Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income persons receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing federal law provides for various home- and community-based services waivers that promote coverage and services that enable an individual who would otherwise be institutionalized to live at home or in the community.

This bill would require the department to submit a waiver application or an amendment to the state plan for home- and community-based services (HCBS) to authorize an individual who is eligible for those services to enroll in Medi-Cal when the military service member has received military orders to transfer into California, upon receipt of the orders and the beneficiary was receiving Medicaid HCBS in the last state of residence. The bill would authorize a veteran beneficiary or a child beneficiary whose parent or guardian is an active or retired military service member to retain eligibility for Medi-Cal HCBS if the service member receives a governmental order to relocate to another state, as long as the parent or guardian retains California as the state of legal residence and the beneficiary retains eligibility for the services.

Date of Hearing: April 25, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 2295

Author:(Voepel) – As Introduced Ver:February 13, 2018

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

SUMMARY:

This bill a) requires the Department of Health Care Services (DHCS) to submit a waiver application or a state plan amendment for home and community based services (HCBS) pursuant to federal Medicaid law and b) establishes an entitlement to enroll in HCBS for specified and otherwise eligible military veterans, active duty service members, and their dependents.

FISCAL EFFECT:

1. Administrative costs to DHCS exceeding $500,000 GF per year for a period of at least two years to develop and implement a new HCBS waiver to serve the specified populations.
2. Ongoing GF costs would depend on the size, scope, and complexity of the waiver, but would likely be in a similar range as the waiver development costs cited above.

COMMENTS:

1. Purpose. According to the author, military service members, veterans, and their dependents may receive Medicaid HCBS waiver services in another state, but have difficulty transitioning to a California HCBS waiver when they relocate to the state.
2. Background. Medicaid (Medi-Cal in California) is a joint state-federal program that provides a variety of health care and long-term care services to eligible low-income beneficiaries. Federal law strictly defines program standards, but also allows states to seek federal approval for "waivers" of these standards, which allows states to tailor their Medicaid programs to a certain extent. According to DHCS, HCBS waivers allow creative alternatives for individuals who would otherwise require care in a nursing facility or hospital. Beneficiaries certified eligible for institutional or inpatient services but who would prefer to receive care at home may be eligible for a HCBS waiver, whereby they receive health care and supportive services that allow them to remain in the community. Federal rules limit the cost of services offered under the waiver to no more than the cost of an alternative institutional placement. California operates an Assisted Living waiver, a Home and Community-Based Alternatives waiver approved in 2017 that provides care management services to persons at risk for nursing home or institutional placement, and a HCBS waiver for the developmentally disabled.
3. Related Legislation. AB 2233 (Kalra), pending in this committee, requires DHCS to submit to the federal Centers for Medicare and Medicaid Services (CMS) a request for renewal of an expanded Assisted Living Waiver program with specified amendments.
4. Staff Comments. This bill could be clarified to better specify the target population. The current language is difficult to interpret. For instance, a list of three eligibility criteria is provided, but it is unclear whether the beneficiary needs to meet all three criteria or fewer. In addition, many HCBS waivers cap the number of individuals that can be served, whereas this bill establishes an entitlement to enroll if eligible. Finally, the intent appears to be that persons eligible for HCBS in another state become eligible for a Medi-Cal HBCS waiver program in a streamlined manner. However, the federal CMS notes more than 300 HCBS waivers are active nationwide; each has its own target population and covered services. It may be difficult or inappropriate to base enrollment in a Medi-Cal waiver on a different waiver in another state.

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

Date of Hearing: April 3, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2295

Author:(Voepel) – As Introduced Ver:February 13, 2018

SUBJECT: Medi-Cal: veterans: home- and community-based services.

SUMMARY: Requires the Department of Health Care Services (DHCS) to submit a waiver application or a state plan amendment for the home and community based services (HCBS) pursuant to federal law. Specifically, this bill:

1. Requires DHCS to submit to the federal Centers for Medicare and Medicaid services a HCBS waiver application or a state plan amendment for HCBS pursuant to federal law.
2. Allows an individual who is eligible for HCBS to enroll for those services if:
   1. The beneficiary is a veteran in need of HCBS services or if the beneficiary’s parent or guardian is an active or retired military service member;
   2. The military service member has received military orders to transfer into California and a copy of the military order is submitted with the application; and,
   3. The beneficiary was receiving Medicaid HCBS in the last state of residence.
3. Allows a veteran beneficiary or child beneficiary whose parent or guardian is an active or retired military service member to retain eligibility for Medi-Cal HCBS if the service member receives a governmental order to relocate to another state, as long as the parent or guardian retains California as the state of legal residence and the beneficiary retains eligibility for the services.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services.
   
2. Establishes a schedule of benefits in the Medi-Cal program. Includes HCBS approved by the federal Department of Health and Human Services to the extent that federal financial participation is available under the state plan or waivers. Permits the Director of DHCS to seek waivers for any or all HCBS approvable under specified provisions of federal law. Requires coverage for HCBS to be limited by the terms, conditions, and duration of the federal waivers. This provision of federal law is referred to as a Medicaid 1915(c) HCBS Waiver, and it enables the state to received federal Medicaid matching funds for HCBS.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill is simply asking DHCS to submit a state plan amendment for an HCBS waiver. Allowing active-duty service members and their eligible dependents to access the healthcare they were already once enrolled for in a faster, more convenient way is only a small service California can provide for the huge service and sacrifice our military members provide to us.
2. BACKGROUND. Medicaid, known as Medi-Cal in California, is a jointly-funded, federal-state health insurance program for certain low income and needy people that includes long-term care benefits. In 1981, President Reagan signed into law the HCBS Waiver program contained in section 1915(c) of the Social Security Act. The legislation provided a vehicle for California and other states to offer services not otherwise available through the Medi-Cal program to serve people (including individuals with developmental disabilities) in their own homes and communities. The HCBS Waiver program recognizes that many individuals at risk of being placed in medical facilities can be cared for in their homes and communities, preserving their independence and ties to family and friends at a cost no higher than that of institutional care.
   
   Within broad Federal guidelines, states can develop HCBS Waivers to meet the needs of people who prefer to get long-term care services and supports in their home or community, rather than in an institutional setting. In 2009, nearly one million individuals were receiving services under HCBS Waivers.
   
   Nearly all states and the District of Columbia offer services through HCBS Waivers. States can operate as many HCBS Waivers as they want, currently more than 300 HCBS Waiver programs are active nationwide.
   
   State HCBS Waiver programs must:
   1. Demonstrate that providing waiver services won’t cost more than providing these services in an institution;
   2. Ensure the protection of people’s health and welfare;
   3. Provide adequate and reasonable provider standards to meet the needs of the target population; and,
   4. Ensure that services follow an individualized and person-centered plan of care.

States can waive certain Medicaid program requirements under HCBS Waivers, including:

• 1. Statewideness: Lets states target waivers to areas of the state where the need is greatest, or where certain types of providers are available;
  2. Comparability of services: Lets states make waiver services available only to certain groups of people who are at risk of institutionalization. For example, States can use this authority to target services to the elderly, technology-dependent children, people with behavioral conditions, or people with intellectual disabilities. States might also target services on the basis of disease or condition, such as Acquired Immune Deficiency Syndrome; and,
  3. Income and resource rules applicable in the community: Lets states provide Medicaid to people who would otherwise be eligible only in an institutional setting, often due to the income and resources of a spouse or parent.  States can also use spousal impoverishment rules to determine financial eligibility for waiver services. 
     
     States can offer a variety of unlimited services under an HCBS Waiver program.  Programs can provide a combination of standard medical services and non-medical services.  Standard services include but are not limited to: case management (i.e. supports and service coordination), homemaker, home health aide, personal care, adult day health services, habilitation (both day and residential), and respite care.  States can also propose “other” types of services that may assist in diverting and/or transitioning individuals from institutional settings into their homes and community.

According to DHCS, the Home and Community Based Alternatives Waiver (HCB Alternatives Waiver) offers services in the home or community to Medi-Cal beneficiaries who would otherwise receive care in a skilled nursing facility. Eligibility into the waiver is based on skilled nursing levels of care. The level of care is determined by the Medi-Cal beneficiary’s medical need. The waiver is held to the principle of federal cost neutrality. Services are arranged so that the overall total costs for the waiver and Medi-Cal State Plan services cannot exceed the costs of facilities offering equivalent levels of care. DHCS received approval for an amendment to the Nursing Facility / Acute Hospital Waiver in November 2016, retroactive to February 1, 2016. The primary change enacted through this amendment was to allow a shift to the calculation of cost neutrality in the aggregate, based upon medical necessity. DHCS received approval of the waiver renewal application on May 16, 2017, retroactive to January 1, 2017. As part of the approved renewal application, the waiver was renamed to the HCB Alternatives Waiver.

According to Military One Source, a resource Website providing 24/7 support for military personnel, spouses, family members and survivors, states can offer waivers to children and adults in order to receive health care services through Medicaid in their own home or community. The HCBS Waivers provide service members and their families with special needs services above and beyond benefits typically provided by TRICARE when service members separate or retire from the military. During those critical transition periods, individual state Medicaid-eligibility requirements and lengthy waiting lists can hinder military families from obtaining supplemental financial support. The mobility of military life, with families moving every two to three years, can make the waiting periods even more problematic.

1. SUPPORT. The National Association of Social Workers, California Chapter (NASW-CA), states that currently none of the HCBS Waivers operated by California have priority enrollment for veterans, active military service members, or their dependents. According to NASW-CA, service members and/or beneficiaries are forced to start the entire application process in each state and as such, these individuals have no support during long waiting periods until eligibility is established for Medicaid and then HCBS.
2. RELATED LEGISLATION. AB 2233 (Kalra) requires DHCS to submit, in 2019, to the federal Centers for Medicare and Medicaid Services a request for renewal of the Assisted Living Waiver program with specified amendments. AB 2233 requires, as part of the amendments, additional slots, as specified, in the 15 existing waiver counties, expansion of the program beyond those counties on a regional basis, and modification to the provider reimbursement tiers while also maintaining the program’s budget-neutral provisions.

REGISTERED SUPPORT / OPPOSITION:

Support

National Association of Social Workers, California Chapter

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097