual eligible beneficiaries eligible for the demonstration project into the demonstration sites D-SNP.
(6)The department shall not terminate contracts in a demonstration site with a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive beneficiaries or who have been diagnosed with AIDS and with any entity with a contract pursuant to Chapter 8.75 (commencing with Section 14591), except as provided in the contract or pursuant to state or federal law.
(m)Notwithstanding Section 10231.5 of the Government Code, the department shall conduct an evaluation, in partnership with CMS, to assess outcomes and the experience of dual eligibles in these demonstration sites and shall provide a report to the Legislature after the first full year of demonstration operation, and annually thereafter. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code. The department shall consult with stakeholders regarding the scope and structure of the evaluation.
(n)This section shall be implemented only if and to the extent that federal financial participation or funding is available.
(o)It is the intent of the Legislature that:
(1)In order to maintain adequate provider networks, demonstration sites shall reimburse providers at rates sufficient to ensure access to care for beneficiaries.
(2)Savings under the demonstration project are intended to be achieved through shifts in utilization, and not through reduced reimbursement rates to providers.
(3)Reimbursement policies shall not prevent demonstration sites and providers from entering into payment arrangements that allow for the alignment of financial incentives and provide opportunities for shared risk and shared savings in order to promote appropriate utilization shifts, which encourage the use of home- and community-based services and quality of care for dual eligible beneficiaries enrolled in the demonstration sites.
(4)To the extent permitted under the demonstration project, and to the extent that a public entity voluntarily provides an intergovernmental transfer for this purpose, both of the following shall apply:
(A)The department shall work with CMS in ensuring that the capitation rates under the demonstration project are inclusive of funding currently provided through certified public expenditures supplemental payment programs that would otherwise be impacted by the demonstration project.
(B)Demonstration sites shall pay to a public entity voluntarily providing intergovernmental transfers that previously received reimbursement under a certified public expenditures supplemental payment program, rates that include the additional funding under the capitation rates that are funded by the public entitys intergovernmental transfer.
(5)The department shall work with CMS in developing other reimbursement policies and shall inform demonstration sites, providers, and the Legislature of the final policy guidance.
(6)The department shall seek approval from CMS to permit the provider payment requirements contained in subparagraph (G) of paragraph (1) and paragraphs (10) and (11) of subdivision (i), and Section 14132.276.
(7)Demonstration sites that contract with hospitals for hospital services on a fee-for-service basis that otherwise would have been traditionally Medicare services will achieve savings through utilization changes and not by paying hospitals at rates lower than prevailing Medicare fee-for-service rates.
(p)The department shall enter into an interagency agreement with the Department of Managed Health Care to perform some or all of the departments oversight and readiness review activities specified in this section. These activities may include providing consumer assistance to beneficiaries affected by this section and conducting financial audits, medical surveys, and a review of the adequacy of provider networks of the managed care health plans participating in this section. The interagency agreement shall be updated, as necessary, on an annual basis in order to maintain functional clarity regarding the roles and responsibilities of the Department of Managed Health Care and the department. The department shall not delegate its authority under this section as the single state Medicaid agency to the Department of Managed Health Care.
(q)(1)Beginning with the May Revision to the 201314 Governors Budget, and annually thereafter, the department shall report to the Legislature on the enrollment status, quality measures, and state costs of the actions taken pursuant to this section.
(2)(A)By January 1, 2013, or as soon thereafter as practicable, the department shall develop, in consultation with CMS and stakeholders, quality and fiscal measures for health plans to reflect the short- and long-term results of the implementation of this section. The department shall also develop quality thresholds and milestones for these measures. The department shall update these measures periodically to reflect changes in this program due to implementation factors and the structure and design of the benefits and services being coordinated by managed care health plans.
(B)The department shall require health plans to submit Medicare and Medi-Cal data to determine the results of these measures. If the department finds that a health plan is not in compliance with one or more of the measures set forth in this section, the health plan shall, within 60 days, submit a corrective action plan to the department for approval. The corrective action plan shall, at a minimum, include steps that the health plan shall take to improve its performance based on the standard or standards with which the health plan is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the health plan in order to avoid a sanction pursuant to Section 14304. Nothing in this subparagraph is intended to limit Section 14304.
(C)The department shall publish the results of these measures, including via posting on the departments Internet Web site, on a quarterly basis.
(r)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 section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance.
(s)This section shall be inoperative if the Coordinated Care Initiative becomes inoperative pursuant to Section 34 of the act that added this subdivision.
SEC. 2.The Legislature finds and declares that a special law is necessary and that a general law cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the unique circumstances regarding the availability of resources for dual eligible beneficiaries in the County of San Mateo.
(a)The department shall seek federal approval to establish the demonstration project described in this section pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof. Under a Medicare demonstration, the department may contract with the federal Centers for Medicare and Medicaid Services (CMS) and demonstration sites to operate the Medicare and Medicaid benefits in a demonstration project that is overseen by the state as a delegated Medicare benefit administrator, and may enter into financing arrangements with CMS to share in any Medicare program savings generated by the demonstration project.
(b)After federal approval is obtained, the department shall establish the demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports and behavioral health services, including mental health and substance use disorder treatment services. The purpose of the demonstration project is to integrate services authorized under the federal Medicaid Program (Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the federal Medicare Program (Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.)). The demonstration project may also include additional services as approved through a demonstration project or waiver, or a combination thereof.
(c)For purposes of this section, the following definitions shall apply:
(1)Behavioral health means Medi-Cal services provided pursuant to Section 51341 of Title 22 of the California Code of Regulations and Drug Medi-Cal substance abuse services provided pursuant to Section 51341.1 of Title 22 of the California Code of Regulations, and any mental health benefits available under the Medicare Program.
(2)Capitated payment model means an agreement entered into between CMS, the state, and a managed care health plan, in which the managed care health plan receives a capitation payment for the comprehensive, coordinated provision of Medi-Cal services and benefits under Medicare Part C (42 U.S.C. Sec. 1395w-21 et seq.) and Medicare Part D (42 U.S.C. Sec. 1395w-101 et seq.), and CMS shares the savings with the state from improved provision of Medi-Cal and Medicare services that reduces the cost of those services. Medi-Cal services include long-term services and supports as defined in Section 14186.1, behavioral health services, and any additional services offered by the demonstration site.
(3)Demonstration site means a managed care health plan that is selected to participate in the demonstration project under the capitated payment model.
(4)Dual eligible beneficiary means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) and Medicare Part B (42 U.S.C. Sec. 1395j et seq.) and is eligible for medical assistance under the Medi-Cal State Plan.
(d)No sooner than March 1, 2011, the department shall identify health care models that may be included in the demonstration project, shall develop a timeline and process for selecting, financing, monitoring, and evaluating the demonstration sites, and shall provide this timeline and process to the appropriate fiscal and policy committees of the Legislature. The department may implement these demonstration sites in phases.
(e)The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of any report submitted to CMS to meet the requirements under the demonstration project.
(f)Goals for the demonstration project shall include all of the following:
(1)Coordinate Medi-Cal and Medicare benefits across health care settings and improve the continuity of care across acute care, long-term care, behavioral health, including mental health and substance use disorder services, and home- and community-based services settings using a person-centered approach.
(2)Coordinate access to acute and long-term care services for dual eligible beneficiaries.
(3)Maximize the ability of dual eligible beneficiaries to remain in their homes and communities with appropriate services and supports in lieu of institutional care.
(4)Increase the availability of and access to home- and community-based services.
(5)Coordinate access to necessary and appropriate behavioral health services, including mental health and substance use disorder services.
(6)Improve the quality of care for dual eligible beneficiaries.
(7)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.
(g)No sooner than March 1, 2013, demonstration sites shall be established in up to eight counties, and shall include at least one county that provides Medi-Cal services via a two-plan model pursuant to Article 2.7 (commencing with Section 14087.3) and at least one county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5). The director shall consult with the Legislature, CMS, and stakeholders when determining the implementation date for this section. In determining the counties in which to establish a demonstration site, the director shall consider the following:
(1)Local support for integrating medical care, long-term care, and home- and community-based services networks.
(2)A local stakeholder process that includes health plans, providers, mental health representatives, community programs, consumers, designated representatives of in-home supportive services personnel, and other interested stakeholders in the development, implementation, and continued operation of the demonstration site.
(h)In developing the process for selecting, financing, monitoring, and evaluating the health care models for the demonstration project, the department shall enter into a memorandum of understanding with CMS. Upon completion, the memorandum of understanding shall be provided to the fiscal and appropriate policy committees of the Legislature and posted on the departments Internet Web site.
(i)The department shall negotiate the terms and conditions of the memorandum of understanding, which shall address, but are not limited to, the following:
(1)Reimbursement methods for a capitated payment model. Under the capitated payment model, the demonstration sites shall meet all of the following requirements:
(A)Have Medi-Cal managed care health plan and Medicare dual eligible-special needs plan contract experience, or evidence of the ability to meet these contracting requirements.
(B)Be in good financial standing and meet licensure requirements under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), except for county organized health system plans that are exempt from licensure pursuant to Section 14087.95.
(C)Meet quality measures, which may include Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set measures and other quality measures determined or developed by the department or CMS.
(D)Demonstrate a local stakeholder process that includes dual eligible beneficiaries, managed care health plans, providers, mental health representatives, county health and human services agencies, designated representatives of in-home supportive services personnel, and other interested stakeholders that advise and consult with the demonstration site in the development, implementation, and continued operation of the demonstration project.
(E)Pay providers reimbursement rates sufficient to maintain an adequate provider network and ensure access to care for beneficiaries.
(F)Follow final policy guidance determined by CMS and the department with regard to reimbursement rates for providers pursuant to paragraphs (4) to (7), inclusive, of subdivision (o).
(G)To the extent permitted under the demonstration, pay noncontracted hospitals prevailing Medicare fee-for-service rates for traditionally Medicare covered benefits and prevailing Medi-Cal fee-for-service rates for traditionally Medi-Cal covered benefits.
(2)Encounter data reporting requirements for both Medi-Cal and Medicare services provided to beneficiaries enrolling in the demonstration project.
(3)Quality assurance withholding from the demonstration site payment, to be paid only if quality measures developed as part of the memorandum of understanding and plan contracts are met.
(4)Provider network adequacy standards developed by the department and CMS, in consultation with the Department of Managed Health Care, the demonstration site, and stakeholders.
(5)Medicare and Medi-Cal appeals and hearing process.
(6)Unified marketing requirements and combined review process by the department and CMS.
(7)Combined quality management and consolidated reporting process by the department and CMS.
(8)Procedures related to combined federal and state contract management to ensure access, quality, program integrity, and financial solvency of the demonstration site.
(9)To the extent permissible under federal requirements, implementation of the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under Medi-Cal and the Medicare Program.
(10)(A)In consultation with the hospital industry, CMS approval to ensure that Medicare supplemental payments for direct graduate medical education and Medicare add-on payments, including indirect medical education and disproportionate share hospital adjustments continue to be made available to hospitals for services provided under the demonstration.
(B)The department shall seek CMS approval for CMS to continue these payments either outside the capitation rates or, if contained within the capitation rates, and to the extent permitted under the demonstration project, shall require demonstration sites to provide this reimbursement to hospitals.
(11)To the extent permitted under the demonstration project, the default rate for noncontracting providers of physician services shall be the prevailing Medicare fee schedule for services covered by the Medicare program and the prevailing Medi-Cal fee schedule for services covered by the Medi-Cal program.
(j)(1)The department shall comply with and enforce the terms and conditions of the memorandum of understanding with CMS, as specified in subdivision (i). To the extent that the terms and conditions do not address the specific selection, financing, monitoring, and evaluation criteria listed in subdivision (i), the department:
(A)Shall require the demonstration site to do all of the following:
(i)Comply with additional site readiness criteria specified by the department.
(ii)Comply with long-term services and supports requirements in accordance with Article 5.7 (commencing with Section 14186).
(iii)To the extent permissible under federal requirements, comply with the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under both Medi-Cal and the Medicare Program.
(iv)Comply with all transition of care requirements for Medicare Part D benefits as described in Chapters 6 and 14 of the Medicare Managed Care Manual, published by CMS, including transition timeframes, notices, and emergency supplies.
(B)May require the demonstration site to forgo charging premiums, coinsurance, copayments, and deductibles for Medicare Part C and Medicare Part D services.
(2)The department shall notify the Legislature within 30 days of the implementation of each provision in paragraph (1).
(k)The director may enter into exclusive or nonexclusive contracts on a bid or negotiated basis and may amend existing managed care contracts to provide or arrange for services provided under this section. 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.
(l)(1)(A)Except for the exemptions provided for in this section and in Section 14132.277, the department shall enroll dual eligible beneficiaries into a demonstration site unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled on or before June 1, 2013, in a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS or in any entity with a contract with the department pursuant to Chapter 8.75 (commencing with Section 14591).
(B)Dual eligible beneficiaries who opt out of enrollment into a demonstration site may choose to remain enrolled in fee-for-service Medicare or a Medicare Advantage plan for their Medicare benefits, but shall be mandatorily enrolled into a Medi-Cal managed care health plan pursuant to Section 14182.16, except as exempted under subdivision (c) of Section 14182.16.
(C)(i)Persons meeting requirements for the Program of All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section 14591) or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) of Chapter 7 to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS may select either of these managed care health plans for their Medicare and Medi-Cal benefits if one is available in that county.
(ii)In areas where a PACE plan is available, the PACE plan shall be presented as an enrollment option, included in all enrollment materials, enrollment assistance programs, and outreach programs related to the demonstration project, and made available to beneficiaries whenever enrollment choices and options are presented. Persons meeting the age qualifications for PACE and who choose PACE shall remain in the fee-for-service Medi-Cal and Medicare programs, and shall not be assigned to a managed care health plan for the lesser of 60 days or until they are assessed for eligibility for PACE and determined not to be eligible for a PACE plan. Persons enrolled in a PACE plan shall receive all Medicare and Medi-Cal services from the PACE program pursuant to the three-way agreement between the PACE program, the department, and the Centers for Medicare and Medicaid Services.
(2)To the extent that federal approval is obtained, the department may require that any beneficiary, upon enrollment in a demonstration site, remain enrolled in the Medicare portion of the demonstration project on a mandatory basis for six months from the date of initial enrollment. After the sixth month, a dual eligible beneficiary may elect to enroll in a different demonstration site, a different Medicare Advantage plan, fee-for-service Medicare, PACE, or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS, for his or her Medicare benefits.
(A)During the six-month mandatory enrollment in a demonstration site, a beneficiary may continue receiving services from an out-of-network Medicare provider for primary and specialty care services only if all of the following criteria are met:
(i)The dual eligible beneficiary demonstrates an existing relationship with the provider prior to enrollment in a demonstration site.
(ii)The provider is willing to accept payment from the demonstration site based on the current Medicare fee schedule.
(iii)The demonstration site would not otherwise exclude the provider from its provider network due to documented quality of care concerns.
(B)The department shall develop a process to inform providers and beneficiaries of the availability of continuity of services from an existing provider and ensure that the beneficiary continues to receive services without interruption.
(3)(A)Notwithstanding subparagraph (A) of paragraph (1), a dual eligible beneficiary shall be excluded from enrollment in the demonstration project if the beneficiary meets any of the following:
(i)The beneficiary has a prior diagnosis of end-stage renal disease. This clause shall not apply to beneficiaries diagnosed with end-stage renal disease subsequent to enrollment in the demonstration project. The director may, with stakeholder input and federal approval, authorize beneficiaries with a prior diagnosis of end-stage renal disease in specified counties to voluntarily enroll in the demonstration project.
(ii)The beneficiary has other health coverage, as defined in paragraph (5) of subdivision (b) of Section 14182.16.
(iii)The beneficiary is enrolled in a home- and community-based waiver that is a Medi-Cal benefit under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n et seq.), except for persons enrolled in Multipurpose Senior Services Program services.
(iv)The beneficiary is receiving services through a regional center or state developmental center. However, a beneficiary receiving services through a regional center who resides in the County of San Mateo, by making an affirmative choice to opt in, may voluntarily enroll in the demonstration project, upon receipt of all legal notifications required pursuant to this section and applicable federal requirements.
(v)The beneficiary resides in a geographic area or ZIP Code not included in managed care, as determined by the department and CMS.
(vi)The beneficiary resides in one of the Veterans Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code.
(B)(i)Beneficiaries who have been diagnosed with HIV/AIDS may opt out of the demonstration project at the beginning of any month. The State Department of Public Health may share relevant data relating to a beneficiarys enrollment in the AIDS Drug Assistance Program with the department, and the department may share relevant data relating to HIV-positive beneficiaries with the State Department of Public Health.
(ii)The information provided by the State Department of Public Health pursuant to this subparagraph shall not be further disclosed by the State Department of Health Care Services, and shall be subject to the confidentiality protections of subdivisions (d) and (e) of Section 121025 of the Health and Safety Code, except this information may be further disclosed as follows:
(I)To the person to whom the information pertains or the designated representative of that person.
(II)To the Office of AIDS within the State Department of Public Health.
(C)Beneficiaries who are Indians receiving Medi-Cal services in accordance with Section 55110 of Title 22 of the California Code of Regulations may opt out of the demonstration project at the beginning of any month.
(D)The department, with stakeholder input, may exempt specific categories of dual eligible beneficiaries from enrollment requirements in this section based on extraordinary medical needs of specific patient groups or to meet federal requirements.
(4)For the 2013 calendar year, the department shall offer federal Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) compliant contracts to existing Medicare Advantage Dual Special Needs Plans (D-SNP plans) to continue to provide Medicare benefits to their enrollees in their service areas as approved on January 1, 2012. In the 2013 calendar year, beneficiaries in Medicare Advantage and D-SNP plans shall be exempt from the enrollment provisions of subparagraph (A) of paragraph (1), but may voluntarily choose to enroll in the demonstration project. Enrollment into the demonstration projects managed care health plans shall be reassessed in 2014 depending on federal reauthorization of the D-SNP model and the departments assessment of the demonstration plans.
(5)For the 2013 calendar year, demonstration sites shall not offer to enroll dual eligible beneficiaries eligible for the demonstration project into the demonstration sites D-SNP.
(6)The department shall not terminate contracts in a demonstration site with a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive beneficiaries or who have been diagnosed with AIDS and with any entity with a contract pursuant to Chapter 8.75 (commencing with Section 14591), except as provided in the contract or pursuant to state or federal law.
(m)Notwithstanding Section 10231.5 of the Government Code, the department shall conduct an evaluation, in partnership with CMS, to assess outcomes and the experience of dual eligibles in these demonstration sites and shall provide a report to the Legislature after the first full year of demonstration operation, and annually thereafter. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code. The department shall consult with stakeholders regarding the scope and structure of the evaluation.
(n)This section shall be implemented only if and to the extent that federal financial participation or funding is available.
(o)It is the intent of the Legislature that:
(1)In order to maintain adequate provider networks, demonstration sites shall reimburse providers at rates sufficient to ensure access to care for beneficiaries.
(2)Savings under the demonstration project are intended to be achieved through shifts in utilization, and not through reduced reimbursement rates to providers.
(3)Reimbursement policies shall not prevent demonstration sites and providers from entering into payment arrangements that allow for the alignment of financial incentives and provide opportunities for shared risk and shared savings in order to promote appropriate utilization shifts, which encourage the use of home- and community-based services and quality of care for dual eligible beneficiaries enrolled in the demonstration sites.
(4)To the extent permitted under the demonstration project, and to the extent that a public entity voluntarily provides an intergovernmental transfer for this purpose, both of the following shall apply:
(A)The department shall work with CMS in ensuring that the capitation rates under the demonstration project are inclusive of funding currently provided through certified public expenditures supplemental payment programs that would otherwise be impacted by the demonstration project.
(B)Demonstration sites shall pay to a public entity voluntarily providing intergovernmental transfers that previously received reimbursement under a certified public expenditures supplemental payment program, rates that include the additional funding under the capitation rates that are funded by the public entitys intergovernmental transfer.
(5)The department shall work with CMS in developing other reimbursement policies and shall inform demonstration sites, providers, and the Legislature of the final policy guidance.
(6)The department shall seek approval from CMS to permit the provider payment requirements contained in subparagraph (G) of paragraph (1) and paragraphs (10) and (11) of subdivision (i), and Section 14132.276.
(7)Demonstration sites that contract with hospitals for hospital services on a fee-for-service basis that otherwise would have been traditionally Medicare services will achieve savings through utilization changes and not by paying hospitals at rates lower than prevailing Medicare fee-for-service rates.
(p)The department shall enter into an interagency agreement with the Department of Managed Health Care to perform some or all of the departments oversight and readiness review activities specified in this section. These activities may include providing consumer assistance to beneficiaries affected by this section and conducting financial audits, medical surveys, and a review of the adequacy of provider networks of the managed care health plans participating in this section. The interagency agreement shall be updated, as necessary, on an annual basis in order to maintain functional clarity regarding the roles and responsibilities of the Department of Managed Health Care and the department. The department shall not delegate its authority under this section as the single state Medicaid agency to the Department of Managed Health Care.
(q)(1)Beginning with the May Revision to the 201314 Governors Budget, and annually thereafter, the department shall report to the Legislature on the enrollment status, quality measures, and state costs of the actions taken pursuant to this section.
(2)(A)By January 1, 2013, or as soon thereafter as practicable, the department shall develop, in consultation with CMS and stakeholders, quality and fiscal measures for health plans to reflect the short- and long-term results of the implementation of this section. The department shall also develop quality thresholds and milestones for these measures. The department shall update these measures periodically to reflect changes in this program due to implementation factors and the structure and design of the benefits and services being coordinated by managed care health plans.
(B)The department shall require health plans to submit Medicare and Medi-Cal data to determine the results of these measures. If the department finds that a health plan is not in compliance with one or more of the measures set forth in this section, the health plan shall, within 60 days, submit a corrective action plan to the department for approval. The corrective action plan shall, at a minimum, include steps that the health plan shall take to improve its performance based on the standard or standards with which the health plan is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the health plan in order to avoid a sanction pursuant to Section 14304. Nothing in this subparagraph is intended to limit Section 14304.
(C)The department shall publish the results of these measures, including via posting on the departments Internet Web site, on a quarterly basis.
(r)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 section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance.
(s)This section shall be inoperative if the Coordinated Care Initiative becomes inoperative pursuant to Section 34 of the act that added this subdivision.
SEC. 2.The Legislature finds and declares that a special law is necessary and that a general law cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the unique circumstances regarding the availability of resources for dual eligible beneficiaries in the County of San Mateo.
(a)The department shall seek federal approval to establish the demonstration project described in this section pursuant to a Medicare or a Medicaid demonstration project or waiver, or a combination thereof. Under a Medicare demonstration, the department may contract with the federal Centers for Medicare and Medicaid Services (CMS) and demonstration sites to operate the Medicare and Medicaid benefits in a demonstration project that is overseen by the state as a delegated Medicare benefit administrator, and may enter into financing arrangements with CMS to share in any Medicare program savings generated by the demonstration project.
(b)After federal approval is obtained, the department shall establish the demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports and behavioral health services, including mental health and substance use disorder treatment services. The purpose of the demonstration project is to integrate services authorized under the federal Medicaid Program (Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396 et seq.)) and the federal Medicare Program (Title XVIII of the federal Social Security Act (42 U.S.C. Sec. 1395 et seq.)). The demonstration project may also include additional services as approved through a demonstration project or waiver, or a combination thereof.
(c)For purposes of this section, the following definitions shall apply:
(1)Behavioral health means Medi-Cal services provided pursuant to Section 51341 of Title 22 of the California Code of Regulations and Drug Medi-Cal substance abuse services provided pursuant to Section 51341.1 of Title 22 of the California Code of Regulations, and any mental health benefits available under the Medicare Program.
(2)Capitated payment model means an agreement entered into between CMS, the state, and a managed care health plan, in which the managed care health plan receives a capitation payment for the comprehensive, coordinated provision of Medi-Cal services and benefits under Medicare Part C (42 U.S.C. Sec. 1395w-21 et seq.) and Medicare Part D (42 U.S.C. Sec. 1395w-101 et seq.), and CMS shares the savings with the state from improved provision of Medi-Cal and Medicare services that reduces the cost of those services. Medi-Cal services include long-term services and supports as defined in Section 14186.1, behavioral health services, and any additional services offered by the demonstration site.
(3)Demonstration site means a managed care health plan that is selected to participate in the demonstration project under the capitated payment model.
(4)Dual eligible beneficiary means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) and Medicare Part B (42 U.S.C. Sec. 1395j et seq.) and is eligible for medical assistance under the Medi-Cal State Plan.
(d)No sooner than March 1, 2011, the department shall identify health care models that may be included in the demonstration project, shall develop a timeline and process for selecting, financing, monitoring, and evaluating the demonstration sites, and shall provide this timeline and process to the appropriate fiscal and policy committees of the Legislature. The department may implement these demonstration sites in phases.
(e)The department shall provide the fiscal and appropriate policy committees of the Legislature with a copy of any report submitted to CMS to meet the requirements under the demonstration project.
(f)Goals for the demonstration project shall include all of the following:
(1)Coordinate Medi-Cal and Medicare benefits across health care settings and improve the continuity of care across acute care, long-term care, behavioral health, including mental health and substance use disorder services, and home- and community-based services settings using a person-centered approach.
(2)Coordinate access to acute and long-term care services for dual eligible beneficiaries.
(3)Maximize the ability of dual eligible beneficiaries to remain in their homes and communities with appropriate services and supports in lieu of institutional care.
(4)Increase the availability of and access to home- and community-based services.
(5)Coordinate access to necessary and appropriate behavioral health services, including mental health and substance use disorder services.
(6)Improve the quality of care for dual eligible beneficiaries.
(7)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.
(g)No sooner than March 1, 2013, demonstration sites shall be established in up to eight counties, and shall include at least one county that provides Medi-Cal services via a two-plan model pursuant to Article 2.7 (commencing with Section 14087.3) and at least one county that provides Medi-Cal services under a county organized health system pursuant to Article 2.8 (commencing with Section 14087.5). The director shall consult with the Legislature, CMS, and stakeholders when determining the implementation date for this section. In determining the counties in which to establish a demonstration site, the director shall consider the following:
(1)Local support for integrating medical care, long-term care, and home- and community-based services networks.
(2)A local stakeholder process that includes health plans, providers, mental health representatives, community programs, consumers, designated representatives of in-home supportive services personnel, and other interested stakeholders in the development, implementation, and continued operation of the demonstration site.
(h)In developing the process for selecting, financing, monitoring, and evaluating the health care models for the demonstration project, the department shall enter into a memorandum of understanding with CMS. Upon completion, the memorandum of understanding shall be provided to the fiscal and appropriate policy committees of the Legislature and posted on the departments Internet Web site.
(i)The department shall negotiate the terms and conditions of the memorandum of understanding, which shall address, but are not limited to, the following:
(1)Reimbursement methods for a capitated payment model. Under the capitated payment model, the demonstration sites shall meet all of the following requirements:
(A)Have Medi-Cal managed care health plan and Medicare dual eligible-special needs plan contract experience, or evidence of the ability to meet these contracting requirements.
(B)Be in good financial standing and meet licensure requirements under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), except for county organized health system plans that are exempt from licensure pursuant to Section 14087.95.
(C)Meet quality measures, which may include Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set measures and other quality measures determined or developed by the department or CMS.
(D)Demonstrate a local stakeholder process that includes dual eligible beneficiaries, managed care health plans, providers, mental health representatives, county health and human services agencies, designated representatives of in-home supportive services personnel, and other interested stakeholders that advise and consult with the demonstration site in the development, implementation, and continued operation of the demonstration project.
(E)Pay providers reimbursement rates sufficient to maintain an adequate provider network and ensure access to care for beneficiaries.
(F)Follow final policy guidance determined by CMS and the department with regard to reimbursement rates for providers pursuant to paragraphs (4) to (7), inclusive, of subdivision (o).
(G)To the extent permitted under the demonstration, pay noncontracted hospitals prevailing Medicare fee-for-service rates for traditionally Medicare covered benefits and prevailing Medi-Cal fee-for-service rates for traditionally Medi-Cal covered benefits.
(2)Encounter data reporting requirements for both Medi-Cal and Medicare services provided to beneficiaries enrolling in the demonstration project.
(3)Quality assurance withholding from the demonstration site payment, to be paid only if quality measures developed as part of the memorandum of understanding and plan contracts are met.
(4)Provider network adequacy standards developed by the department and CMS, in consultation with the Department of Managed Health Care, the demonstration site, and stakeholders.
(5)Medicare and Medi-Cal appeals and hearing process.
(6)Unified marketing requirements and combined review process by the department and CMS.
(7)Combined quality management and consolidated reporting process by the department and CMS.
(8)Procedures related to combined federal and state contract management to ensure access, quality, program integrity, and financial solvency of the demonstration site.
(9)To the extent permissible under federal requirements, implementation of the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under Medi-Cal and the Medicare Program.
(10)(A)In consultation with the hospital industry, CMS approval to ensure that Medicare supplemental payments for direct graduate medical education and Medicare add-on payments, including indirect medical education and disproportionate share hospital adjustments continue to be made available to hospitals for services provided under the demonstration.
(B)The department shall seek CMS approval for CMS to continue these payments either outside the capitation rates or, if contained within the capitation rates, and to the extent permitted under the demonstration project, shall require demonstration sites to provide this reimbursement to hospitals.
(11)To the extent permitted under the demonstration project, the default rate for noncontracting providers of physician services shall be the prevailing Medicare fee schedule for services covered by the Medicare program and the prevailing Medi-Cal fee schedule for services covered by the Medi-Cal program.
(j)(1)The department shall comply with and enforce the terms and conditions of the memorandum of understanding with CMS, as specified in subdivision (i). To the extent that the terms and conditions do not address the specific selection, financing, monitoring, and evaluation criteria listed in subdivision (i), the department:
(A)Shall require the demonstration site to do all of the following:
(i)Comply with additional site readiness criteria specified by the department.
(ii)Comply with long-term services and supports requirements in accordance with Article 5.7 (commencing with Section 14186).
(iii)To the extent permissible under federal requirements, comply with the provisions of Sections 14182.16 and 14182.17 that are applicable to beneficiaries simultaneously eligible for full-scope benefits under both Medi-Cal and the Medicare Program.
(iv)Comply with all transition of care requirements for Medicare Part D benefits as described in Chapters 6 and 14 of the Medicare Managed Care Manual, published by CMS, including transition timeframes, notices, and emergency supplies.
(B)May require the demonstration site to forgo charging premiums, coinsurance, copayments, and deductibles for Medicare Part C and Medicare Part D services.
(2)The department shall notify the Legislature within 30 days of the implementation of each provision in paragraph (1).
(k)The director may enter into exclusive or nonexclusive contracts on a bid or negotiated basis and may amend existing managed care contracts to provide or arrange for services provided under this section. 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.
(l)(1)(A)Except for the exemptions provided for in this section and in Section 14132.277, the department shall enroll dual eligible beneficiaries into a demonstration site unless the beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled on or before June 1, 2013, in a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS or in any entity with a contract with the department pursuant to Chapter 8.75 (commencing with Section 14591).
(B)Dual eligible beneficiaries who opt out of enrollment into a demonstration site may choose to remain enrolled in fee-for-service Medicare or a Medicare Advantage plan for their Medicare benefits, but shall be mandatorily enrolled into a Medi-Cal managed care health plan pursuant to Section 14182.16, except as exempted under subdivision (c) of Section 14182.16.
(C)(i)Persons meeting requirements for the Program of All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section 14591) or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) of Chapter 7 to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS may select either of these managed care health plans for their Medicare and Medi-Cal benefits if one is available in that county.
(ii)In areas where a PACE plan is available, the PACE plan shall be presented as an enrollment option, included in all enrollment materials, enrollment assistance programs, and outreach programs related to the demonstration project, and made available to beneficiaries whenever enrollment choices and options are presented. Persons meeting the age qualifications for PACE and who choose PACE shall remain in the fee-for-service Medi-Cal and Medicare programs, and shall not be assigned to a managed care health plan for the lesser of 60 days or until they are assessed for eligibility for PACE and determined not to be eligible for a PACE plan. Persons enrolled in a PACE plan shall receive all Medicare and Medi-Cal services from the PACE program pursuant to the three-way agreement between the PACE program, the department, and the Centers for Medicare and Medicaid Services.
(2)To the extent that federal approval is obtained, the department may require that any beneficiary, upon enrollment in a demonstration site, remain enrolled in the Medicare portion of the demonstration project on a mandatory basis for six months from the date of initial enrollment. After the sixth month, a dual eligible beneficiary may elect to enroll in a different demonstration site, a different Medicare Advantage plan, fee-for-service Medicare, PACE, or a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive or who have been diagnosed with AIDS, for his or her Medicare benefits.
(A)During the six-month mandatory enrollment in a demonstration site, a beneficiary may continue receiving services from an out-of-network Medicare provider for primary and specialty care services only if all of the following criteria are met:
(i)The dual eligible beneficiary demonstrates an existing relationship with the provider prior to enrollment in a demonstration site.
(ii)The provider is willing to accept payment from the demonstration site based on the current Medicare fee schedule.
(iii)The demonstration site would not otherwise exclude the provider from its provider network due to documented quality of care concerns.
(B)The department shall develop a process to inform providers and beneficiaries of the availability of continuity of services from an existing provider and ensure that the beneficiary continues to receive services without interruption.
(3)(A)Notwithstanding subparagraph (A) of paragraph (1), a dual eligible beneficiary shall be excluded from enrollment in the demonstration project if the beneficiary meets any of the following:
(i)The beneficiary has a prior diagnosis of end-stage renal disease. This clause shall not apply to beneficiaries diagnosed with end-stage renal disease subsequent to enrollment in the demonstration project. The director may, with stakeholder input and federal approval, authorize beneficiaries with a prior diagnosis of end-stage renal disease in specified counties to voluntarily enroll in the demonstration project.
(ii)The beneficiary has other health coverage, as defined in paragraph (5) of subdivision (b) of Section 14182.16.
(iii)The beneficiary is enrolled in a home- and community-based waiver that is a Medi-Cal benefit under Section 1915(c) of the federal Social Security Act (42 U.S.C. Sec. 1396n et seq.), except for persons enrolled in Multipurpose Senior Services Program services.
(iv)The beneficiary is receiving services through a regional center or state developmental center. However, a beneficiary receiving services through a regional center who resides in the County of San Mateo may voluntarily enroll in the demonstration project, upon receipt of all legal notifications required pursuant to this section and applicable federal requirements.
(v)The beneficiary resides in a geographic area or ZIP Code not included in managed care, as determined by the department and CMS.
(vi)The beneficiary resides in one of the Veterans Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code.
(B)(i)Beneficiaries who have been diagnosed with HIV/AIDS may opt out of the demonstration project at the beginning of any month. The State Department of Public Health may share relevant data relating to a beneficiarys enrollment in the AIDS Drug Assistance Program with the department, and the department may share relevant data relating to HIV-positive beneficiaries with the State Department of Public Health.
(ii)The information provided by the State Department of Public Health pursuant to this subparagraph shall not be further disclosed by the State Department of Health Care Services, and shall be subject to the confidentiality protections of subdivisions (d) and (e) of Section 121025 of the Health and Safety Code, except this information may be further disclosed as follows:
(I)To the person to whom the information pertains or the designated representative of that person.
(II)To the Office of AIDS within the State Department of Public Health.
(C)Beneficiaries who are Indians receiving Medi-Cal services in accordance with Section 55110 of Title 22 of the California Code of Regulations may opt out of the demonstration project at the beginning of any month.
(D)The department, with stakeholder input, may exempt specific categories of dual eligible beneficiaries from enrollment requirements in this section based on extraordinary medical needs of specific patient groups or to meet federal requirements.
(4)For the 2013 calendar year, the department shall offer federal Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) compliant contracts to existing Medicare Advantage Dual Special Needs Plans (D-SNP plans) to continue to provide Medicare benefits to their enrollees in their service areas as approved on January 1, 2012. In the 2013 calendar year, beneficiaries in Medicare Advantage and D-SNP plans shall be exempt from the enrollment provisions of subparagraph (A) of paragraph (1), but may voluntarily choose to enroll in the demonstration project. Enrollment into the demonstration projects managed care health plans shall be reassessed in 2014 depending on federal reauthorization of the D-SNP model and the departments assessment of the demonstration plans.
(5)For the 2013 calendar year, demonstration sites shall not offer to enroll dual eligible beneficiaries eligible for the demonstration project into the demonstration sites D-SNP.
(6)The department shall not terminate contracts in a demonstration site with a managed care organization licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) that has previously contracted with the department as a primary care case management plan pursuant to Article 2.9 (commencing with Section 14088) to provide services to beneficiaries who are HIV positive beneficiaries or who have been diagnosed with AIDS and with any entity with a contract pursuant to Chapter 8.75 (commencing with Section 14591), except as provided in the contract or pursuant to state or federal law.
(m)Notwithstanding Section 10231.5 of the Government Code, the department shall conduct an evaluation, in partnership with CMS, to assess outcomes and the experience of dual eligibles in these demonstration sites and shall provide a report to the Legislature after the first full year of demonstration operation, and annually thereafter. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code. The department shall consult with stakeholders regarding the scope and structure of the evaluation.
(n)This section shall be implemented only if and to the extent that federal financial participation or funding is available.
(o)It is the intent of the Legislature that:
(1)In order to maintain adequate provider networks, demonstration sites shall reimburse providers at rates sufficient to ensure access to care for beneficiaries.
(2)Savings under the demonstration project are intended to be achieved through shifts in utilization, and not through reduced reimbursement rates to providers.
(3)Reimbursement policies shall not prevent demonstration sites and providers from entering into payment arrangements that allow for the alignment of financial incentives and provide opportunities for shared risk and shared savings in order to promote appropriate utilization shifts, which encourage the use of home- and community-based services and quality of care for dual eligible beneficiaries enrolled in the demonstration sites.
(4)To the extent permitted under the demonstration project, and to the extent that a public entity voluntarily provides an intergovernmental transfer for this purpose, both of the following shall apply:
(A)The department shall work with CMS in ensuring that the capitation rates under the demonstration project are inclusive of funding currently provided through certified public expenditures supplemental payment programs that would otherwise be impacted by the demonstration project.
(B)Demonstration sites shall pay to a public entity voluntarily providing intergovernmental transfers that previously received reimbursement under a certified public expenditures supplemental payment program, rates that include the additional funding under the capitation rates that are funded by the public entitys intergovernmental transfer.
(5)The department shall work with CMS in developing other reimbursement policies and shall inform demonstration sites, providers, and the Legislature of the final policy guidance.
(6)The department shall seek approval from CMS to permit the provider payment requirements contained in subparagraph (G) of paragraph (1) and paragraphs (10) and (11) of subdivision (i), and Section 14132.276.
(7)Demonstration sites that contract with hospitals for hospital services on a fee-for-service basis that otherwise would have been traditionally Medicare services will achieve savings through utilization changes and not by paying hospitals at rates lower than prevailing Medicare fee-for-service rates.
(p)The department shall enter into an interagency agreement with the Department of Managed Health Care to perform some or all of the departments oversight and readiness review activities specified in this section. These activities may include providing consumer assistance to beneficiaries affected by this section and conducting financial audits, medical surveys, and a review of the adequacy of provider networks of the managed care health plans participating in this section. The interagency agreement shall be updated, as necessary, on an annual basis in order to maintain functional clarity regarding the roles and responsibilities of the Department of Managed Health Care and the department. The department shall not delegate its authority under this section as the single state Medicaid agency to the Department of Managed Health Care.
(q)(1)Beginning with the May Revision to the 201314 Governors Budget, and annually thereafter, the department shall report to the Legislature on the enrollment status, quality measures, and state costs of the actions taken pursuant to this section.
(2)(A)By January 1, 2013, or as soon thereafter as practicable, the department shall develop, in consultation with CMS and stakeholders, quality and fiscal measures for health plans to reflect the short- and long-term results of the implementation of this section. The department shall also develop quality thresholds and milestones for these measures. The department shall update these measures periodically to reflect changes in this program due to implementation factors and the structure and design of the benefits and services being coordinated by managed care health plans.
(B)The department shall require health plans to submit Medicare and Medi-Cal data to determine the results of these measures. If the department finds that a health plan is not in compliance with one or more of the measures set forth in this section, the health plan shall, within 60 days, submit a corrective action plan to the department for approval. The corrective action plan shall, at a minimum, include steps that the health plan shall take to improve its performance based on the standard or standards with which the health plan is out of compliance. The plan shall establish interim benchmarks for improvement that shall be expected to be met by the health plan in order to avoid a sanction pursuant to Section 14304. Nothing in this subparagraph is intended to limit Section 14304.
(C)The department shall publish the results of these measures, including via posting on the departments Internet Web site, on a quarterly basis.
(r)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 section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance.
(s)This section shall be inoperative if the Coordinated Care Initiative becomes inoperative pursuant to Section 34 of the act that added this subdivision.
SEC. 2.The Legislature finds and declares that a special law is necessary and that a general law cannot be made applicable within the meaning of Section 16 of Article IV of the California Constitution because of the unique circumstances regarding the availability of resources for dual eligible beneficiaries in the County of San Mateo.
|
Date
|
Status
|
|---|---|
| May 28, 2015 | Referred to Com. on HEALTH. |
| Aug 13, 2015 | Chaptered by Secretary of State - Chapter 199, Statutes of 2015. |
| Aug 13, 2015 | Approved by the Governor. |
| Aug 3, 2015 | Enrolled and presented to the Governor at 3 p.m. |
| Jul 16, 2015 | Senate amendments concurred in. To Engrossing and Enrolling. (Ayes 79. Noes 0. Page 2407.). |
| Jul 16, 2015 | Senate amendments concurred in. To Engrossing and Enrolling. |
| Jul 9, 2015 | Read third time. Passed. Ordered to the Assembly. (Ayes 39. Noes 0. Page 1876.). |
| Jul 9, 2015 | Read third time. Passed. Ordered to the Assembly. |
| Jul 9, 2015 | In Assembly. Concurrence in Senate amendments pending. May be considered on or after July 11 pursuant to Assembly Rule 77. |
| Jun 23, 2015 | Read second time. Ordered to third reading. |
| Jun 22, 2015 | From committee: Be placed on second reading file pursuant to Senate Rule 28.8. |
| Jun 11, 2015 | From committee: Do pass and re-refer to Com. on APPR. (Ayes 9. Noes 0.) (June 10). Re-referred to Com. on APPR. |
| Jun 1, 2015 | From committee chair, with author's amendments: Amend, and re-refer to committee. Read second time, amended, and re-referred to Com. on HEALTH. |
| Feb 23, 2015 | Read first time. To print. |
| May 14, 2015 | Read third time. Passed. Ordered to the Senate. (Ayes 79. Noes 0. Page 1429.) |
| May 14, 2015 | Read third time. Passed. Ordered to the Senate. |
| May 14, 2015 | In Senate. Read first time. To Com. on RLS. for assignment. |
| Apr 30, 2015 | Read second time. Ordered to third reading. |
| Apr 29, 2015 | From committee: Do pass. (Ayes 17. Noes 0.) (April 29). |
| Apr 22, 2015 | Re-referred to Com. on APPR. |
| Apr 21, 2015 | Read second time and amended. |
| Apr 20, 2015 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 17. Noes 0.) (April 14). |
| Apr 7, 2015 | In committee: Hearing postponed by committee. |
| Mar 5, 2015 | Referred to Com. on HEALTH. |
| Feb 24, 2015 | From printer. May be heard in committee March 26. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Jul 16, 2015 | AB 461 MULLIN Concurrence in Senate Amendments | Assembly Floor |
Passed |
|
| Jul 9, 2015 | Assembly 3rd Reading AB461 Mullin By Hill | Senate Floor |
Passed |
|
| Jun 10, 2015 | Do pass, but first be re-referred to the Committee on [Appropriations] | Senate Standing Committee on Health |
Passed |
|
| May 14, 2015 | AB 461 MULLIN Assembly Third Reading | Assembly Floor |
Passed |
|
| Apr 29, 2015 | Do pass. | Assembly Standing Committee on Appropriations |
Passed |
|
| Apr 14, 2015 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| Association Of Regional Center Agencies | ** Support | Jul 9, 2015 |
| California Association Of Public Authorities For Ihss | ** Support | Jul 9, 2015 |
| Congress of California Seniors | ** Support | Jul 9, 2015 |
| Golden Gate Regional Center | ** Support | Jul 9, 2015 |
| Health Plan Of San Mateo | ** Support | Jul 9, 2015 |
| Local Health Plans Of California | ** Support | Jul 9, 2015 |
| Regional Center of Orange County | ** Support | Jul 9, 2015 |
| San Mateo County Board of Supervisors | ** Support | Jul 9, 2015 |
AB 461
Page 2
CONCURRENCE IN SENATE AMENDMENTS
AB 461
(Mullin)
As Amended June 1, 2015
Majority vote
ASSEMBLY: |
79-0 |
(May 14, 2015) |
SENATE: |
39-0 |
(July 9, 2015) |
Original Committee Reference: HEALTH
SUMMARY: Authorizes a beneficiary receiving services through a regional center who resides in the County of San Mateo to voluntarily enroll in the Cal MediConnect demonstration project under the Coordinated Care Initiative (CCI), as specified.
The Senate amendments clarify that a dual eligible beneficiary, or an individual who is eligible for both Medicare and Medi-Cal, who is receiving services through a regional center located in San Mateo County, is eligible to enroll in the Cal MediConnect demonstration project, even if he or she is already enrolled in a federal home- and community-based waiver.
FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.
COMMENTS: According to the author, in San Mateo County, Health Plan of San Mateo (HPSM) serves about 12,000 dual eligible beneficiaries (beneficiaries eligible for both Medicare and Medi-Cal) through its dual-eligible special needs plan (D-SNP), the vast majority of whom transitioned into the CCI this year. The author states that approximately 600 dually eligible developmentally disabled individuals remain in the D-SNP; however, HPSM may close its D-SNP due to the costly nature of running a program for such a small population, leaving this population without a health plan that would integrate and maximize Medi-Cal and Medicare benefits. The author concludes that by allowing this population to voluntarily enroll in the CCI, HPSM will be able to continue to provide them with the option of managed care.
CCI. The 2012 state budget authorized the CCI, a program intended to integrate and coordinate the delivery of health benefits, including behavioral health benefits and long-term services and supports to dual eligibles and seniors and persons with disabilities living in specified counties, including San Mateo County. The CCI includes the Cal MediConnect Program, a three-year demonstration project designed to coordinate medical, behavioral health, long-term institutional, and home- and community-based services by combining Medicare and Medi-Cal benefits into one integrated health plan. Certain dual eligible beneficiaries are not permitted to participate in Cal MediConnect, including individuals with developmental disabilities receiving services through a regional center.
HPSM. In certain counties, Medi-Cal managed care is operated by a single County Organized Health System (COHS). San Mateo County is a COHS county, and HPSM is the single plan to serve all Medi-Cal beneficiaries enrolled in managed care. As such, HPSM operates the only Cal MediConnect plan called CareAdvantage. Passive enrollment into CareAdvantage commenced in April 2014, and as of March 2015, 10,100 dual eligibles were actively enrolled in Cal MediConnect. San Mateo County has an enrollment rate of 84%, with 13% of dual eligibles opting out of Cal MediConnect, and 4% disenrolling from Cal MediConnect. The enrollment rate is significantly higher than any other CCI county.
HPSM also operates a D-SNP in which developmentally disabled individuals receiving care from a regional center are enrolled. A D-SNP is a type of Medicare Advantage plan that limits membership to people with specific diseases or characteristics, and tailors their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. D-SNPs serve dual eligibles, and similar to Cal MediConnect plans, D-SNPs combine Medicare and Medicaid benefits into one plan.
Under the CCI, D-SNPs operated by plans that also operate a Cal MediConnect plan will be phased out. In January 2015, beneficiaries enrolled in a D-SNP operated by a Cal MediConnect plan were transitioned into Cal MediConnect. Additionally, beneficiaries who are eligible for Cal MediConnect will not be able to enroll in a D-SNP after January 2015.
Support. HPSM supports this bill stating that it serves dual eligibles, 600 of which are developmentally disabled and receive care through its SNP. HPSM states that the SNP is costly and inefficient to operate for only 600 members, and it intends to close the SNP in the next year or two, potentially leaving the 600 developmentally disabled members without a consolidated health plan to maximize Medi-Cal and Medicare benefits. HPSM states that this bill will correct this problem by allowing this special needs population to voluntarily enroll in Cal MediConnect. According to HPSM, this bill also enjoys the support of the local San Mateo County disability rights community.
Golden Gate Regional Center (GGRC), the regional center serving San Mateo County, and other supporters state that persons with developmental disabilities who are enrolled in HPSM’s D-SNP should have the option to continue with HPSM through the CCI. GGRC states that the inability of these individuals to continue with HPSM through the CCI would be extremely disruptive to their care, and without the option for voluntary CCI enrollment created under this bill, the alternative for these beneficiaries will be a fragmented system between Medicare fee-for-service and Medi-Cal through HPSM.
Opposition. There is no opposition on file.
Analysis Prepared by: Kelly Green / HEALTH / (916) 319-2097 FN: 0001070
AB 461
Page 6
|
Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 |
THIRD READING
Bill No: AB 461
Amended: 6/1/15 in Senate
SENATE HEALTH COMMITTEE: 9-0, 6/10/15
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk
SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8
ASSEMBLY FLOOR: 79-0, 5/14/15 - See last page for vote
SUBJECT: Coordinated Care Initiative
SOURCE: Health Plan of San Mateo
Local Health Plans of California
DIGEST: This bill authorizes a Medi-Cal beneficiary receiving services through a regional center or who is enrolled in a Medi-Cal home- and community-based waiver who resides in San Mateo County to voluntarily enroll in the CalMediConnect demonstration project for individuals dually eligible for Medicare and Medi-Cal under the Coordinated Care Initiative.
Existing law:
Establishes, under federal law, the Medicare program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under the age of 65.
Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services, including home- and community-based services (HCBS).
Requires DHCS to seek federal approval to establish a demonstration project under a Medicare or a Medicaid demonstration project or waiver. Authorizes DHCS, under a Medicare demonstration, to contract with the federal Centers for Medicare and Medicaid Services (CMS) and demonstration sites to operate the Medicare and Medicaid benefits in a demonstration project that is overseen by the state as a delegated Medicare benefit administrator, and to enter into financing arrangements with CMS to share in any Medicare program savings generated by the demonstration project. This demonstration project is known as CalMediConnect.
Requires DHCS, after federal approval is obtained, to establish the CalMediConnect demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports (LTSS) and behavioral health services, including mental health and substance use disorder treatment services. The purpose of this demonstration project is to integrate services authorized under Medi-Cal and Medicare.
Requires DHCS to enroll dual eligible beneficiaries into a CalMediConnect demonstration site unless the beneficiary makes an affirmative choice to opt out of enrollment, with specified exceptions.
Requires DHCS to require dual eligibles to be assigned as mandatory enrollees into new or existing Medi-Cal managed care health plans for their Medi-Cal benefits in Coordinated Care Initiative (CCI) counties. CCI counties are the Counties of Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. Allows individuals to opt out of Medi-Cal managed care for the Medicare portion of their benefits.
Excludes from enrollment in the CalMediConnect demonstration project specified Medi-Cal beneficiaries, including beneficiaries:
With a prior diagnosis of end-stage renal disease, except where authorized by the DHCS director;
With other health coverage;
Enrolled in a Medi-Cal home- and community-based waiver that is a Medi-Cal benefit, beneficiaries receiving services through a regional center or state developmental center, except for persons enrolled in the Multipurpose Senior Services Program;
Residing in a geographic area or ZIP Code not included in managed care, as determined by DHCS and the CMS; and,
Residing in one of the Veterans’ Homes of California.
This bill authorizes a dually eligible Medi-Cal beneficiary who resides in San Mateo County and who is receiving services through a regional center or who is enrolled in a Medi-Cal home- and community-based waiver to voluntarily enroll in the CalMediConnect demonstration project.
Comments
Author’s statement. According to the author, AB 461 will allow dually eligible developmentally disabled individuals in San Mateo County to voluntarily enroll in the CCI. By allowing them to join CCI, Health Plan of San Mateo (HPSM) will be able to continue providing them with the option of managed care.
CCI. The CCI is a program intended to integrate and coordinate the delivery of health benefits, including behavioral health benefits and LTSS to dual eligibles and seniors and persons with disabilities (SPDs) living in seven California counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara (state law allows for CCI implementation in eight counties, but CCI will not be implemented in Alameda County). Goals for the CCI include coordinating Medi-Cal benefits and Medicare benefits across health care settings and improving continuity of acute care, long-term care, and HCBS, coordinating access to acute and long-term care services for dual eligibles, maximizing the ability of dual eligibles to remain in their homes and communities with appropriate services and supports in lieu of institutional care, and increasing the availability of and access to home- and community-based alternatives. The three major components of the CCI are as follows:
CalMediConnect Program: A three-year demonstration project designed to coordinate medical, behavioral health, long-term institutional, and HCBS services for dual eligibles by combining Medicare and Medi-Cal benefits into one integrated health plan;
Mandatory enrollment of dual eligibles and Medi-Cal-only SPDs into Medi-Cal managed care; and,
Managed Long-Term Supports and Services: Integration of nursing facility care, In-Home Supportive Services, Community-Based Adult Services, and Multipurpose Senior Services Program as managed care benefits.
Health Plan of San Mateo. In 22 counties, Medi-Cal managed care is operated by one of six County Organized Health System (COHS) plans. San Mateo County is a COHS county, and HPSM is the single plan to serve all Medi-Cal beneficiaries enrolled in managed care. HPSM operates the CalMediConnect plan, which is called CareAdvantage. Passive enrollment into CareAdvantage commenced in April 2014. HPSM indicates it has approximately 10,300 dual eligibles actively enrolled in CalMediConnect. San Mateo County has a much higher enrollment rate (84 percent) in CalMediConnect, with 13 percent of dual eligibles opting out of CalMediConnect, and four percent disenrolling. The enrollment rate is significantly higher than any other CCI county.
HPSM also operates a dual eligible-special needs plan (D-SNP) for developmentally disabled individuals receiving care from a regional center are enrolled. The D-SNP has approximately 900 members who are ineligible for its CalMediConnect Plan, of whom 600 are developmentally disabled. A D-SNP is a type of Medicare Advantage plan that limits membership to people with specific diseases or characteristics, and tailors their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. D-SNPs serve dual eligibles, and similar to CalMediConnect plans, D-SNPs combine Medicare and Medicaid benefits into one plan.
Under the CCI, D-SNPs operated by plans that also operate a CalMediConnect plan will be phased out. In January 2015, beneficiaries enrolled in a D-SNP operated by a CalMediConnect plan were transitioned into CalMediConnect. HPSM indicates it originally intended to close its D-SNP after 2015 and operate just the CCI program going forward, but because of the uncertainty surrounding CCI long-term (as mentioned in the Governor’s January Budget), it will review its decision to continue to operate a D-SNP annually.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No
Health Plan of San Mateo (co-source)
Local Health Plans of California (co-source)
Association of Regional Center Agencies
California Association of Public Authorities for IHSS
Congress of California Seniors
Golden Gate Regional Center
Regional Center of Orange County
San Mateo County Board of Supervisors
OPPOSITION: (Verified 6/19/15)
None received
ARGUMENTS IN SUPPORT: The HPSM writes that it serves 600 developmentally disabled individuals in its D-SNP, but that the D-SNP is costly and inefficient to operate for only a small number of members, and it intends to close the D-SNP in the next year or two. HPSM states this would leave the 600 developmentally disabled members without a consolidated health plan for their Medi-Cal and Medicare benefits. HPSM states that this bill will correct this problem by allowing this special needs population to voluntarily enroll in CalMediConnect.
Golden Gate Regional Center (GGRC), the regional center serving San Mateo County, argues that persons with developmental disabilities who are enrolled in HPSM’s D-SNP should have the option to continue with HPSM through the CCI. GGRC states that the inability of these individuals to continue with HPSM through the CCI would be extremely disruptive to their care, and without the option for voluntary CCI enrollment created under this bill, the alternative for these beneficiaries will be a fragmented system between fee-for-service Medicare and Medi-Cal through HPSM.
ASSEMBLY FLOOR: 79-0, 5/14/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins
NO VOTE RECORDED: Roger Hernández
Prepared by: Scott Bain / HEALTH /
6/23/15 11:41:28
**** END ****
AB 461 (Mullin) Page 5 of 5
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 461
AUTHOR: |
Mullin |
||
VERSION: |
June 1, 2015 |
||
HEARING DATE: |
June 10, 2015 |
|
|
CONSULTANT: |
Scott Bain |
||
SUBJECT: Coordinated Care Initiative.
SUMMARY:
Authorizes a Medi-Cal beneficiary receiving services through a regional center or who is enrolled in a Medi-Cal home- and community-based waiver who resides in San Mateo County to voluntarily enroll in the CalMediConnect demonstration project for individuals dually eligible for Medicare and Medi-Cal under the Coordinated Care Initiative.
Existing law:
Establishes, under federal law, the Medicare program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under the age of 65.
Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services, including home- and community-based services (HCBS).
Requires DHCS to seek federal approval to establish a demonstration project under a Medicare or a Medicaid demonstration project or waiver. Authorizes DHCS, under a Medicare demonstration, to contract with the federal Centers for Medicare and Medicaid Services (CMS) and demonstration sites to operate the Medicare and Medicaid benefits in a demonstration project that is overseen by the state as a delegated Medicare benefit administrator, and to enter into financing arrangements with CMS to share in any Medicare program savings generated by the demonstration project. This demonstration project is known as CalMediConnect.
Requires DHCS, after federal approval is obtained, to establish the CalMediConnect demonstration project that enables dual eligible beneficiaries to receive a continuum of services that maximizes access to, and coordination of, benefits between the Medi-Cal and Medicare programs and access to the continuum of long-term services and supports (LTSS) and behavioral health services, including mental health and substance use disorder treatment services. The purpose of this demonstration project is to integrate services authorized under Medi-Cal and Medicare.
Requires CalMediConnect demonstration sites to be established in up to eight counties, and to include at least one county that provides Medi-Cal services via the two-plan model of Medi-Cal managed care.
Requires DHCS to enroll dual eligible beneficiaries into a CalMediConnect demonstration site unless the beneficiary makes an affirmative choice to opt out of enrollment, with specified exceptions.
Requires DHCS to require dual eligibles to be assigned as mandatory enrollees into new or existing Medi-Cal managed care health plans for their Medi-Cal benefits in Coordinated Care Initiative (CCI) counties. CCI counties are the Counties of Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. Allows individuals to opt out of Medi-Cal managed care for the Medicare portion of their benefits.
Excludes from enrollment in the CalMediConnect demonstration project specified Medi-Cal beneficiaries, including beneficiaries:
With a prior diagnosis of end-stage renal disease, except where authorized by the DHCS director;
With other health coverage;
Enrolled in a Medi-Cal home- and community-based waiver that is a Medi-Cal benefit, beneficiaries receiving services through a regional center or state developmental center, except for persons enrolled in the Multipurpose Senior Services Program;
Residing in a geographic area or ZIP Code not included in managed care, as determined by DHCS and the federal Centers for Medicare and Medicaid Services; and,
Residing in one of the Veterans’ Homes of California.
This bill: Authorizes a dually eligible Medi-Cal beneficiary who resides in San Mateo County and who is receiving services through a regional center or who is enrolled in a Medi-Cal home- and community-based waiver to voluntarily enroll in the CalMediConnect demonstration project.
FISCAL EFFECT:
According to the Assembly Appropriations Committee, this bill has a negligible fiscal effect, given that the impacted individuals currently incur costs as Medi-Cal beneficiaries, and allowing them to enroll in a different delivery system should not increase costs for their care.
PRIOR VOTES:
Assembly Floor: |
79 - 0 |
Assembly Appropriations Committee: |
17 - 0 |
Assembly Health Committee: |
17 - 0 |
COMMENTS:
Author’s statement. According to the author, AB 461 will allow dually eligible developmentally disabled individuals in San Mateo County to voluntarily enroll in the Coordinated Care Initiative. By allowing them to join CCI, Health Plan of San Mateo (HPSM) will be able to continue providing them with the option of managed care.
CCI. The CCI is a program intended to integrate and coordinate the delivery of health benefits, including behavioral health benefits and LTSS to dual eligibles and seniors and persons with disabilities (SPDs) living in seven California counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara (state law allows for CCI implementation in eight counties, but CCI will not be implemented in Alameda County). Goals for the CCI include coordinating Medi-Cal benefits and Medicare benefits across health care settings and improving continuity of acute care, long-term care, and HCBS, coordinating access to acute and long-term care services for dual eligibles, maximizing the ability of dual eligibles to remain in their homes and communities with appropriate services and supports in lieu of institutional care, and increasing the availability of and access to home- and community-based alternatives. The three major components of the CCI are as follows:
CalMediConnect Program: A three-year demonstration project designed to coordinate medical, behavioral health, long-term institutional, and HCBS services for dual eligibles by combining Medicare and Medi-Cal benefits into one integrated health plan;
Mandatory enrollment of dual eligibles and Medi-Cal-only seniors and persons with disabilities into Medi-Cal managed care; and,
Managed Long-Term Supports and Services (MLTSS): Integration of nursing facility care, In-Home Supportive Services, Community-Based Adult Services, and Multipurpose Senior Services Program as managed care benefits.
Health Plan of San Mateo. In twenty-two counties, Medi-Cal managed care is operated by one of six County Organized Health System (COHS) plans. San Mateo County is a COHS county, and HPSM is the single plan to serve all Medi-Cal beneficiaries enrolled in managed care. HPSM operates the CalMediConnect plan, which is called CareAdvantage. Passive enrollment into CareAdvantage commenced in April 2014. HPSM indicates it has approximately 10,300 dual eligibles actively enrolled in CalMediConnect. San Mateo County has a much higher enrollment rate (84 percent) in CalMediConnect, with 13 percent of dual eligibles opting out of CalMediConnect, and 4 percent disenrolling. The enrollment rate is significantly higher than any other CCI county.
HPSM also operates a D-SNP for developmentally disabled individuals receiving care from a regional center are enrolled. The D-SNP has approximately 900 members who are ineligible for its CalMediConnect Plan, of whom 600 are developmentally disabled. A D-SNP is a type of Medicare Advantage plan that limits membership to people with specific diseases or characteristics, and tailors their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. D-SNPs serve dual eligibles, and similar to CalMediConnect plans, D-SNPs combine Medicare and Medicaid benefits into one plan.
Under the CCI, D-SNPs operated by plans that also operate a CalMediConnect plan will be phased out. In January 2015, beneficiaries enrolled in a D-SNP operated by a CalMediConnect plan were transitioned into CalMediConnect. HPSM indicates it originally intended to close its D-SNP after 2015 and operate just the CCI program going forward, but because of the uncertainty surrounding CCI long-term (as mentioned in the Governor’s January Budget), it will review its decision to continue to operate a D-SNP annually.
Related legislation. SB 492 (Liu) would enact the "Coordinated Care Initiative
Consumer and Patient Educational and Informational Guide," which requires DHCS to develop and post on its Internet Web site an educational and informational guide for consumers and patients about the CCI. SB 492 is pending hearing in Assembly Health Committee.
Prior legislation.
SB 857 (Committee on Budget and Fiscal Review, Chapter 31, Statutes of 2014), institutes various requirements regarding contracts and enrollment limitations on D-SNP plans in the context of the CCI.
SB 1008 (Committee on Budget and Fiscal Review, Chapter 33, Statutes of 2012), establishes the main components of the CCI, including the provisions for the CalMediConnect Program, mandatory Medi-Cal managed care for SPDs, and MLTSS.
SB 1036 (Committee on Budget and Fiscal Review, Chapter 45, Statutes of 2012), authorizes other components of the CCI, includes provisions that require the development and pilot implementation of a universal assessment tool as well as data-sharing agreements between managed care plans and HCBS administrators.
SB 208 (Steinberg, Chapter 714, Statutes of 2010), authorizes a pilot project in up to four counties, to integrate the full range of Medicare and Medi-Cal services, including LTSS and behavioral health services for dual eligible individuals.
Support. The HPSM writes as a co-sponsor that it serves 600 developmentally disabled individuals in its D-SNP, but that the D-SNP is costly and inefficient to operate for only a small number of members, and it intends to close the D-SNP in the next year or two. HPSM states this would leave the 600 developmentally disabled members without a consolidated health plan for their Medi-Cal and Medicare benefits. HPSM states that this bill will correct this problem by allowing this special needs population to voluntarily enroll in CalMediConnect.
Golden Gate Regional Center (GGRC), the regional center serving San Mateo County, argues that persons with developmental disabilities who are enrolled in HPSM’s D-SNP should have the option to continue with HPSM through the CCI. GGRC states that the inability of these individuals to continue with HPSM through the CCI would be extremely disruptive to their care, and without the option for voluntary CCI enrollment created under this bill, the alternative for these beneficiaries will be a fragmented system between fee-for-service Medicare and Medi-Cal through HPSM.
Concerns. The California Advocates for Nursing Home Reform (CANHR) states that, while HPSM is seen as a model managed care plan with regard to the CCI, plans in other counties are struggling to provide coordinated care and have a large number of problems that seriously harm enrollees. As such, CANHR states that the CCI is currently in jeopardy of being terminated because of failure to meet projected savings, and if the transition of regional center clients in San Mateo is successful, other counties and plans may push to expand voluntary enrollment of this population in other counties as a way to meet savings goals and keep the CCI afloat. Further, CANHR states that if the CCI fails, this new vulnerable population will have their continuity of care interrupted along with thousands of other beneficiaries enrolled, surrogate decision-makers will face challenges. CANHR concludes that regional center clients have surrogate decision-makers, many of whom will run into roadblocks when they want to assist beneficiaries to disenroll from a plan or change doctors within the plan.
Requested amendment. The Regional Center of Orange County (RCOC) writes requesting an amendment to allow residents with developmental disabilities in Orange County to voluntary participate in the CCI. RCOC writes that the OneCare Program (a D-SNP) in Orange County is scheduled to be retired, and not all of the consumers enrolled in it will quality for the new OneCare CalMediConnect program that will replace it. RCOC argues that including Orange County residents in this bill will give these consumers the option to voluntarily join OneCare CalMediConnect when the current OneCare program ends.
SUPPORT AND OPPOSITION:
Support: Health Plan of San Mateo (co-sponsor)
Local Health Plans of California (co-sponsor)
Association of Regional Center Agencies
California Association of Public Authorities for IHSS
Congress of California Seniors
Golden Gate Regional Center
Regional Center of Orange County
San Mateo County Board of Supervisors
Oppose: None received
-- END --
AB 461
Page 2
ASSEMBLY THIRD READING
AB 461
(Mullin)
As Amended April 21, 2015
Majority vote
Committee |
Votes |
Ayes |
Noes |
Health |
17-0 |
Bonta, Maienschein, Bonilla, Burke, Chávez, Chiu, Gomez, Gonzalez, Lackey, Nazarian, Patterson, Ridley-Thomas, Rodriguez, Santiago, Thurmond, Waldron, Wood |
|
Appropriations |
17-0 |
Gomez, Bigelow, Bloom, Bonta, Calderon, Chang, Daly, Eggman, Gallagher, Eduardo Garcia, Holden, Jones, Quirk, Rendon, Wagner, Weber, Wood |
|
SUMMARY: Authorizes a beneficiary receiving services through a regional center who resides in the County of San Mateo to voluntarily enroll in the Cal MediConnect demonstration project under the Coordinated Care Initiative (CCI), as specified.
FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill has a negligible fiscal effect, given that the impacted individuals currently incur costs as Medi-Cal beneficiaries, and allowing them to enroll in a different delivery system should not increase costs for their care.
COMMENTS: According to the author, in San Mateo County, Health Plan of San Mateo (HPSM) serves about 12,000 dual eligible beneficiaries (beneficiaries eligible for both Medicare and Medi-Cal) through its dual-eligible special needs plan (D-SNP), the vast majority of whom transitioned into the CCI this year. The author states that approximately 600 dually eligible developmentally disabled individuals remain in the D-SNP; however, HPSM may close its D-SNP due to the costly nature of running a program for such a small population, leaving this population without a health plan that would integrate and maximize Medi-Cal and Medicare benefits. The author concludes that by allowing this population to voluntarily enroll in the CCI, HPSM will be able to continue to provide them with the option of managed care.
CCI. The 2012 state budget authorized the CCI, a program intended to integrate and coordinate the delivery of health benefits, including behavioral health benefits and long-term services and supports to dual eligibles and seniors and persons with disabilities living in specified counties, including San Mateo County. The CCI includes the Cal MediConnect Program, a three-year demonstration project designed to coordinate medical, behavioral health, long-term institutional, and home- and community-based services by combining Medicare and Medi-Cal benefits into one integrated health plan. Certain dual eligible beneficiaries are not permitted to participate in Cal MediConnect, including individuals with developmental disabilities receiving services through a regional center.
HPSM. In certain counties, Medi-Cal managed care is operated by a single County Organized Health System (COHS). San Mateo County is a COHS county, and HPSM is the single plan to serve all Medi-Cal beneficiaries enrolled in managed care. As such, HPSM operates the only Cal MediConnect plan called CareAdvantage. Passive enrollment into CareAdvantage commenced in April 2014, and as of March 2015, 10,100 dual eligibles were actively enrolled in Cal MediConnect. San Mateo County has an enrollment rate of 84%, with 13% of dual eligibles opting out of Cal MediConnect, and 4% disenrolling from Cal MediConnect. The enrollment rate is significantly higher than any other CCI county.
HPSM also operates a D-SNP in which developmentally disabled individuals receiving care from a regional center are enrolled. A D-SNP is a type of Medicare Advantage plan that limits membership to people with specific diseases or characteristics, and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. D-SNPs serve dual eligibles, and similar to Cal MediConnect plans, D-SNPs combine Medicare and Medicaid benefits into one plan.
Under the CCI, D-SNPs operated by plans that also operate a Cal MediConnect plan will be phased out. In January 2015, beneficiaries enrolled in a D-SNP operated by a Cal MediConnect plan were transitioned into Cal MediConnect. Additionally, beneficiaries who are eligible for Cal MediConnect will not be able to enroll in a D-SNP after January 2015.
SUPPORT. HPSM supports this bill stating that it serves dual eligibles, 600 of which are developmentally disabled and receive care through its SNP. HPSM states that the SNP is costly and inefficient to operate for only 600 members, and it intends to close the SNP in the next year or two, potentially leaving the 600 developmentally disabled members without a consolidated health plan to maximize Medi-Cal and Medicare benefits. HPSM states that this bill will correct this problem by allowing this special needs population to voluntarily enroll in Cal MediConnect. According to HPSM, this bill also enjoys the support of the local San Mateo County disability rights community.
Golden Gate Regional Center (GGRC), the regional center serving San Mateo County, and other supporters state that persons with developmental disabilities who are enrolled in HPSM’s D-SNP should have the option to continue with HPSM through the CCI. GGRC states that the inability of these individuals to continue with HPSM through the CCI would be extremely disruptive to their care, and without the option for voluntary CCI enrollment created under this bill, the alternative for these beneficiaries will be a fragmented system between Medicare FFS and Medi-Cal through HPSM.
OPPISITION. There is no opposition on file.
Analysis Prepared by: Kelly Green / HEALTH / (916) 319-2097 FN: 0000223
AB 461
Page 2
Date of Hearing: April 29, 2015
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Jimmy Gomez, Chair
AB 461
(Mullin) – As Amended April 21, 2015
Policy Committee: |
Health |
Vote: |
17 - 0 |
|
|
|
|
|
|
|
|
Urgency: No State Mandated Local Program: No Reimbursable: No
SUMMARY:
This bill authorizes Medi-Cal beneficiaries receiving services through a regional center, and who reside in the County of San Mateo, to voluntarily enroll in the Cal MediConnect demonstration project under the Coordinated Care Initiative (CCI) (a demonstration project that is providing coordinated Medicare and Medi-Cal benefits in certain counties).
FISCAL EFFECT:
Negligible fiscal effect. The impacted individuals are already Medi-Cal-eligible and costs are already being incurred, but current law does not allow them to enroll in the CCI. This bill will allow them to enroll in a different delivery system, but it should not increase costs for their care.
COMMENTS:
Purpose. According to the author, in San Mateo County, Health Plan of San Mateo (HPSM) served about 12,000 dual eligible beneficiaries through a dual eligible-special needs plan (or D-SNP, a plan that coordinates benefits for individuals dually enrolled in Medicare and Medi-Cal). The vast majority of D-SNP enrollees transitioned into the the HPSM Cal MediConnect plan this year. The author states that approximately 600 dually eligible developmentally disabled individuals remain in the D-SNP; however, HPSM may close its D-SNP due to the costly nature of running a program for such a small population. By allowing this population to voluntarily enroll in the CCI, HPSM will be able to continue to provide these individuals with the option of managed care.
Background. Cal MediConnect is a Medi-Cal initiative intended to integrate and coordinate the delivery of health benefits, including behavioral health benefits and long-term care, to dual eligibles and SPDs living in seven California counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. Cal MediConnect plans are paid a monthly capitated rate for each enrollee, and are responsible for providing a package of Medicare and Medi-Cal services in exchange for that rate. Certain vulnerable populations were excluded from the enrollment in the CCI and Cal MediConnect, including individuals with developmental disabilities receiving services through a regional center.
Related Legislation. SB 492 (Liu), pending in the Senate Health Committee, establishes the CCI Consumer Bill of Rights.
Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081
AB 461
Page 6
Date of Hearing: April 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 461
(Mullin) – As Introduced February 23, 2015
SUBJECT: Coordinated Care Initiative.
SUMMARY: Authorizes a beneficiary receiving services through a regional center who resides in the County of San Mateo to voluntarily enroll in the Cal MediConnect demonstration project under the Coordinated Care Initiative (CCI), upon receipt of all legal notifications required under state and federal law, and makes findings and declarations that a special law is necessary because of the unique circumstances regarding the availability of resources for dual eligible beneficiaries in the County of San Mateo.
EXISTING LAW:
Establishes, under federal law, the Medicare program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under the age of 65.
Establishes the Medi-Cal program, under which qualified low-income individuals receive health care services, including home and community-based services (HCBS).
Establishes, in eight counties throughout the state, the CCI which is designed to integrate, as managed care plan benefits, medical care and long-term services and supports (LTSS) for individuals dually eligible for Medicare and Medi-Cal (dual eligibles) and seniors and persons with disabilities (SPDs) enrolled in Medi-Cal only.
Requires, under the CCI, the Department of Health Care Services (DHCS) to seek federal approval to establish a demonstration project that integrates services between Medicare and Medi-Cal, and enables dual eligibles to receive a continuum of services that maximizes access to, and coordination of, benefits between the programs. This demonstration project is referred to as the Cal Medi-Connect program.
Establishes goals for the demonstration project, including coordination of access to acute and long-term services for dual eligibles, maximizing the ability of dual eligibles to remain in their homes and communities, improve the quality of care for dual eligibles, and promoting a system that is sustainable and person- and family-centered by providing dual eligibles with timely access to appropriate, coordinated health care services and community resources.
Requires DHCS, no sooner than March 1, 2013, to establish demonstration sites in up to eight counties, and to enter into a memorandum of understanding (MOU) with the federal Centers for Medicare and Medicaid Services (CMS) which addresses specified requirements for demonstration sites, including having Medi-Cal managed care health plan and Medicare dual eligible-special needs plan (D-SNP) contract experience, or evidence of the ability to meet these contracting requirements.
Requires DHCS to enroll dual eligible beneficiaries into a demonstration site, unless the beneficiary makes an affirmative choice to opt out of enrollment. This process is referred to as passive enrollment. Provides that dual eligible beneficiaries who opt out of enrollment may choose to remain enrolled in Medicare fee-for-service (FFS) or a Medicare Advantage plan for their Medicare benefits, but shall be mandatorily enrolled into a Medi-Cal managed care health plan for Medi-Cal benefits.
Exempts specified beneficiary populations from enrollment in the demonstration project, including beneficiaries with a prior diagnosis of end-stage renal disease; beneficiaries already enrolled in a Medi-Cal home and community-based waiver program; and, beneficiaries who receive services through a regional center or state developmental center.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
PURPOSE OF THIS BILL. According to the author, in San Mateo County, Health Plan of San Mateo (HPSM) serves about 12,000 dual eligible beneficiaries through its D-SNP, the vast majority of whom transitioned into the CCI this year. The author states that approximately 600 dually eligible developmentally disabled individuals remain in the D-SNP; however, HPSM may close its D-SNP due to the costly nature of running a program for such a small population, leaving this population without a health plan that would integrate and maximize Medi-Cal and Medicare benefits. The author concludes that by allowing this population to voluntarily enroll in the CCI, HPSM will be able to continue to provide them with the option of managed care.
BACKGROUND.
CCI. The 2012 state budget authorized the CCI with the goal of promoting the coordination of health, behavioral health and social services for certain Medi-Cal beneficiaries. The CCI is a program intended to integrate and coordinate the delivery of health benefits, including behavioral health benefits and LTSS to dual eligibles and SPDs living in seven California counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. (While current statute allows for CCI implementation in eight counties, Alameda County, which had been selected as a CCI demonstration site, will no longer move forward with CCI implementation.) The goals of the CCI are to improve quality of care for beneficiaries; maximize the ability of beneficiaries to remain safely in their homes and communities; coordinate Medi-Cal and Medicare benefits and improve continuity of care across settings, and promote a person- and family-centered system by which beneficiaries attain or maintain personal health goals through timely access to coordinated health care services and community resources.
There are three major components to the CCI:
Cal MediConnect Program: A three-year demonstration project designed to coordinate medical, behavioral health, long-term institutional, and HCBS services by combining Medicare and Medi-Cal benefits into one integrated health plan.
Mandatory enrollment of dual eligibles and Medi-Cal-only SPDs into Medi-Cal managed care.
Managed Long-Term Supports and Services (MLTSS): Integration of nursing facility care, In-Home Supportive Services, Community-Based Adult Services, and Multipurpose Senior Services Program as managed care benefits.
Cal Medi-Connect. The state received federal approval of the Cal MediConnect program through an MOU entered into between DHCS and CMS in March 2013. Cal MediConnect plans meeting all required selection criteria entered into three-way contracts with DHCS and CMS, which outline the plan’s responsibilities under the Cal MediConnect program. Cal MediConnect plans are paid a monthly capitated rate for each individual enrollee, and are responsible for providing a package of Medicare and Medi-Cal services in exchange for that rate. Cal MediConnect plans provide Medicare and Medi-Cal services using a network of contracted providers from which enrollees may receive services.
A dual eligible may opt out of enrollment in CalMediConnect. However, through passive enrollment, if a dual eligible does not opt out, and does not affirmatively choose a particular Cal MediConnect plan, the dual eligible will be enrolled into a plan by DHCS. Additionally, a dual eligible who has enrolled in Cal MediConnect may change plans or disenroll at any time.
If a dual eligible opts out or disenrolls from Cal MediConnect, he or she will receive Medicare benefits through Medicare FFS or a Medicare Advantage plan, and will not be passively enrolled again for the remainder of the life of the demonstration. A dual eligible who opts out of Cal MediConnect must still enroll in a Medi-Cal managed care plan for Medi-Cal benefits.
Dual eligibles who enroll in a Cal MediConnect plan are eventually required to receive all covered services from physicians and other providers who are a part of the plan’s network. However, pursuant to existing law, as well as the MOU entered into between DHCS and CMS, Cal MediConnect enrollees are entitled to specified rights regarding continuity of care that allow them to temporarily continue to see existing providers outside of the Cal MediConnect network.
Certain dual eligible beneficiaries are not permitted to participate in Cal MediConnect. These include beneficiaries with End Stage Renal Disease, beneficiaries already enrolled in an Medi-Cal HCBS waiver program, beneficiaries residing in certain geographic areas and zip codes not included in managed care, and individuals with developmental disabilities receiving services through a regional center.
HPSM. In certain counties, Medi-Cal managed care is operated by a single County Organized Health System (COHS). In COHS counties, a single plan serves all Medi-Cal beneficiaries who are enrolled in managed care.
San Mateo County is a COHS county, and HPSM is the single plan to serve all Medi-Cal beneficiaries enrolled in managed care. As such, HPSM operates the only Cal MediConnect plan called CareAdvantage. Passive enrollment into CareAdvantage commenced in April 2014, and as of March 2015, 10,100 dual eligibles were actively enrolled in Cal MediConnect. San Mateo County has an enrollment rate of 84%, with 13% of dual eligibles opting out of Cal MediConnect, and 4% disenrolling from Cal MediConnect. The enrollment rate is significantly higher than any other CCI county.
SNPs and the CCI. Medicare SNPs are a type of Medicare Advantage Plan which limit membership to people with specific diseases or characteristics, and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. D-SNPs serve dual eligibles, and similar to Cal MediConnect plans, D-SNPs combine Medicare and Medicaid benefits into one plan.
In CCI counties, D-SNPs that are operated by a plan that also operates a CalMediConnect plan will be phased out. In January 2015, beneficiaries enrolled in a D-SNP operated by a Cal MediConnect plan were transitioned into Cal MediConnect. Additionally, beneficiaries who are eligible for Cal MediConnect will not be able to enroll in a D-SNP after January 2015.
Like other beneficiaries eligible for Cal MediConnect, D-SNP enrollees receive 90-, 60-, and 30-day Cal MediConnect notices as well as guide book and choice book to provide them with information about Cal MediConnect plans in their respective county.
Under this bill, the developmentally disabled persons receiving care from a regional center who are currently enrolled in HPSM’s D-SNP are required to receive notices of their option to enroll in HPSM’s Cal MediConnect plan. Additionally, according to HPSM, its Cal MediConnect plan and its D-SNP use the same provider network providing for continuity of care as the beneficiaries transition into the Cal MediConnect plan. According to HPSM, it will work with DHCS and CMS on notice requirements and timeframes for voluntary enrollment, and its CareAdvantage D-SNP will remain available throughout 2016.
SUPPORT. HPSM supports this bill stating that it serves dual eligibles, 600 of which are developmentally disabled and receive care through its SNP. HPSM states that the SNP is costly and inefficient to operate for only 600 members, and it intends to close the SNP in the next year or two, potentially leaving the 600 developmentally disabled members without a consolidated health plan to maximize Medi-Cal and Medicare benefits. HPSM states that this bill will correct this problem by allowing this special needs population to voluntarily enroll in Cal MediConnect. According to HPSM, this bill also enjoys the support of the local San Mateo County disability rights community.
Golden Gate Regional Center (GGRC), the regional center serving San Mateo County, supports this bill stating that the persons with developmental disabilities who are enrolled in HPSM’s Medicare SNP should have the option to continue with HPSM through the CCI. GGRC states that the inability of these individuals to continue with HPSM through the CCI would be extremely disruptive to their care, and without the option for voluntary CCI enrollment created under this bill, the alternative for these beneficiaries will be a fragmented system between Medicare FFS and Medi-Cal through HPSM.
STATEMENT OF CONCERN. The California Advocates for Nursing Home Reform (CANHR) states that, while HPSM is seen as a model managed care plan with regard to the CCI, plans in other counties are struggling to provide coordinated care and have a large number of problems that seriously harm enrollees. As such, CANHR states that the CCI is currently in jeopardy of being terminated because of failure to meet projected savings, and if the transition of regional center clients in San Mateo is successful, other counties and plans may push to expand voluntary enrollment of this population in other counties as a way to meet savings goals and keep the CCI afloat. Further, CANHR states that if the CCI fails, this new vulnerable population will have their continuity of care interrupted along with thousands of other beneficiaries enrolled, surrogate decision-makers will face challenges. CANHR concludes that regional center clients have surrogate decision-makers, many of whom will run into roadblocks when they want to assist beneficiaries to disenroll from a plan or change doctors within the plan.
RELATED LEGISLATION. SB 492 (Liu) establishes the CCI Consumer Bill of Rights, which sets fort rights regarding self-direction, quality, flexibility, accessibility of services, and others. SB 492 is pending hearing in Senate Health Committee.
PREVIOUS LEGISLATION.
SB 857 (Committee on Budget and Fiscal Review), Chapter 31, Statutes of 2014, institutes various requirements regarding contracts and enrollment limitations on D-SNP plans in the context of the CCI.
SB 1008 (Committee on Budget and Fiscal Review), Chapter 33, Statutes of 2012, establishes the main components of the CCI, including the provisions for the Cal MediConnect Program, mandatory Medi-Cal managed care for SPDs, and MLTSS.
SB 1036 (Committee on Budget and Fiscal Review), Chapter 45, Statutes of 2012, legislation authorizing other components of the CCI, includes provisions that require the development and pilot implementation of a universal assessment tool as well as data-sharing agreements between managed care plans and HCBS administrators.
SB 208 (Steinberg), Chapter 714, Statutes of 2010, authorized a pilot project in up to four counties, to integrate the full range of Medicare and Medi-Cal services, including LTSS and behavioral health services for dual eligible individuals.
POLICY COMMENT. Under this bill, developmentally disabled persons being served by a regional center will be able to voluntarily enroll in Cal MediConnect. According to the author, voluntary enrollment under this bill is not intended to be passive enrollment. However, the passive enrollment process could be interpreted by some as voluntary given that a beneficiary may opt-out or disenroll. Further, according to some fact sheets published by DHCS, enrollment in Cal Medi-Connect is referred to as "optional." As such, to ensure that the author's intent is met, the committee may wish to amend the bill to clarify that the enrollment under this bill shall not be conducted pursuant to passive enrollment, but rather via a process by which the targeted population may opt-in.
REGISTERED SUPPORT / OPPOSITION:
Support
Association of Regional Center Agencies
California Association of Public Authorities for IHSS
County of San Mateo Board of Supervisors
Golden Gate Regional Center
Health Plan of San Mateo
Local Health Plans of California
Opposition
None on file.
Analysis Prepared by: Kelly Green / HEALTH / (916) 319-2097
Bill Author
