Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions. Existing law provides for a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for seniors and persons with disabilities and maximization of opportunities to reduce the number of uninsured individuals.

This bill would authorize the Director of Health Care Services, if the State Department of Health Care Services has not received adequate assurances from the federal Centers for Medicare and Medicaid Services before November 1, 2015, that the departments application for a subsequent demonstration project, as specified, is likely to be approved with an effective date of November 1, 2015, to request one or more temporary extensions until the approved effective date of the subsequent demonstration project. The bill would require the department, under an approved temporary extension, subsequent demonstration project, or as otherwise permitted under existing federal Medicaid law, to extend and apply existing payment methodologies and allocations, as prescribed. Requirements of the bill would be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not jeopardized. The bill would authorize the department, until July 1, 2016, to implement, interpret, or make specific these provisions by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking regulatory action.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions. Existing law provides for a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for seniors and persons with disabilities and maximization of opportunities to reduce the number of uninsured individuals.

This bill would authorize the Director of Health Care Services, if the State Department of Health Care Services has not received adequate assurances from the federal Centers for Medicare and Medicaid Services before November 1, 2015, that the departments application for a subsequent demonstration project, as specified, is likely to be approved with an effective date of November 1, 2015, to request one or more temporary extensions until the approved effective date of the subsequent demonstration project. The bill would require the department, under an approved temporary extension, subsequent demonstration project, or as otherwise permitted under existing federal Medicaid law, to extend and apply existing payment methodologies and allocations, as prescribed. Requirements of the bill would be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not jeopardized. The bill would authorize the department, until July 1, 2016, to implement, interpret, or make specific these provisions by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking regulatory action.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions. Existing law provides for a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for seniors and persons with disabilities and maximization of opportunities to reduce the number of uninsured individuals.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income persons receive health care benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid provisions. Existing law provides for a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for seniors and persons with disabilities and maximization of opportunities to reduce the number of uninsured individuals.

This bill would require the State Department of Health Care Services to submit an application to the federal Centers for Medicare and Medicaid Services for a waiver to implement a demonstration project that, among other things, continues the states momentum and successes in innovation achieved under the demonstration project described above. The bill would require the department to consult with interested stakeholders and the Legislature in developing the waiver application.

This bill would declare that it is to take effect immediately as an urgency statute.

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 36

PURSUANT TO SENATE RULE 29.10

SUBJECT: Medi-Cal: demonstration project.

SUMMARY:

This bill authorizes the Department of Health Care Services (DHCS) to request one or more temporary waiver extensions to continue the operation of, and the authorities provided under, the current "California Bridge to Reform Demonstration," the state’s Section 1115 Medicaid waiver. Requires DHCS to extend and apply the existing hospital payment methodologies and allocations on a state fiscal year, annual, partial year, or other basis, to the extent permitted under any approved temporary waiver extension, an approved subsequent waiver, or as otherwise permitted under federal Medicaid law.

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS and under which qualified low-income persons receive health care benefits.

2. Establishes a Medicaid Section 1115 demonstration project under the Medi-Cal program until October 31, 2015 known as California’s Bridge to Reform, to implement specified objectives, including better care coordination for Seniors and Persons with Disabilities (SPDs) and maximization of opportunities to reduce the number of uninsured individuals.

3. Provides for payments under the Bridge to Reform under the “Medi-Cal Hospital/Uninsured Care Demonstration Project Act” to designated public hospitals (DPHs are the approximately 20 UC and county hospitals), and for federal disproportionate share (DSH), payments to private hospitals (referred to as “DSH replacement payments”) and non-designated public hospitals (NDPHs are district hospitals) through October 1, 2015. These provisions:

1. Make DPHs eligible for cost-based fee-for-service Medicaid funding using certified public expenditures (CPEs) as the federal match, instead of state General Fund. DPHs put up the nonfederal share of Medi-Cal fee-for-service payments used to draw down federal Medicaid matching funds, and receive cost-based reimbursement, using CPEs to draw down federal Medicaid matching funds;

2. Provide DSH payments to DPHs, using CPEs and intergovernmental transfers (IGTs) to draw down federal DHS funds;

3. Provide DSH payments to eligible non-designated public hospitals (NDPH are primarily district hospitals) meeting DSH eligibility criteria, using state General Fund to draw down federal DSH funds;

4. Provide for “DSH replacement payments” to private hospitals meeting DSH eligibility criteria, using non-DSH Medicaid funds and state General Fund as the fund source;

5. Make DPHs eligible for payments from the federally funded Safety Net Care Pool (SNCP) for uncompensated care; and,

6. Make DPHs eligible for payments from the federally funded delivery system reform incentive pool (DSRIP), based on the DPH’s progress toward and achievement of milestones and metrics established in its DSRIP proposal, funded by federal funds and IGTs.

This bill:

1. Permits the director of DHCS to request one or more temporary waiver extensions, as necessary to continue the operation of, and the authorities provided under, the current "California Bridge to Reform Demonstration" waiver until the approved effective date of the next waiver, if DHCS has not received adequate assurances from the federal Centers for Medicare and Medicaid Services (CMS) before November 1, 2015, that DHCS’s application for a subsequent waiver is likely to be approved with an effective date of November 1, 2015.

2. Requires DHCS, after consulting with the affected DPHs, to extend and apply the payment methodologies and allocations in the existing “Medi-Cal Hospital/Uninsured Care Demonstration Project Act” that are in effect under the current waiver, on a state fiscal year, annual, partial year, or other basis.

3. Requires the extension and application of the current payment methodologies and allocations to be consistent with any applicable implementing provisions of the Medi-Cal state plan and requirements imposed by CMS.

4. Implements the provisions in 2) and 3) above to the extent permitted under the terms of any approved temporary waiver extension obtained by DHCS, an approved subsequent waiver, or as otherwise permitted under federal Medicaid law.

5. Permits DHCS to make payments on an interim basis, subject to reconciliation to amounts payable under the payment and allocation methodologies in any approved temporary extension obtained by DHCS under this bill, or under an approved subsequent waiver.

6. Implements this bill only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not jeopardized.

7. Requires, until July 1, 2016, in the event of a conflict between the terms of any federally approved waiver extension obtained by DHCS and the provisions of the “Medi-Cal Hospital/Uninsured Care Demonstration Project Act,” the terms of the federally approved temporary extension to control. Requires DHCS to provide notice of the conflict to the appropriate policy and fiscal committees of the Legislature.

8. Permits DHCS to implement, interpret, or make specific this bill by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking regulatory action until July 1, 2016.

9. Would take effect immediately as an urgency statute.

FISCAL EFFECT:

This current version of the bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, According to the author, this bill is needed because the current Section 1115 Medicaid waiver known as California Bridge to Reform Waiver (Waiver) expires on October 31, 2015, but an agreement on a subsequent waiver have not been agreed to by the state and the federal government, and an agreement appears unlikely to be reached before the Legislature adjourns on September 11, 2015 so that state law could be amended to incorporate the new waiver-related funding provisions. This two-part bill would bridge the gap between the current waiver and the new waiver by allowing DHCS to request one or more temporary waiver extensions, and by requiring DHCS to extend and apply the current hospital payment methodologies and allocations in effect under the current waiver on a state fiscal year, annual, partial year, or other basis, to the extent allowed by the federal government. The extension of the current hospital financing methodologies would continue to provide essential funding for safety net providers in the event of a delay in completion of the next waiver and until state hospital financing law is amended to determine the new DSH and waiver-related funding provisions for private hospitals, NDPHs and DPHs resulting from the next federal Section 1115 Medicaid waiver.

2. Bridge to Reform Waiver. California’s existing Section 1115 “California Bridge to Reform Demonstration” Waiver is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers. California is currently in the fourth year of this waiver, which began November 1, 2010 and expires October 31, 2015. Under the current waiver, California is required to submit an extension request no later than six months prior to the expiration date of the current demonstration. California also operates its Medi-Cal managed care delivery system under this federal waiver. The Bridge to Reform Waiver enabled California to:

1. Implement an early expansion of Medicaid to low-income adults without minor children under ACA through the Low Income Health Program, which enrolled 650,000 individuals;

2. Require the mandatory enrollment of SPDs into Medi-Cal managed care plans in specified counties;

3. Provide federal funding for delivery system reform and uncompensated care in designated public hospital systems (21 county and University of California hospitals) through the DSRIP and SNCP;

4. Provided federal funding for designated state health care programs and workforce development programs related to medically disadvantaged service areas;

5. Operate its Medi-Cal managed care program, Community-Based Adult Services program, and seven county Coordinated Care Initiative (under the Initiative, individuals dually eligible for Medicare and Medi-Cal receive their Medi-Cal and Medicare benefits through one health plan)..

3. Support. The California Association of Public Hospitals and Health Systems (CAPH) writes in support that there is a chance wavier negotiations could extend beyond October 31, 2015 when the “Bridge to Reform” waiver expires. CAPH argues, in the event of a delay, it is critical for the state to maintain existing expenditure authority in order to ensure that funds can continue to flow to public safety net providers. CAPH states this bill includes two important provisions to allow for continuity during these negotiations. These provisions grant DHCS the authority to extend the existing waiver and make waiver expenditures in the case of a delay, as many other states have experienced delays in renewing their waivers due to the time it can take the federal government to complete a Section 1115 waiver negotiation. In addition, this bill requires the continuation of existing hospital funding distribution methodologies in the event of a delay. While waivers make certain payment streams available, state law specifies how those funds must be distributed amongst providers. As such, if there are any delays in renewing the waiver, there would be no new guidance for how to distribute DSH and SNCP payments to public and private hospitals, and SNCP payments to public hospitals. This bill requires the continued distribution of DSH and SNCP payments according to current methodologies in the event of a delay, which is important to hospitals as the total federal funding for these programs in the current waiver year is $1.2 billion in federal DSH funds and $236 million in federal SNCP funds.

SUPPORT AND OPPOSITION:

Support: Association of California Health Care Districts

California Association of Public Hospitals and Health Systems

California Hospital Association

California State Association of Counties

District Hospital Leadership Forum

Oppose: None received.

-- END --

 UNFINISHED BUSINESS  

Bill No: SB 36

Author: Hernandez (D) and De León (D), et al.

Amended: 9/4/15

Vote: 27 - Urgency

SENATE HEALTH COMMITTEE: 9-0, 4/8/15

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

SENATE APPROPRIATIONS COMMITTEE: 7-0, 4/20/15

AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

SENATE HEALTH COMMITTEE: 9-0, 9/11/15 (pursuant to Senate Rule 29.10)

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

SENATE FLOOR: 35-0, 4/27/15

AYES: Allen, Anderson, Bates, Beall, Berryhill, Block, Cannella, De León, Fuller, Gaines, Galgiani, Hall, Hancock, Hernandez, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Morrell, Nguyen, Nielsen, Pan, Roth, Runner, Stone, Wieckowski, Wolk

NO VOTE RECORDED: Hertzberg, Moorlach, Pavley, Vidak

ASSEMBLY FLOOR: Not available

SUBJECT: Medi-Cal: demonstration project

SOURCE: Author

DIGEST: This bill authorizes the Department of Health Care Services (DHCS) to request one or more temporary waiver extensions to continue the operation of, and the authorities provided under, the current "California Bridge to Reform Demonstration," the state’s Section 1115 Medicaid waiver. This bill requires DHCS to extend and apply the existing hospital payment methodologies and allocations on a state fiscal year, annual, partial year, or other basis, to the extent permitted under any approved temporary waiver extension, an approved subsequent waiver, or as otherwise permitted under federal Medicaid law.

Assembly Amendments delete the Senate-approved dealing with a new Section 1115 Medicaid waiver, with the exception of the urgency clause, and instead insert the provisions described in the summary above.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS and under which qualified low-income persons receive health care benefits.
   
   

2. Establishes a Medicaid Section 1115 demonstration project under the Medi-Cal program until October 31, 2015 known as California’s Bridge to Reform, to implement specified objectives, including better care coordination for Seniors and Persons with Disabilities (SPDs) and maximization of opportunities to reduce the number of uninsured individuals.
   
   

3. Provides for payments under the Bridge to Reform under the “Medi-Cal Hospital/Uninsured Care Demonstration Project Act” to designated public hospitals (DPHs are the approximately 20 University of California and county hospitals), and for federal disproportionate share (DSH), payments to private hospitals (referred to as “DSH replacement payments”) and non-designated public hospitals (NDPHs are district hospitals) through October 1, 2015. These provisions:
   
   

   1. Make DPHs eligible for cost-based fee-for-service Medicaid funding using certified public expenditures (CPEs) as the federal match, instead of state General Fund. DPHs put up the nonfederal share of Medi-Cal fee-for-service payments used to draw down federal Medicaid matching funds, and receive cost-based reimbursement, using CPEs to draw down federal Medicaid matching funds;

   2. Provide DSH payments to DPHs, using CPEs and intergovernmental transfers (IGTs) to draw down federal DHS funds;

   3. Provide DSH payments to eligible non-designated public hospitals (NDPHs are primarily district hospitals) meeting DSH eligibility criteria, using state General Fund to draw down federal DSH funds;

   4. Provide for “DSH replacement payments” to private hospitals meeting DSH eligibility criteria, using non-DSH Medicaid funds and state General Fund as the fund source;

   5. Make DPHs eligible for payments from the federally funded Safety Net Care Pool (SNCP) for uncompensated care; and,

   6. Make DPHs eligible for payments from the federally funded delivery system reform incentive pool (DSRIP), based on the DPH’s progress toward and achievement of milestones and metrics established in its DSRIP proposal, funded by federal funds and IGTs.

This bill:

1. Permits the director of DHCS to request one or more temporary waiver extensions, as necessary to continue the operation of, and the authorities provided under, the current "California Bridge to Reform Demonstration" waiver until the approved effective date of the next waiver, if DHCS has not received adequate assurances from the federal Centers for Medicare and Medicaid Services (CMS) before November 1, 2015, that DHCS’s application for a subsequent waiver is likely to be approved with an effective date of November 1, 2015.

2. Requires DHCS, after consulting with the affected DPHs, to extend and apply the payment methodologies and allocations in the existing “Medi-Cal Hospital/Uninsured Care Demonstration Project Act” that are in effect under the current waiver, on a state fiscal year, annual, partial year, or other basis.

3. Requires the extension and application of the current payment methodologies and allocations to be consistent with any applicable implementing provisions of the Medi-Cal state plan and requirements imposed by CMS.

4. Implements the provisions in 2) and 3) above to the extent permitted under the terms of any approved temporary waiver extension obtained by DHCS, an approved subsequent waiver, or as otherwise permitted under federal Medicaid law.

5. Permits DHCS to make payments on an interim basis, subject to reconciliation to amounts payable under the payment and allocation methodologies in any approved temporary extension obtained by DHCS under this bill, or under an approved subsequent waiver.

6. Implements this bill only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not jeopardized.

7. Requires, until July 1, 2016, in the event of a conflict between the terms of any federally approved waiver extension obtained by DHCS and the provisions of the “Medi-Cal Hospital/Uninsured Care Demonstration Project Act,” the terms of the federally approved temporary extension to control. Requires DHCS to provide notice of the conflict to the appropriate policy and fiscal committees of the Legislature.

8. Permits DHCS to implement, interpret, or make specific this bill by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking regulatory action until July 1, 2016.

9. Takes effect immediately as an urgency statute.

Comments

1. Author’s statement. According to the author, this bill is needed because the current Section 1115 Medicaid waiver known as California Bridge to Reform Waiver expires on October 31, 2015, but an agreement on a subsequent waiver have not been agreed to by the state and the federal government, and an agreement appears unlikely to be reached before the Legislature adjourns on September 11, 2015 so that state law could be amended to incorporate the new waiver-related funding provisions. This two-part bill will bridge the gap between the current waiver and the new waiver by allowing DHCS to request one or more temporary waiver extensions, and by requiring DHCS to extend and apply the current hospital payment methodologies and allocations in effect under the current waiver on a state fiscal year, annual, partial year, or other basis, to the extent allowed by the federal government. The extension of the current hospital financing methodologies would continue to provide essential funding for safety net providers in the event of a delay in completion of the next waiver and until state hospital financing law is amended to determine the new DSH and waiver-related funding provisions for private hospitals, NDPHs and DPHs resulting from the next federal Section 1115 Medicaid waiver.

2. Bridge to Reform Waiver. California’s existing Section 1115 “California Bridge to Reform Demonstration” Waiver is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers. California is currently in the fourth year of this waiver, which began November 1, 2010 and expires October 31, 2015. Under the current waiver, California is required to submit an extension request no later than six months prior to the expiration date of the current demonstration. California also operates its Medi-Cal managed care delivery system under this federal waiver. The Bridge to Reform Waiver enabled California to:
   
   

   1. Implement an early expansion of Medicaid to low-income adults without minor children under the Patient Protection and Affordable Care Act through the Low Income Health Program, which enrolled 650,000 individuals;
      
      

   2. Require the mandatory enrollment of SPDs into Medi-Cal managed care plans in specified counties;
      
      

   3. Provide federal funding for delivery system reform and uncompensated care in DPH systems (21 county and University of California hospitals) through the DSRIP and SNCP;
      
      

   4. Provided federal funding for designated state health care programs and workforce development programs related to medically disadvantaged service areas;
      
      

   5. Operate its Medi-Cal managed care program, Community-Based Adult Services program, and seven county Coordinated Care Initiative (under the Initiative, individuals dually eligible for Medicare and Medi-Cal receive their Medi-Cal and Medicare benefits through one health plan).

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

Unknown with latest amendments.

SUPPORT: (Verified 9/8/15)

Association of California Health Care Districts
California Association of Public Hospitals and Health Systems
California Hospital Association
California State Association of Counties
District Hospital Leadership Forum

OPPOSITION: (Verified 9/8/15)

None received

ARGUMENTS IN SUPPORT: The California Association of Public Hospitals and Health Systems (CAPH) writes in support that there is a chance wavier negotiations could extend beyond October 31, 2015 when the “Bridge to Reform” waiver expires. CAPH argues, in the event of a delay, it is critical for the state to maintain existing expenditure authority in order to ensure that funds can continue to flow to public safety net providers. CAPH states this bill includes two important provisions to allow for continuity during these negotiations. These provisions grant DHCS the authority to extend the existing waiver and make waiver expenditures in the case of a delay, as many other states have experienced delays in renewing their waivers due to the time it can take the federal government to complete a Section 1115 waiver negotiation. In addition, this bill requires the continuation of existing hospital funding distribution methodologies in the event of a delay. While waivers make certain payment streams available, state law specifies how those funds must be distributed amongst providers. As such, if there are any delays in renewing the waiver, there would be no new guidance for how to distribute DSH and SNCP payments to public and private hospitals, and SNCP payments to public hospitals. This bill requires the continued distribution of DSH and SNCP payments according to current methodologies in the event of a delay, which is important to hospitals as the total federal funding for these programs in the current waiver year is $1.2 billion in federal DSH funds and $236 million in federal SNCP funds.

Prepared by: Scott Bain / HEALTH /

9/11/15 19:32:06

**** END ****

SENATE THIRD READING

STR Bill Id:SB 36

Author:(Hernandez and De León)

As Amended Ver:September 4, 2015

2/3 vote. Urgency

SENATE VOTE: Vote not relevant

SUMMARY: Authorizes the Department of Health Care Services (DHCS) to request one or more temporary waiver extensions to continue the operation of, and the authorities provided under, the current "California Bridge to Reform Demonstration," the state's Section 1115 Medicaid waiver which is set to expire on October 31, 2015. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect upon enactment. Specifically, this bill:

1. Requires DHCS to extend and apply the existing hospital payment methodologies and allocations on a state fiscal year, annual, partial year, or other basis, to the extent permitted under any approved temporary waiver extension, an approved subsequent waiver, or as otherwise permitted under federal Medicaid law.

2. Conditions the provisions of this bill on DHCS obtaining any necessary federal approvals and continuing eligibility to obtain federal matching funds.

EXISTING LAW:

1. Establishes the Medi-Cal program to provide comprehensive health benefits to low-income persons.

2. Establishes a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for Seniors and Persons with Disabilities (SPDs) and increased opportunities to reduce the number uninsured.

FISCAL EFFECT: This bill, as amended, has not been analyzed by a fiscal committee.

COMMENTS:

1. Purpose. According to the author, this bill bridges the gap between the current Medicaid Section 1115 waiver which expires October 31, 2015, and the new waiver by allowing DHCS to request one or more temporary waiver extensions, and by requiring DHCS to extend the current hospital payment methodologies. The author states a new waiver agreement has not been reached between the state and federal government and is unlikely to be reached before the Legislature adjourns on September 11, 2015. An extension of the current hospital financing methodologies would continue to provide essential funding for safety net hospitals in the event of a delay in completion of the next waiver.

2. Federal Section 1115 Waiver and Expenditure Authority. Medicaid (Medi-Cal in California) is a joint federal-state program to provide health coverage to low-income individuals. Section 1115 of the federal Social Security Act gives the Secretary of the Department of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs. This includes certain federal Medicaid requirements in any experimental pilot or demonstration project which, in the judgment of the HHS Secretary, is likely to assist in promoting the objectives of Medicaid. In addition, Section 1115 also allows states to use federal Medicaid funds to reimburse for costs in ways that are not otherwise allowed under federal Medicaid law.

3. Bridge to Reform Waiver. California's existing Section 1115 waiver, commonly called "the California Bridge to Reform Demonstration," is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers.

California is currently in the fourth year of this waiver, which began November 1, 2010. Under the current waiver, California is required to submit an extension request no later than six months prior to the expiration date of the current demonstration. California also operates its Medi-Cal managed care delivery system under this federal waiver.

4. Support. According to the California Association of Public Hospitals (CAPH), in the event of a delay in negotiating a new waiver, it is critical for the state to maintain existing expenditure authority, in order to ensure that funds can continue to flow to public safety net providers. CAPH argues this bill includes two important provisions to allow for continuity during these negotiations. The Association of California Healthcare Districts argues in support because the waiver extension will build on the priorities of the association, which include access to care, workforce development, expanding the use of telehealth and improving mental health and substance use disorder treatment.

5. Opposition. There is no known opposition on file.

Analysis Prepared by: Roger Dunstan / HEALTH / (916) 319-2097 FN: 0002342

Date of Hearing: September 9, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

SBPCA Bill Id:SB 36

Author:(Hernandez) – As Amended Ver:September 4, 2015

SENATE VOTE: Not relevant

SUBJECT: Medi-Cal: demonstration project.

SUMMARY: Authorizes the Department of Health Care Services (DHCS) to request one or more temporary waiver extensions to continue the operation of, and the authorities provided under, the current "California Bridge to Reform Demonstration," the state’s Section 1115 Medicaid waiver which is set to expire on October 31, 2015. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect upon enactment. Specifically, this bill:

1. Requires DHCS to extend and apply the existing hospital payment methodologies and allocations on a state fiscal year, annual, partial year, or other basis, to the extent permitted under any approved temporary waiver extension, an approved subsequent waiver, or as otherwise permitted under federal Medicaid law.

2. Conditions the provisions of this bill on DHCS obtaining any necessary federal approvals and continuing eligibility to obtain federal matching funds.

EXISTING LAW:

1. Establishes the Medi-Cal program to provide comprehensive health benefits to low-income persons.

2. Establishes a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for Seniors and Persons with Disabilities (SPDs) and maximization of opportunities to reduce the number of uninsured individuals.

FISCAL EFFECT: This bill, as amended, has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill bridges the gap between the current Medicaid Section 1115 waiver which expires October 31, 2015 and the new waiver by allowing DHCS to request one or more temporary waiver extensions, and by requiring DHCS to extend the current hospital payment methodologies. The author states a new waiver agreement has not been reached between the state and federal government and is unlikely to be reached before the Legislature adjourns on September 11, 2015. An extension of the current hospital financing methodologies would continue to provide essential funding for safety net hospitals in the event of a delay in completion of the next waiver and until state hospital financing law is amended to determine the new waiver-related hospital funding provisions resulting from the next federal Section 1115 Medicaid waiver.

2. BACKGROUND.
   
   
   

   1. Federal Section 1115 Waiver and Expenditure Authority. Medicaid (Medi-Cal in California) is a joint federal-state program to provide health coverage to low-income individuals. Section 1115 of the federal Social Security Act gives the Secretary of the Department of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs. This includes certain federal Medicaid requirements in any experimental pilot or demonstration project which, in the judgment of the HHS Secretary, is likely to assist in promoting the objectives of Medicaid. In addition, Section 1115 also allows states to use federal Medicaid funds to reimburse for costs in ways that are not otherwise allowed under federal Medicaid law. This is referred to as expenditure authority for costs not otherwise matchable.
      
      Section 1115 waivers are approved at the discretion of the Secretary of HHS through negotiations between a state and the federal Centers for Medicare and Medicaid Services (CMS). Section 1115 waivers are generally approved for a five-year period and then must be renewed. Although not required by statute or regulation, longstanding federal administrative policy has required waivers to be budget neutral for the federal government, meaning that federal spending under a waiver must not be more than projected federal spending in the state without the waiver.

2. Bridge to Reform Waiver. California’s existing Section 1115 waiver, commonly called “the California Bridge to Reform Demonstration,” is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers.
   
   California is currently in the fourth year of this waiver, which began November 1, 2010. Under the current waiver, California is required to submit an extension request no later than six months prior to the expiration date of the current demonstration. California also operates its Medi-Cal managed care (MCMC) delivery system under this federal waiver. The current Bridge to Reform waiver enabled California to:

   1. Implement an early expansion of Medicaid to low-income adults without minor children under the Patient Protection and Affordable Care Act through the Low Income Health Program, which enrolled 650,000 individuals;

   2. Require the mandatory enrollment of SPDs into MCMC plans in specified counties;

   3. Provide federal funding for delivery system reform and uncompensated care in designated public hospital systems (21 county and University of California hospitals) through Delivery System Reform Incentive Payments Program and Safety Net Care Pool Uncompensated Care (SNCP);

   4. Provide federal funding for designated state health care programs and workforce development programs related to medically disadvantaged service areas; and,

   5. Operate its MCMC program, Community-Based Adult Services (CBAS) program, and seven county Coordinated Care Initiative (under the Coordinated Care Initiative), individuals dually eligible for Medicare and Medi-Cal receive their Medi-Cal and Medicare benefits through one health plan).
      
      

1. RELATED LEGISLATION. AB 72 (Bonta) requires DHCS to submit an application to CMS for a waiver of federal Medicaid requirements to implement a demonstration project. This bill was subsequently amended to a different subject.

2. SUPPORT. According to the California Association of Public Hospitals (CAPH), in the event of a delay in negotiating a new waiver, it is critical for the state to maintain existing expenditure authority, in order to ensure that funds can continue to flow to public safety net providers. CAPH argues this bill includes two important provisions to allow for continuity during these negotiations. The Association of California Healthcare Districts argues in support because the waiver extension will build on the priorities of the association, which include access to care, workforce development, expanding the use of telehealth and improving mental health and substance use disorder treatment.

REGISTERED SUPPORT / OPPOSITION:

Support

Association of California Healthcare Districts

California Association of Public Hospitals

Opposition

None on file.

Analysis Prepared by: Roger Dunstan / HEALTH / (916) 319-2097

SENATE THIRD READING

STR Bill Id:SB 36

Author:(Hernandez and De León)

As Introduced Ver:December 1, 2014

2/3 vote. Urgency

SENATE VOTE: 35-0

SUMMARY: Requires the Department of Health Care Services (DHCS) to submit an application to the federal Centers for Medicare and Medicaid Services (CMS) for a waiver of federal Medicaid requirements to implement a demonstration project. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect upon enactment.

EXISTING LAW:

1. Establishes the Medi-Cal program to provide comprehensive health benefits to low-income persons.

2. Establishes a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for seniors and persons with disabilities and maximization of opportunities to reduce the number of uninsured individuals.

FISCAL EFFECT: According to the Assembly Appropriations committee, this bill in its current form does not result in additional state costs. DHCS is currently incurring staff and in-kind costs for development of a "Section 1115 Waiver," so called for the section of federal law that provides CMS broad authority to waive provisions of federal Medicaid law to seek improved outcomes. Private foundations have committed about $650,000, and about $250,000 in federal matching funds are likely available for these purposes. Foundations are also funding additional consulting work related to waiver development.

If this bill is amended to include specific waiver provisions, such provisions are likely to have significant fiscal effects.

COMMENTS: According to the author, Section 1115 Medicaid waiver renewal is critical to the long–term fiscal sustainability of the Medi-Cal program and to California's ability to continue to provide high quality health care to Medi-Cal beneficiaries. The goals of the waiver are to continue to support Patient Protection and Affordable Care Act implementation, improve the health care outcomes of the over 12 million individuals enrolled in Medi-Cal, and provide long-term fiscal stability of the Medi-Cal program through delivery system transformation.

Specific strategies anticipated to be included in the waiver renewal include a federal-state shared savings initiative; housing and supportive services for vulnerable populations; various health plan and provider delivery system transformation and alignment incentive programs, including a new Delivery System Reform Incentive Program at designated public hospitals and non–designated public hospitals; workforce development strategies to expand provider access and, capacity; and safety net payment and delivery system transformation.

Federal Section 1115 Waiver and Expenditure Authority. Medicaid (Medi-Cal in California) is a joint federal-state program to provide health coverage to low-income individuals. Section 1115 of the federal Social Security Act gives the Secretary of the Department of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs. This includes certain federal Medicaid requirements in any experimental pilot or demonstration project which, in the judgment of the HHS Secretary, is likely to assist in promoting the objectives of Medicaid. In addition, Section 1115 also allows states to use federal Medicaid funds to reimburse for costs in ways that are not otherwise allowed under federal Medicaid law.

Bridge to Reform Waiver. California’s existing Section 1115 waiver, commonly called "the California Bridge to Reform Demonstration" is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers. California is currently in the fourth year of this waiver, which began November 1, 2010, and expires October 31, 2015.

Support. The California Association of Physician Groups (CAPG) supports this bill as a measure that encourages the implementation of the Triple Aim which includes decreased cost, improved patient experience and development of population health management. CAPG writes the new "Medi-Cal 2020" waiver seeks approximately $17 billion in federal investment to further the achievements California has made in health care reform. The California State Association of Counties supports this bill because DHCS’ Medi-Cal 2020 waiver renewal addresses the counties’ priorities, and introduces a new concept transforming California’s public safety net for the remaining uninsured by creating a global payment system.

There is no known opposition to this bill.

Analysis Prepared by: Roger Dunstan / HEALTH / (916) 319-2097 FN: 0001443

Date of Hearing: August 19, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

SBPCA Bill Id:SB 36

Author:(Hernandez) – As Introduced Ver:December 1, 2014

Urgency: Yes State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the Department of Health Care Services (DHCS) to submit an application to the federal Centers for Medicare and Medicaid Services (CMS) for a waiver to implement a specified demonstration project related to the Medi-Cal program. It also requires DHCS to consult with stakeholders. The bill is vague as to the requirements of the waiver.

FISCAL EFFECT:

This bill in its current form does not result in additional state costs.

DHCS is currently incurring staff and in-kind costs for development of a "Section 1115 Waiver," so called for the section of federal law that provides CMS broad authority to waive provisions of federal Medicaid law to seek improved outcomes. Private foundations have committed about $650,000, and about $250,000 in federal matching funds are likely available for these purposes. Foundations are also funding additional consulting work related to waiver development.

If the bill is amended to include specific waiver provisions, such provisions are likely to have significant fiscal effects.

COMMENTS:

1. Purpose. According to the author, this bill is one of two legislative vehicles to make statutory changes necessary to implement a new Section 1115 Medicaid waiver, and contains important Legislative notification and stakeholder consultation requirements. The waiver renewal is critical to the long-term fiscal sustainability of the Medi-Cal program and to California’s ability to continue to provide high quality health care to Medi-Cal beneficiaries. Specific strategies anticipated for inclusion are: a federal-state shared savings initiative; housing and supportive services for vulnerable populations; health plan and provider delivery system transformation and alignment incentive programs, including a new Delivery System Reform Incentive Payment (DSRIP) program at designated public hospitals and non–designated public hospitals; workforce development strategies to expand provider access and capacity; and safety net payment and delivery system transformation.

2. Background. Section 1115 of the Social Security Act gives the federal Secretary of Health and Human Services authority to waive certain federal rules in order to allow states to expand eligibility, improve services, enhance delivery systems, and receive federal reimbursement for activities that are normally not eligible for reimbursement. Authority for the current 1115 waiver, titled "A Bridge to Reform," expires October 31, 2015. This waiver included a number of initiatives to prepare the state for implementation of the federal Affordable Care Act, including mandatory enrollment of additional Medi-Cal populations into managed care, early expansion of Medi-Cal at local option called the Low-Income Health Program (LIHP), a DSRIP program that provided over $3 billion in federal matching funds for quality improvement at public hospitals, and federal matching funds for certain state health programs that were otherwise ineligible for matching funds. The new waiver, titled "Medi-Cal 2020" is currently under development. After months of stakeholder input, DHCS submitted a concept paper to CMS on March 27, 2015. Discussions with federal authorities are ongoing.

3. Related Legislation. AB 72 (Bonta) is nearly identical to this bill. AB 72 is pending in the Senate Appropriations Committee.

AB 1432 (Bonta), in a previous version, required DHCS to submit a waiver application specific to substance use and co-occurring disorders. It was amended to a different subject area.

4. Prior Legislation. Prior legislation has implemented components of the 2010 Bridge to Reform Waiver, including the following:

1. AB 342 (John A. Pérez), Chapter 723, Statutes of 2010 enacted the LIHP.

2. SB 208 (Steinberg), Chapter 714, Statutes of 2010, implemented provisions related to the DSRIP program for public hospital quality improvement, mandatory enrollment in managed care, and authorized pilot projects to test new approaches to the California Childrens' Services (CCS) program.

3. AB 1066 (John A. Pérez), Chapter 86, Statutes of 2011, enacted funding provisions for public hospitals.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: July 14, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

SBPCA Bill Id:SB 36

Author:(Ed Hernandez and De León) – As Introduced Ver:December 1, 2014

SENATE VOTE: 35-0

SUBJECT: Medi-Cal: demonstration project.

SUMMARY: Requires the Department of Health Care Services (DHCS) to submit an application to the federal Centers for Medicare and Medicaid Services (CMS) for a waiver of federal Medicaid requirements to implement a demonstration project. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect upon enactment. Specifically, this bill:

1. Requires that the demonstration project to do all of the following:
   
   

1. Further the delivery of high-quality and cost-efficient care for Medi-Cal beneficiaries;
   
   

2. Ensure the long-term viability of the delivery system following the expansion of Medi-Cal eligibility under the federal Patient Protection and Affordable Care Act (ACA); and,
   
   

3. Continue California’s momentum and successes in innovation achieved under the 2010 waiver.

2. Requires DHCS to consult with interested stakeholders and the Legislature in developing the waiver application.

EXISTING LAW:

1. Establishes the Medi-Cal program to provide comprehensive health benefits to low-income persons.

2. Establishes a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for Seniors and Persons with Disabilities (SPDs) and maximization of opportunities to reduce the number of uninsured individuals.

FISCAL EFFECT: According to the Senate Appropriations Committee, no new administrative costs to DHCS are anticipated due to this bill. DHCS is currently in the process of developing a waiver application and has been engaged in planning and stakeholder discussions which will continue into 2015-16. Because DHCS is already undertaking these efforts, this bill will not impose new administrative duties on DHCS.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill is one of two legislative vehicles to make the necessary statutory changes to implement a new Section 1115 Medicaid waiver as the 2010 California Bridge to Reform Waiver expires on October 31, 2015. The waiver renewal is critical to the long–term fiscal sustainability of the Medi-Cal program and to California’s ability to continue to provide high quality health care to Medi-Cal beneficiaries. The goals of the waiver are to continue to support ACA implementation, improve the health care quality and outcomes of the over 12 million individuals enrolled in Medi-Cal, and provide for the long-term fiscal stability of the Medi-Cal program through delivery system transformation.
   
   Specific strategies anticipated to be included in the waiver renewal include a federal-state shared savings initiative; housing and supportive services for vulnerable populations; various health plan and provider delivery system transformation and alignment incentive programs, including a new Delivery System Reform Incentive Program (DSRIP) at designated public hospitals and non–designated public hospitals; workforce development strategies to expand provider access and, capacity; and safety net payment and delivery system transformation.

2. BACKGROUND.
   
   
   

1. Federal Section 1115 Waiver and Expenditure Authority. Medicaid (Medi-Cal in California) is a joint federal-state program to provide health coverage to low-income individuals. Section 1115 of the federal Social Security Act gives the Secretary of the Department of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs. This includes certain federal Medicaid requirements in any experimental pilot or demonstration project which, in the judgment of the HHS Secretary, is likely to assist in promoting the objectives of Medicaid. In addition, Section 1115 also allows states to use federal Medicaid funds to reimburse for costs in ways that are not otherwise allowed under federal Medicaid law. This is referred to as expenditure authority for costs not otherwise matchable.
   
   Section 1115 waivers are approved at the discretion of the Secretary of HHS through negotiations between a state and CMS. Section 1115 waivers are generally approved for a five-year period and then must be renewed. Although not required by statute or regulation, longstanding federal administrative policy has required waivers to be budget neutral for the federal government, meaning that federal spending under a waiver must not be more than projected federal spending in the state without the waiver.

2. Bridge to Reform Waiver. California’s existing Section 1115 waiver, commonly called “the California Bridge to Reform Demonstration” is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers.
   
   California is currently in the fourth year of this waiver, which began November 1, 2010 and expires October 31, 2015. Under the current waiver, California is required to submit an extension request no later than six months prior to the expiration date of the current demonstration. California also operates its Medi-Cal managed care (MCMC) delivery system under this federal waiver. The current Bridge to Reform waiver enabled California to:
   
   

   1. Implement an early expansion of Medicaid to low-income adults without minor children under the ACA through the Low Income Health Program (LIHP), which enrolled 650,000 individuals;

   2. Require the mandatory enrollment of SPDs into MCMC plans in specified counties;

   3. Provide federal funding for delivery system reform and uncompensated care in designated public hospital systems (21 county and University of California hospitals) through DSRIP and Safety Net Care Pool Uncompensated Care (SNCP);

   4. Provide federal funding for designated state health care programs and workforce development programs related to medically disadvantaged service areas; and,

   5. Operate its MCMC program, Community-Based Adult Services (CBAS) program, and seven county Coordinated Care Initiative (under the Coordinated Care Initiative (CCI), individuals dually eligible for Medicare and Medi-Cal receive their Medi-Cal and Medicare benefits through one health plan).

3. What Provisions of federal law are “Waived” in the Current Waiver? In the current Bridge to Reform waiver, the federal government waived specified federal Medicaid provisions. Major provisions waived include the following:
   
   

   1. The “freedom of choice” requirement to enable California to require participants to receive benefits through certain providers and to permit the state to require that Medi-Cal beneficiaries receive benefits through managed care plans, who could not otherwise be required to enroll in managed care;

   2. The “statewideness” requirement to enable California to operate the demonstration and implement coverage for new Medi-Cal eligibles on a county-by-county basis, and to provide managed care plans only in certain geographic areas; and,

3. The “amount, duration, and scope of services and comparability” requirement to enable California to offer a different benefit package to Medi-Cal beneficiaries in the SPD program that includes benefits that are not available to all categorically needy individuals.

4. DHCS Waiver Submission. On March 27, 2014, following several months of waiver-related stakeholder meetings, DHCS submitted an application to renew the state’s section 1115 waiver demonstration entitled “Medi-Cal 2020: Key Concepts for Renewal.” DHCS identified five core goals in that document, as follows:

1. Improve health care quality and outcomes for the Medi-Cal population;
   
   

2. Strengthen primary care delivery and access;
   
   

3. Build a foundation for an integrated health care delivery system that incentivizes quality and efficiency;
   
   

4. Address social determinants of health and improve health care equity; and,
   
   

5. Use California’s sophisticated Medicaid program as an incubator to test innovative approaches to whole-person care.

DHCS indicates the focus of the waiver renewal will be on continuing to drive the transformation of its Medi-Cal program, ensuring ongoing support for the safety net in California, and ensuring the long-term viability of the program and the Medicaid expansion. Existing 1115 waiver authorities and programs that would continue under the next waiver include the CCI, the CBAS waiver, managed care program, Indian Health Services uncompensated care, Designated State Health Programs, the pending Drug Medi-Cal Organized Delivery System program, and the provision of full scope benefits for pregnant women with incomes between 109% to 138% of the federal poverty level (FPL).

In addition to the continuation of existing waiver programs, DHCS will pursue a set of six, cross-cutting approaches that together will advance delivery system transformation in California as part of Medi-Cal waiver renewal. In support of California’s efforts to transform the delivery system, DHCS seeks to test a new investment strategy in partnership with the federal government by initiating a federal-state shared savings model. California’s shared savings initiative would involve a reinvestment of Federal funding in recognition of the savings that California’s Section 1115 demonstration initiatives generate to the benefit of both the state and the federal government.

This reinvestment would provide the state with a portion of the federal savings that are generated through the demonstration to facilitate and augment continued Medi-Cal delivery system transformation. Under this initiative, California would be required to demonstrate that the federal savings generated under the waiver are substantial enough to permit California to retain a portion or percentage of that savings. The state would need to demonstrate that, even after reinvestment in the waiver strategies, the federal government will continue to realize savings. If the waiver strategies implemented through Medi-Cal 2020 do not result in the level of federal savings that is projected, California would be required to limit the spending on waiver reinvestment initiatives to ensure overall savings and budget neutrality.

3. SUPPORT. The California Association of Physician Groups (CAPG) writes that it supports policy measures that encourage the implementation of the Triple Aim which include decreased cost, improved patient experience and development of population health management. CAPG writes the new “Medi-Cal 2020” waiver seeks approximately $17 billion in federal investment to further the achievements California has made in health care reform that a set of payment and delivery system transformation strategies. CAPH states it continues to support and participate in the waiver renewal stakeholder process.

The California State Association of Counties (CSAC) supports this bill because DHCS’ Medi-Cal 2020 waiver renewal addresses the counties’ priorities, and introduces a new concept transforming California’s public safety net for the remaining uninsured by creating a global payment system. CSAC states the global payments offer a unique opportunity for California to serve as an incubator in testing new payment methods for delivering care to the uninsured and in transforming care away from high-cost settings (such as emergency rooms) towards primary care. CSAC argues these individual payments would allow each hospital system more certainty about its budget and how much in federal funds will be available.

4. RELATED LEGISLATION. AB 72 (Bonta) is similar to this bill and is scheduled to be heard in the Senate Health Committee on July 14, 2015.

REGISTERED SUPPORT / OPPOSITION:

Support

Association of California Health Care Districts

California Association of Physician Groups

California Association of Public Hospitals and Health Systems

California Commission on Aging

California Primary Care Association

California State Association of Counties

California State Council of the Service Employees International Union

Community Clinic Association of Los Angeles County

District Hospital Leadership Forum

MidPen Housing Coalition

Planned Parenthood Affiliates of California

The Arc and United Cerebral Palsy California Collaboration

University of California

Opposition

None on file.

Analysis Prepared by: Roger Dunstan / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 36

Author: Hernandez (D) and De León (D)

Introduced: 12/1/14

Vote: 27 - Urgency

SENATE HEALTH COMMITTEE: 9-0, 4/8/15

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

SENATE APPROPRIATIONS COMMITTEE: 7-0, 4/20/15

AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

SUBJECT: Medi-Cal: demonstration project

SOURCE: Author

DIGEST: This bill requires the Department of Health Care Services (DHCS) to submit an application to the federal Centers for Medicare and Medicaid Services (CMS) for a waiver to implement a demonstration project that furthers the delivery of high-quality and cost-efficient care for Medi-Cal beneficiaries, ensures the long-term viability of the delivery system following the expansion of Medi-Cal eligibility under the federal Patient Protection and Affordable Care Act (ACA), and continues California’s momentum and successes in innovation achieved under the 2010 “Bridge to Reform” Waiver.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS and under which qualified low-income persons receive health care benefits.
   
   

2. Establishes a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for Seniors and Persons with Disabilities (SPDs) and maximization of opportunities to reduce the number of uninsured individuals.
   
   

This bill:

1. Requires DHCS to submit an application to CMS for a waiver to implement a demonstration project that does all of the following:
   
   

   1. Furthers the delivery of high-quality and cost-efficient care for Medi-Cal beneficiaries;

   2. Ensures the long-term viability of the delivery system following the expansion of Medi-Cal eligibility under ACA; and,

   3. Continues California’s momentum and successes in innovation achieved under the 2010 “Bridge to Reform” Waiver.

2. Requires DHCS to consult with interested stakeholders and the Legislature in developing the waiver application.

3. Contains an urgency clause that will make this bill effective upon enactment.

Comments

1. Author’s statement. According to the author, this bill is one of two legislative vehicles to make the necessary statutory changes to implement a new Section 1115 Medicaid waiver as the 2010 California Bridge to Reform Waiver (Waiver) expires on October 31, 2015. The Waiver renewal is critical to the long–term fiscal sustainability of the Medi–Cal program and to California’s ability to continue to provide high quality health care to Medi-Cal beneficiaries. The goals of the Waiver are to continue to support ACA implementation, improve the health care quality and outcomes of the over 12 million individuals enrolled in Medi-Cal, and provide for the long–term fiscal stability of the Medi-Cal program through delivery system transformation. Specific strategies anticipated to be included in the waiver renewal include a federal-state shared savings initiative; housing and supportive services for vulnerable populations; various health plan and provider delivery system transformation and alignment incentive programs, including a new Delivery System Reform Incentive Program (DSRIP) at designated public hospitals and non–designated public hospitals; workforce development strategies to expand provider access and capacity; and safety net payment and delivery system transformation.

2. Federal Section 1115 Waiver and Expenditure Authority. Medicaid (known as Medi-Cal in California) is a joint federal-state program to provide health coverage to low-income individuals. Section 1115 of the federal Social Security Act (Act) gives the Secretary of the Department of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs authorized under the Act. This includes certain federal Medicaid requirements in any experimental pilot or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives of Medicaid. In addition, Section 1115 also allows states to use federal Medicaid funds to reimburse for costs in ways that are not otherwise allowed under federal Medicaid law. This is referred to as expenditure authority for “costs not otherwise matchable” or CNOM.
   
   Section 1115 waivers are approved at the discretion of the Secretary of HHS through negotiations between a state and CMS for projects that the Secretary determines promote Medicaid program objectives. Section 1115 waivers are generally approved for a five-year period and then must be renewed. Although not required by statute or regulation, longstanding federal administrative policy has required waivers to be “budget neutral” for the federal government, meaning that federal spending under a waiver must not be more than projected federal spending in the state without the waiver.
   
   

3. Bridge to Reform Waiver. California’s existing Section 1115 “California Bridge to Reform Demonstration” Waiver is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers. California is currently in the fourth year of this waiver, which began November 1, 2010 and expires October 31, 2015. Under the current waiver, California is required to submit an extension request no later than six months prior to the expiration date of the current demonstration. California also operates its Medi-Cal managed care delivery system under this federal waiver. The Bridge to Reform Waiver enabled California to:
   
   

1. Implement an early expansion of Medicaid to low-income adults without minor children under ACA through the Low Income Health Program, which enrolled 650,000 individuals;
   
   

2. Require the mandatory enrollment of SPDs into Medi-Cal managed care plans in specified counties;
   
   

3. Provide federal funding for delivery system reform and uncompensated care in designated public hospital systems (21 county and University of California hospitals) through the DSRIP and Safety Net Care Pool Uncompensated Care;
   
   

4. Provided federal funding for designated state health care programs and workforce development programs related to medically disadvantaged service areas;
   
   

5. Operate its Medi-Cal managed care program, Community-Based Adult Services program, and seven county Coordinated Care Initiative (under the Initiative, individuals dually eligible for Medicare and Medi-Cal receive their Medi-Cal and Medicare benefits through one health plan).
   
   

4. DHCS Waiver Submission. On March 27, 2014, following several months of waiver-related stakeholder meetings, DHCS submitted an application to renew the state’s Section 1115 Waiver Demonstration entitled “Medi-Cal 2020: Key Concepts for Renewal” (Medi-Cal 2020). DHCS identified five core goals in that document, as follows:

1. Improve health care quality and outcomes for the Medi-Cal population;

2. Strengthen primary care delivery and access;

3. Build a foundation for an integrated health care delivery system that incentivizes quality and efficiency;

4. Address social determinants of health and improve health care equity; and,

5. Use California’s sophisticated Medicaid Program as an incubator to test innovative approaches to whole-person care.

In addition to the continuation of existing waiver programs, DHCS will pursue a set of six, cross-cutting approaches that together will advance delivery system transformation in California as part of Medi-Cal waiver renewal:

1. Managed Care Systems Transformation & Improvement Program;

2. Fee-for-Service Transformation & Improvement Program;

3. Public Safety Net System Transformation & Improvement Program;

4. Workforce Development Program;

5. Increased Access to Housing and Supportive Services Program;

6. Whole Person Care Pilots; and,

7. Public Safety Net System Global Payment for the Remaining Uninsured.

In support of California’s efforts to achieve the goals outlined above, DHCS seeks to test a new investment strategy in partnership with the federal government by initiating a federal-state shared savings model. California’s shared savings initiative would involve a reinvestment of federal funding in recognition of the savings that California’s Section 1115 demonstration initiatives generate to the benefit of both the state and the federal government. This reinvestment would provide the state with a portion of the federal savings that are generated through the demonstration to facilitate and augment continued Medi-Cal delivery system transformation.

The state’s waiver request in Medi-Cal 2020 is for $17.1 billion in federal funds over the five years of the waiver.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee, no new administrative costs to DHCS are anticipated due to this bill. DHCS is currently in the process of developing a waiver application and has been engaged in planning and stakeholder discussions which will continue into 2015-16. Because DHCS is already undertaking these efforts, this bill will not impose new administrative duties on DHCS.

SUPPORT: (Verified 4/22/15)

Arc and United Cerebral Palsy California Collaboration

Association of California Health Care Districts

California Association of Physician Groups

California Commission on Aging

California Primary Care Association

California State Association of Counties

California State Council of the Service Employees International Union

OPPOSITION: (Verified 4/22/15)

None received

ARGUMENTS IN SUPPORT: The California Association of Physician Groups (CAPG) writes that it supports policy measures that encourage the implementation of the Triple Aim which include decreased cost, improved patient experience and development of population health management. CAPG writes the new “Medi-Cal 2020” waiver seeks approximately $17 billion in federal investment to further the achievements California has made in health care reform that a set of payment and delivery system transformation strategies. CAPH states it continues to support and participate in the waiver renewal stakeholder process.

The California State Association of Counties (CSAC) writes in support that DHCS’ Medi-Cal 2020 waiver renewal addresses the counties’ priorities, and introduces a new concept transforming California’s public safety net for the remaining uninsured by creating a global payment system. CSAC states the global payments offer a unique opportunity for California to serve as an incubator in testing new payment methods for delivering care to the uninsured and in transforming care away from high-cost settings (such as emergency rooms) towards primary care. CSAC argues these individual payments would allow each hospital system more certainty about its budget and how much in federal funds will be available.

Prepared by: Scott Bain / HEALTH /

4/22/15 16:19:58

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

SB 36 (Hernandez) - Medi-Cal: demonstration project

This bill does not meet the criteria for referral to the Suspense File.

Bill Summary:

SB 36 would require the Department of Health Care Services to submit an application to the federal government for a Section 1115 waiver of federal law, to allow the state to make changes to the operation of the Medi-Cal program for the period of 2015 to 2020.

Fiscal Impact:

No new administrative costs to the Department of Health Care Services are anticipated due to this bill. The Department is currently in the process of developing a waiver application and has been engaged in planning and stakeholder discussions which will continue into 2015-16. Because the Department is already undertaking these efforts this bill will not impose new administrative duties on the Department.

Background:

Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. The federal government provides matching funds that vary from 50 percent to 90 percent of expenditures depending on the category of beneficiary.

Current federal law allows states to apply for “Section 1115 waivers” of requirements of the federal Social Security Act. This process allows states, on a case by case basis, to make changes to their Medicaid program with the approval of the federal Centers for Medicare and Medicaid Services. In general, for the federal government to approve a waiver, the state must demonstrate that will assist in promoting the objectives of Medicaid and that total federal costs will not exceed fee-for-service equivalent costs to the federal government over the period of the waiver, typically five years.

California’s existing Section 1115 wavier, referred to as the “Bridge to Reform Waiver” will expire in October 2015. The existing wavier was designed to provide about $10 billion in addition federal funding to the state to fund an early implementation of the coverage expansion under the Affordable Care Act and to invest in safety net health care programs. (The additional federal funds were available due to cost savings created through the use of Medi-Cal managed care to reduce per beneficiary expenditures below what they would have been through fee-for-service health care.)

The Department of Health Care Services has been engaged in the process for developing a new Section 1115 waiver and has submitted a preliminary proposal to the federal government. Under that proposal, the state would be eligible for about $17 billion in additional federal funding to invest in innovative programs, such as more comprehensive care for the uninsured population, workforce development, and programs to transform health care delivery systems.

Proposed Law:

SB 36 would require the Department of Health Care Services to submit an application to the federal government for a Section 1115 waiver of federal law, to allow the state to make changes to the operation of the Medi-Cal program for the period of 2015 to 2020.

The bill is an urgency measure.

Related Legislation:

AB 72 (Bonta and Atkins) is identical to this bill. That bill is on the Assembly Floor.

Staff Comments:

The intention in developing the new Section 1115 wavier is to allow the state to generate cost savings (chiefly by using managed care to provide appropriate primary care and preventative care to avoid costly hospitalizations) and to use a portion of the projected cost savings to fund other state programs, such as safety net programs for the uninsured population. Based on preliminary analyses by the Department, the state has indicated to the federal government that it will be requesting about $17 billion in shared savings over the five year waiver period from the federal government to support additional waiver programs.

While this bill requires the Department to submit a waiver application to the federal government, it does not specify the programmatic requirements of such a waiver.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 36

SUBJECT: Medi-Cal: demonstration project

SUMMARY:

Requires the Department of Health Care Services (DHCS) to submit an application to the federal Centers for Medicare and Medicaid Services (CMS) for a waiver to implement a demonstration project that furthers the delivery of high-quality and cost-efficient care for Medi-Cal beneficiaries, ensures the long-term viability of the delivery system following the expansion of Medi-Cal eligibility under the federal Patient Protection and Affordable Care Act (ACA), and continues California’s momentum and successes in innovation achieved under the 2010 “Bridge to Reform” Waiver.

Existing law:

1. Establishes the Medi-Cal program, which is administered by DHCS and under which qualified low-income persons receive health care benefits.
   
   

2. Establishes a demonstration project under the Medi-Cal program until October 31, 2015, to implement specified objectives, including better care coordination for Seniors and Persons with Disabilities (SPDs) and maximization of opportunities to reduce the number of uninsured individuals.
   
   

This bill:

1. Requires DHCS to submit an application to CMS for a waiver to implement a demonstration project that does all of the following:
   
   

1. Furthers the delivery of high-quality and cost-efficient care for Medi-Cal beneficiaries;

2. Ensures the long-term viability of the delivery system following the expansion of Medi-Cal eligibility under the federal Patient Protection and Affordable Care Act (ACA); and,

3. Continues California’s momentum and successes in innovation achieved under the 2010 “Bridge to Reform” Waiver.

2. Requires DHCS to consult with interested stakeholders and the Legislature in developing the waiver application.

3. Contains an urgency clause that will make this bill effective upon enactment.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, this bill is one of two legislative vehicles to make the necessary statutory changes to implement a new Section 1115 Medicaid waiver as the 2010 California Bridge to Reform Waiver (Waiver) expires on October 31, 2015. The Waiver renewal is critical to the long–term fiscal sustainability of the Medi–Cal program and to California’s ability to continue to provide high quality health care to Medi-Cal beneficiaries. The goals of the Waiver are to continue to support ACA implementation, improve the health care quality and outcomes of the over 12 million individuals enrolled in Medi-Cal, and provide for the long–term fiscal stability of the Medi-Cal program through delivery system transformation. Specific strategies anticipated to be included in the waiver renewal include a federal-state shared savings initiative; housing and supportive services for vulnerable populations; various health plan and provider delivery system transformation and alignment incentive programs, including a new Delivery System Reform Incentive Program (DSRIP) at designated public hospitals and non–designated public hospitals; workforce development strategies to expand provider access and capacity; and safety net payment and delivery system transformation.

2. Federal Section 1115 Waiver and Expenditure Authority. Medicaid (known as Medi-Cal in California) is a joint federal-state program to provide health coverage to low-income individuals. Section 1115 of the federal Social Security Act (Act) gives the Secretary of the Department of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs authorized under the Act. This includes certain federal Medicaid requirements in any experimental pilot or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives of Medicaid. In addition, Section 1115 also allows states to use federal Medicaid funds to reimburse for costs in ways that are not otherwise allowed under federal Medicaid law. This is referred to as expenditure authority for “costs not otherwise matchable” or CNOM.
   
   Section 1115 waivers are approved at the discretion of the Secretary of HHS through negotiations between a state and CMS for projects that the Secretary determines promote Medicaid program objectives. Section 1115 waivers are generally approved for a five-year period and then must be renewed. Although not required by statute or regulation, longstanding federal administrative policy has required waivers to be “budget neutral” for the federal government, meaning that federal spending under a waiver must not be more than projected federal spending in the state without the waiver.
   
   

3. Bridge to Reform Waiver. California’s existing Section 1115 “California Bridge to Reform Demonstration” Waiver is a five-year demonstration of health care reform initiatives that was projected to provide an additional $10 billion in federal funds over the lifetime of the waiver. The waiver prepared the state for successful implementation of health care reform through an early expansion of Medicaid, and tested innovations in health care support for safety net providers. California is currently in the fourth year of this waiver, which began November 1, 2010 and expires October 31, 2015. Under the current waiver, California is required to submit an extension request no later than six months prior to the expiration date of the current demonstration. California also operates its Medi-Cal managed care delivery system under this federal waiver. The Bridge to Reform Waiver enabled California to:
   
   

1. Implement an early expansion of Medicaid to low-income adults without minor children under the Affordable Care Act (ACA) through the Low Income Health Program (LIHP), which enrolled 650,000 individuals;

2. Require the mandatory enrollment of SPDs into Medi-Cal managed care plans in specified counties;

3. Provide federal funding for delivery system reform and uncompensated care in designated public hospital systems (21 county and University of California hospitals) through the Delivery System Reform Incentive Payment program (DSRIP) and Safety Net Care Pool Uncompensated Care (SNCP);

4. Provided federal funding for designated state health care programs and workforce development programs related to medically disadvantaged service areas;

5. Operate its Medi-Cal managed care program, Community-Based Adult Services (CBAS) program, and seven county Coordinated Care Initiative (under the CCI, individuals dually eligible for Medicare and Medi-Cal receive their Medi-Cal and Medicare benefits through one health plan).
   
   

4. What Provisions of Federal Law are “Waived” in the Current Waiver? In the current Bridge to Reform waiver, the federal government waived specified federal Medicaid provisions. Major provisions waived include the following:
   
   

1. The “Freedom of Choice” requirement to enable California to require participants to receive benefits through certain providers and to permit the state to require that Medi-Cal beneficiaries receive benefits through managed care plans, who could not otherwise be required to enroll in managed care;

2. The “Statewideness” requirement to enable California to operate the demonstration and implement coverage for new Medi-Cal eligibles on a county-by-county basis, and to provide managed care plans only in certain geographic areas; and,

3. The “Amount, Duration, and Scope of Services and Comparability” requirement to enable California to offer a different benefit package to Medi-Cal beneficiaries in the SPD program that includes benefits that are not available to all categorically needy individuals.

5. DHCS Waiver Submission. On March 27, 2014, following several months of waiver-related stakeholder meetings, DHCS submitted an application to renew the state’s Section 1115 Waiver Demonstration entitled “Medi-Cal 2020: Key Concepts for Renewal” (Medi-Cal 2020). DHCS identified five core goals in that document, as follows:

1. Improve health care quality and outcomes for the Medi-Cal population;

2. Strengthen primary care delivery and access;

3. Build a foundation for an integrated health care delivery system that incentivizes quality and efficiency;

4. Address social determinants of health and improve health care equity; and,

5. Use California’s sophisticated Medicaid Program as an incubator to test innovative approaches to whole-person care.

DHCS indicates the focus of the Waiver Renewal will be on continuing to drive the transformation of its Medi-Cal program, ensuring ongoing support for the safety net in California, and ensuring the long-term viability of the program and the Medicaid expansion. Existing 1115 Waiver authorities and programs that would continue under the next Waiver include the CCI, the CBAS waiver, managed care program, Indian Health Services (IHS) uncompensated care, Designated State Health Programs (DSHPs), the pending Drug Medi-Cal Organized Delivery System program, and the provision of full scope benefits for pregnant women with incomes between 109 percent to 138 percent of the federal poverty level.

In addition to the continuation of existing waiver programs, DHCS will pursue a set of six, cross-cutting approaches that together will advance delivery system transformation in California as part of Medi-Cal waiver renewal:

1. Managed Care Systems Transformation & Improvement Program – Joint incentive pools for Medi-Cal plans, behavioral health systems and providers to align incentives, improve health outcomes and reduce overall costs.

2. Fee-for-Service (FFS) Transformation & Improvement Program - FFS incentives in dental and maternity care to expand access to dental services through targeted incentives to increase provider participation and incenting delivery of preventative services in lieu of more invasive and costly procedures.

3. Public Safety Net System Transformation & Improvement Program – Funding for quality improvement for public hospitals, and expanding eligibility for this funding to the 40+ non-designated public hospitals.

4. Workforce Development Program – Waiver funding to provide financial incentives to (a) health professionals who have not previously cared for Medi-Cal members, and to existing Medi-Cal providers who treat additional Medi-Cal beneficiaries, targeted to health professionals in geographic areas with the greatest need for Medi-Cal participating providers and to professions and specialties where recruiting is most challenging; (b) voluntary training opportunities to improve quality for non-clinical members of the care team to help those new to coverage navigate the health system through health education and other outreach efforts; and (c) incentives and programs to expand cross-training of providers in primary care, mental health, substance use disorder services, and long-term services and supports, and to support integration of multi-disciplinary teams across care settings.

5. Increased Access to Housing and Supportive Services Program – The Waiver will provide tools to better coordinate care for the most vulnerable Medi-Cal members through policies, data analysis and measurement that facilitate access to supportive services that are also proven to reduce costs, including improved access to affordable housing.

6. Whole Person Care Pilots – An option for enhanced model of regional partnerships requiring proposals for a geographic region, such as a county or group of counties, jointly pursued by the county and applicable Medi-Cal plans for that region whereby managed care plans, counties, and local partners would provide Whole-Person Care for target high need patients through collaborative leadership and systematic coordination with other public and private entities identified by the county.. The pilot design would encourage innovation in delivery and financing strategies to improve health outcomes of target populations.

7. Public Safety Net System Global Payment for the Remaining Uninsured – Moving disproportionate share hospital (DSH) and SNCP funding into a global budget structure where care for the remaining uninsured would be provided within a global budget for all uninsured services, thus giving public hospital systems the incentive to provide more coordinated upstream care for the uninsured and reduce inappropriate utilization.

In support of California’s efforts to achieve the goals outlined above, DHCS seeks to test a new investment strategy in partnership with the federal government by initiating a federal-state shared savings model. California’s shared savings initiative would involve a reinvestment of Federal funding in recognition of the savings that California’s Section 1115 demonstration initiatives generate to the benefit of both the state and the federal government. This reinvestment would provide the state with a portion of the federal savings that are generated through the demonstration to facilitate and augment continued Medi-Cal delivery system transformation. Under this initiative, California would be required to demonstrate that the federal savings generated under the waiver are substantial enough to permit California to retain a portion or percentage of that savings. The state would need to demonstrate that, even after reinvestment in the waiver strategies, the federal government will continue to realize savings. If the waiver strategies implemented through Medi-Cal 2020 do not result in the level of federal savings that is projected, California would be required to limit the spending on waiver reinvestment initiatives to ensure overall savings and budget neutrality.

The state’s waiver request in Medi-Cal 2020 is for $17.1 billion in federal funds over the five years of the waiver.

6. Related legislation. AB 72 (Bonta and Atkins) is identical to this bill. AB 72 is scheduled to be heard in the Assembly Health Committee on April 7, 2015.
   
   

7. Prior legislation. AB 342 (John A. Pérez), Chapter 723, Statutes of 2010 enacted the Low-Income Health Program to provide health care benefits to uninsured adults up to 200 percent of the federal poverty level, at county option through a Medi-Cal waiver demonstration project.

SB 208 (Steinberg), Chapter 714, Statutes of 2010, implemented provisions of the 2010 Section 1115 waiver including establishing the Public Hospital Investment, Improvement and Incentive Fund (known as DRSIP) consisting of IGTs from counties or other specified governmental entities, to be matched with federal funds and to be used for investment, improvement and incentive payments for DPHs and the affiliated governmental entities (counties and UC); authorized DHCS to require the mandatory enrollment of SPDs in a Medi-Cal managed care plan commencing on the later of either June 1, 2011, or obtaining federal approval; and required DHCS to implement pilot projects to provide coordinated care to children in the California Children's Service and to persons who are eligible for Medi-Cal and Medicare.

AB 1066 (John A. Pérez), Chapter 86, Statutes of 2011 enacted statutory changes to implement the Section 1115 Medi-Cal Demonstration Project Waiver approved on November 2, 2010, for funding designated public hospitals (DPHs). AB 1066 continues under the new waiver the fee-for-service cost-based reimbursement for DPHs, with those hospitals providing the required federal match using their own funds through certified public expenditures. AB 1066 also establishes under the waiver a new distribution methodology for DSH and SNCP funds to DPHs, as specified.

8. Support. The California Association of Physician Groups (CAPG) writes that it supports policy measures that encourage the implementation of the Triple Aim which include decreased cost, improved patient experience and development of population health management. CAPG writes the new “Medi-Cal 2020” waiver seeks approximately $17 billion in federal investment to further the achievements California has made in health care reform that a set of payment and delivery system transformation strategies. CAPH states it continues to support and participate in the waiver renewal stakeholder process.
   
   The California State Association of Counties (CSAC) writes in support that DHCS’ Medi-Cal 2020 waiver renewal addresses the counties’ priorities, and introduces a new concept transforming California’s public safety net for the remaining uninsured by creating a global payment system. CSAC states the global payments offer a unique opportunity for California to serve as an incubator in testing new payment methods for delivering care to the uninsured and in transforming care away from high-cost settings (such as emergency rooms) towards primary care. CSAC argues these individual payments would allow each hospital system more certainty about its budget and how much in federal funds will be available.
   
   

9. Request for amendments. California PACE Association (CalPACE) writes requesting amendments to this bill to make PACE more broadly available as a Medi-Cal managed care enrollment option. CalPACE states it is currently offered as an enrollment option in materials under the CCI, but it is not similarly offered as an enrollment option in the state’s other managed care expansion materials for SPDs, including the SPD expansion, the rural managed care expansion, and the long-term services and supports provisions of the CCI despite PACE’s provision track record serving the frailest of these populations and providing a cost-effective alternative to nursing home placement.
   
   

SUPPORT AND OPPOSITION:

Support: Association of California Health Care Districts

California Association of Physician Groups

California Commission on Aging

California Primary Care Association

California State Association of Counties

Oppose: None received

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