CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 426

Author:(Maienschein)

As Amended Ver:August 30, 2019

Majority vote

SUMMARY:

Prohibits a licensed health care professional from charging a fee for the completion of the medical certification form required to be eligible to In-Home Supportive Services (IHSS).

The Senate Amendments:

Delete provisions of the bill and prohibit a licensed health care professional from charging a fee for the completion of the medical certification form.

COMMENTS:

Medical certification for IHSS: SB 72 (Budget and Fiscal Review Committee), Chapter 8, Statutes of 2011, the Human Services Trailer Bill, established the requirement that an individual applying for IHSS obtain certification from a licensed health care professional declaring that they are unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the individual is at risk of placement in out-of-home care. For purposes of complying with this requirement, applicants may obtain medical certification from a broad range of licensed health care professionals including, but not limited to, a physician, physician assistant, regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist, psychologist, optometrist, ophthalmologist, or public health nurse.

Need for this bill: This bill, recognizing the burden that obtaining medical certification may place on many IHSS applicants, seeks to prohibit a licensed health care professional from charging a fee for the completion of the medical certification form.

According to the Author:

"Requiring applicants to consult their doctors to complete the form acts as an unnecessary financial burden on the applicant."

Arguments in Support:

None on file

Arguments in Opposition:

None on file

FISCAL COMMENTS:

According to the Senate Appropriations Committee, this bill will have a negligible fiscal impact.

VOTES:

ASM HUMAN SERVICES: 6-0-2

YES: Reyes, Choi, Friedman, Gipson, Maienschein, Mark Stone

ABS, ABST OR NV: Mathis, Arambula

ASM APPROPRIATIONS: 15-0-3

YES: Gonzalez, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bigelow, Fong, Obernolte

ASSEMBLY FLOOR: 71-0-9

YES: Arambula, Bauer-Kahan, Berman, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Daly, Eggman, Flora, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

ABS, ABST OR NV: Aguiar-Curry, Bigelow, Cooley, Dahle, Diep, Fong, Eduardo Garcia, Obernolte, Patterson

SENATE FLOOR: 39-0-1

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

ABS, ABST OR NV: Mitchell

UPDATED:

VERSION: August 30, 2019

CONSULTANT: Daphne Hunt / HUM. S. / (916) 319-2089 FN: 0001945

 THIRD READING  

Bill No: AB 426

Author: Maienschein (D)

Amended: 8/30/19 in Senate

Vote: 21

SENATE HUMAN SERVICES COMMITTEE: 6-0, 7/8/19

AYES: Hurtado, Stone, Beall, Jackson, Pan, Wiener

SENATE APPROPRIATIONS COMMITTEE: 5-1, 8/30/19

AYES: Portantino, Bradford, Durazo, Hill, Wieckowski

NOES: Jones

NO VOTE RECORDED: Bates

ASSEMBLY FLOOR: 71-0, 5/23/19 - See last page for vote

SUBJECT: In-Home Supportive Services program

SOURCE: Coalition of California Welfare Rights Organizations

DIGEST:

This bill prohibits a licensed health care professional from charging a fee for the completion of the medical certification form that is required to document medical necessity for In-Home Supportive Services (IHSS) services.

ANALYSIS:

Existing law:

1. Establishes, under state and federal law, the Medicaid program (Medi-Cal in California) as a joint federal and state program offering a variety of health and long-term services to low-income women and children, low-income residents of long-term care facilities, seniors, and people with disabilities. (WIC 14001.1)
2. Establishes the IHSS program, which can be funded as a Medicaid benefit, to provide supportive services, including domestic, protective supervision, personal care, and paramedical services as specified, to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. (WIC 12300 et seq.)
3. Maintains an IHSS recipient's right to hire, fire, and supervise the work of any IHSS provider, regardless of the employer responsibilities of a public authority or nonprofit consortium, as specified. (WIC 12301.6 (c))
4. Requires an IHSS applicant to, as a condition of receiving IHSS, obtain certification from a licensed health care professional that: contains certain information, including a description of any condition or functional limitation that has contributed to or resulted in the individual’s need for assistance; declares the applicant’s or recipient’s inability to independently perform some activities of daily living; and states that, without services to assist them with such activities, the applicant or recipient is at risk of placement in out-of-home care. Further, requires the county to consider the medical certification as one indicator of need for IHSS, but prohibits the certification from being the sole determining factor. (WIC 12309.1)
5. Requires the California Department of Social Services (CDSS) to adopt regulations establishing a uniform range of services available to all eligible IHSS recipients based on individual needs. (WIC 12301.1 (a))
6. Requires a county welfare department to assess each IHSS recipient’s ongoing monthly need for services at least once every 12 months in order to establish a recipients weekly authorized number of hours of IHSS, as specified. (WIC 12301.1 (b))
7. Authorizes a county to reassess a recipient’s need for services at a time interval of less than 12 months from a recipient’s initial intake or last reassessment if the county social worker has information indicating that the recipient’s need for services is expected to decrease in under 12 months. (WIC 12301.1 (c)(3)(A))

This bill prohibits a licensed health care professional from charging a fee for the completion of the certification form.

Background

In 2011, the Legislature enacted a requirement that IHSS applicants must submit a statement from a medical professional that they need IHSS services as a condition of eligibility. Under current practice, this statement is submitted on a form (SOC 873), which is used as one indicator of the need for IHSS. According to the sponsor, some doctors charge up to $100 to complete the form.

According to the author, “The SOC 873 form is not used as a sole determining factor in determining if an applicant is eligible for IHSS. Applicants commonly consult a licensed health care professional or social worker to complete the form, but there have been instances of them being charged a fee for completion of the form. Charging for the form creates an undue financial burden, especially for those who are in need of these services. This bill would prohibit charging for completion of the form”

In-Home Supportive Services

The IHSS program provides in-home services for qualified low-income Californians who are at least 65 years of age, blind or living with a disability with assistance in performing activities of daily living to enable them to live in their own homes. IHSS is administered at the state level by CDSS and at the local level by counties.

The program pays care providers to assist with personal care services (such as bathing, toileting, and grooming), domestic and related services (meal preparation, housecleaning, and the like), paramedical services, and protective supervision. IHSS services also may include accompaniment to medical appointments, protective supervision for recipients who have a mental impairment and may place themselves at risk of injury, hazard or accident and paramedical services, when directed by a physician.

Applicants for IHSS services must undergo an initial application and review process, during which a social worker will conduct a home visit and a needs assessment, which includes medical certification from a licensed healthcare professional. Upon determining that an individual is eligible for IHSS services, the county social worker will notify the recipient of the monthly maximum authorized hours of care. IHSS recipients are responsible for selecting, hiring, firing, directing, and supervising their IHSS workers. These responsibilities also include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. About 570,000 Californians receive in-home care through IHSS, 98.5 percent of whom received it as a Medicaid benefit.

Applicants to be IHSS providers must complete an enrollment process, which includes submitting the necessary forms to the county and submitting fingerprint images to the Department of Justice for a criminal background check.

Medical Certification for IHSS

SB 72 (Committee on Budget and Fiscal Review, Chapter 8, Statutes of 2011), the human services trailer bill, established the requirement that an individual applying for IHSS must obtain certification from a licensed health care professional declaring that the individual is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the individual is at risk of placement in out-of-home care. This requirement also applied to recipients already receiving IHSS who had not yet obtained this medical certification.

IHSS applicants may obtain medical certification from a broad range of licensed health care professionals including, but not limited to, a physician, physician assistant, regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist, psychologist, optometrist, ophthalmologist, or public health nurse.

While earlier versions of this bill sought to repeal or work around the medical certification requirement, technical assistance provided by the California Department of Health Care Services indicates that states must verify medical necessity in order to qualify for federal Medicaid funds. As previously noted, about 98.5 percent of IHSS recipients receive the services as a Medicaid benefit. In order to meet federal mandates while also protecting low-income IHSS applicants from being charged out of pocket fees, this bill now prohibits health care providers from charging a fee for completion of the medical certification form.

Related/Prior Legislation

SB 72 (Committee on Budget and Fiscal Review, Chapter 8, Statutes of 2011) adopted the requirement that applicants for, and recipients of, IHSS obtain certification from a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the applicant or recipient is at risk of placement in out-of-home care, among other things.

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

According to the Senate Appropriations Committee, this bill would have negligible fiscal impact.

SUPPORT: (Verified 8/30/19)

Coalition of California Welfare Rights Organizations (source)

Association of Regional Center Agencies

Disability Rights California

UDW/AFSCME Local 3930

OPPOSITION: (Verified 8/30/19)

None received

ASSEMBLY FLOOR: 71-0, 5/23/19

AYES: Arambula, Bauer-Kahan, Berman, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Daly, Eggman, Flora, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Aguiar-Curry, Bigelow, Cooley, Dahle, Diep, Fong, Eduardo Garcia, Obernolte, Patterson

Prepared by: Taryn Smith / HUMAN S. /

9/3/19 11:22:01

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 426 (Maienschein) - In-Home Supportive Services program

Bill Summary:

AB 426 would prohibit in-home supportive services (IHSS) from being denied due to a lack of certification to any applicant who provides good cause, as defined, for not submitting the certification. The bill would also require, on or before February 1, 2021, the California Department of Social Services (CDSS), in consultation with interested stakeholders, to develop or otherwise identify an alternative option to the certification and a proposed method and timeline for implementing the alternative option.

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on August 30, 2019

Fiscal Impact:

• Negligible fiscal impact.

Author Amendments:

• Strike the provisions of the bill.
• Prohibit a licensed health care professional from charging a fee for the completion of the certification form.

-- END --

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 426 (Maienschein) - In-Home Supportive Services program

Bill Summary:

AB 426 would prohibit in-home supportive services (IHSS) from being denied due to a lack of certification to any applicant who provides good cause, as defined, for not submitting the certification. The bill would also require, on or before February 1, 2021, the California Department of Social Services (CDSS), in consultation with interested stakeholders, to develop or otherwise identify an alternative option to the certification and a proposed method and timeline for implementing the alternative option.

Fiscal Impact:

• Ongoing administrative costs up to $5.4 million ($2.7 million GF) for county social workers to assess additional applicants who previously would have been denied.
• Ongoing costs in the millions to hundreds of millions of dollars for providing IHSS services to recipients who were previously denied but would now be receiving services based on good cause reporting.
• One-time costs of $750,000 to update the Case Management, Information and Payrolling System II (CMIPS II). (GF/ federal)

Background:

The IHSS program provides in-home services for qualified low-income Californians who are at least 65 years of age, blind or living with a disability with assistance in performing activities of daily living to enable them to live in their own homes. IHSS is administered at the state level by CDSS and at the local level by counties.

Applicants for IHSS services must undergo an initial application and review process, during which a social worker will conduct a home visit and a needs assessment, which includes medical certification from a licensed healthcare professional. Upon determining that an individual is eligible for IHSS services, the county social worker will notify the recipient of the monthly maximum authorized hours of care. IHSS recipients are responsible for selecting, hiring, firing, directing, and supervising their IHSS workers.

SB 72 (Senate Committee on Budget and Fiscal Review, Chapter 8, Statutes of 2011) established the requirement that an individual applying for IHSS must obtain certification from a licensed health care professional declaring that the individual is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the individual is at risk of placement in out-of-home care. This requirement also applied to recipients already receiving IHSS who had not yet obtained this medical certification.

Proposed Law:

This bill would provide that IHSS services shall not be denied due to a lack of certification to any applicant who provides good cause for not submitting the certification. This bill would also require CDSS, in consultation with interested stakeholders, by February 1, 2021, to develop or otherwise identify an alternative to the certification and a proposed method and timeline for implementing the alternative option. CDSS would be required to convene its first meeting with the interested stakeholders by February 1, 2020.

Related Legislation:

SB 72 (Senate Committee on Budget and Fiscal Review, Chapter 8, Statutes of 2011) adopted the requirement that applicants for, and recipients of, IHSS obtain certification from a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the applicant or recipient is at risk of placement in out-of-home care, among other things.

Staff Comments:

In FY 2018-19, about 41,500 applicants were denied services because of a lack of medical certification. The administrative cost estimate assumes 100 percent of those denied would provide good cause. The estimate also assumes, for the newly admitted recipients, social workers would need 1.5 hours of social worker time ($86.23 per hour) to assess a recipient’s need for IHSS services.

According to CDSS, approximately 10 percent of the cases that are denied due to a lack of health certification are approved for IHSS services after submitting their health certificate. CDSS estimates that the service cost associated with this bill would be negligible as those who were previously denied services due to not having certification from a license health care professional would still not be approved based on good cause reporting. Staff notes that this fiscal estimate assumes that an unknown, but potentially large proportion of those previously denied would now be able to receive services based on good cause reporting. The increase in caseload would increase the state’s overall cost for IHSS services by the average cost per case ($1,800 per month).

-- END --

SENATE COMMITTEE ON HUMAN SERVICES

Senator Hurtado, Chair

2019 - 2020 Regular

Subject: In-Home Supportive Services program

SUMMARY

This bill repeals the requirement that In-Home Supportive Services (IHSS) applicants must obtain a certification from a licensed health care professional as a condition of receiving services.

ABSTRACT

Existing Law:

1. Establishes the IHSS program to provide supportive services, including domestic, protective supervision, personal care, and paramedical services as specified, to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. (WIC 12300 et seq.)
2. Authorizes counties to choose to contract with a nonprofit consortium or establish a public authority for the provision of IHSS services. Requires nonprofit consortia and public authorities to, among other things, establish a registry to assist recipients in locating IHSS providers, and to investigate the background and qualifications of potential providers, as specified. (WIC 12301.6)
3. Maintains an IHSS recipient's right to hire, fire, and supervise the work of any IHSS provider, regardless of the employer responsibilities of a public authority or nonprofit consortium, as specified. (WIC 12301.6 (c))
4. Requires an IHSS applicant to, as a condition of receiving IHSS, obtain certification from a licensed health care professional, as specified. Further, requires the county to consider the medical certification as one indicator of need for IHSS, but prohibits the certification from being the sole determining factor. (WIC 12309.1)
5. Requires the California Department of Social Services (CDSS) to adopt regulations establishing a uniform range of services available to all eligible IHSS recipients based on individual needs. (WIC 12301.1 (a))

This Bill:

1. Removes the medical certification requirements for IHSS services by deleting provisions of current law that, as specified:
   1. Require an IHSS applicant or recipient to, as a condition of receiving IHSS, obtain certification from a licensed health care professional that: contains certain information, including a description of any condition or functional limitation that has contributed to or resulted in the individual’s need for assistance; declares the applicant’s or recipient’s inability to independently perform some activities of daily living; and states that, without services to assist them with such activities, the applicant or recipient is at risk of placement in out-of-home care.
   2. Require the county to consider the medical certification as one indicator of need of IHSS, but prohibit the certification from being the sole determining factor.
   3. Require CDSS, in consultation with the Department of Health Care Services (DHCS) and stakeholders, to develop a standard medical certification form for use in all counties, to contain certain information and, further, prohibit this form from requiring a health care professional to certify an applicant’s or recipient’s need for each individual IHSS service.
   4. Require CDSS, in consultation with DHCS and stakeholders, to identify alternative documentation to be accepted by counties as a way to meet medical certification requirements and, further, require CDSS to develop a letter for counties to use to inform IHSS recipients about the medical certification requirements.
   5. Require DHCS to provide notice directing all Medi-Cal managed care plans to assess all Medi-Cal recipients who are applying for or receiving IHSS in order to make the required medical certifications.
2. Requires that, if the Commission on State Mandates determines that the act contains costs mandated by the state, reimbursement to local agencies and school districts for those costs shall be made, as specified.

FISCAL IMPACT

According to an April 3, 2019 analysis prepared by the Assembly Appropriations Committee, this bill would likely generate the following fiscal impact:

1. Ongoing administrative costs in the mid-millions of dollars (General Fund (GF)/county funds) for county social workers to assess additional applicants. This assumes approximately 60,000 additional applicants will be assessed based on the number of applicants denied in 2018 because they lacked a medical certification form.
2. One-time automation costs of $750,000 (GF) for changes to the CMIPS II, the case management and payroll system for the IHSS program.

BACKGROUND AND DISCUSSION

Purpose of the Bill:

In 2011, the Legislature enacted a requirement that IHSS applicants must submit a statement from a medical professional that they need IHSS services as a condition of eligibility. Under current practice, this statement is submitted on a form (SOC 873), which is used as one indicator of the need for IHSS. According to the sponsor, applicants generally take this form to their doctors who charge up to $100 to complete because Medi-Cal does not pay for completing a form, as it is not a medical service.

AB 426 would remove the requirement that applicants must submit a statement from a medical professional indicating their need for IHSS services. According to the author, “The SOC 873 form is not used as a sole determining factor in determining if an applicant is eligible for IHSS. Requiring that applicants consult their doctors to attain the form acts as an unnecessary financial burden on the applicant, and clogs up the system with additional paperwork.”

In-Home Supportive Services (IHSS)

The IHSS program provides in-home services for qualified low-income Californians who are at least 65 years of age, blind or living with a disability with assistance in performing activities of daily living to enable them to live in their own homes. IHSS is administered at the state level by CDSS and at the local level by counties.

The program pays care providers to assist with personal care services (such as bathing, toileting, and grooming), domestic and related services (meal preparation, housecleaning, and the like), paramedical services, and protective supervision. IHSS services also may include accompaniment to medical appointments, protective supervision for recipients who have a mental impairment and may place themselves at risk of injury, hazard or accident and paramedical services, when directed by a physician.

Applicants for IHSS services must undergo an initial application and review process, during which a social worker will conduct a home visit and a needs assessment, which includes medical certification from a licensed healthcare professional. Upon determining that an individual is eligible for IHSS services, the county social worker will notify the recipient of the monthly maximum authorized hours of care. IHSS recipients are responsible for selecting, hiring, firing, directing, and supervising their IHSS workers. These responsibilities also include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. About 570,000 Californians receive in-home care through IHSS, 98.5 percent of whom received it as a Medicaid benefit.

Applicants to be IHSS providers must complete an enrollment process, which includes submitting the necessary forms to the county and submitting fingerprint images to the Department of Justice for a criminal background check.

Medical Certification for IHSS

SB 72 (Senate Committee on Budget and Fiscal Review, Chapter 8, Statutes of 2011), the human services trailer bill, established the requirement that an individual applying for IHSS must obtain certification from a licensed health care professional declaring that the individual is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the individual is at risk of placement in out-of-home care. This requirement also applied to recipients already receiving IHSS who had not yet obtained this medical certification.

IHSS applicants may obtain medical certification from a broad range of licensed health care professionals including, but not limited to, a physician, physician assistant, regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist, psychologist, optometrist, ophthalmologist, or public health nurse.

This bill seeks to repeal the medical certification requirement as a condition of initial IHSS eligibility.

According to the sponsor of this bill, the medical certification is cost-prohibitive and creates unnecessary delays in IHSS services and increases medical costs for the low-income individuals who are the recipients of IHSS services. Additionally, many IHSS recipients have mobility and transportation limitations, making it difficult to attend a medical appointment necessary to obtain medical certifications.

According to the County Welfare Directors Association of California (CWDA) and California State Association of Counties, before the statewide requirement for certification was implemented, many counties had developed their own certification forms to aid social workers in verifying need for IHSS services and determining how long that need could be expected to continue. CWDA reports that while social workers can observe whether it seems an applicant or recipient can perform various daily activities with or without assistance, they are not medical professionals and are limited in their ability to determine how long an individual will need that assistance. Absent the medical certification, counties could return to implementing their own individual forms.

Related/Prior Legislation:

SB 72 (Senate Committee on Budget and Fiscal Review, Chapter 8, Statutes of 2011) adopted the requirement that applicants for, and recipients of, IHSS obtain certification from a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the applicant or recipient is at risk of placement in out-of-home care, among other things.

COMMENTS

The committee suggests the following amendments, which would preserve the medical verification requirement, but allow for a good cause exemption to that requirement, and create a working group to assess need for or options for modifying the medical requirement in the future. These amendments address concerns raised by counties that social workers rely on medical expertise to establish program eligibility and create a formal stakeholder process to consider alternatives to the medical certification.

On page 2, line 3 insert:

12309.1.  

(a) As a condition of receiving services under this article, or Section 14132.95 or 14132.952, an applicant for or recipient of services shall obtain a certification from a licensed health care professional, including, but not limited to, a physician, physician assistant, regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist, psychologist, optometrist, ophthalmologist, or public health nurse, declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist him or her with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care.

(1) For purposes of this section, a licensed health care professional means an individual licensed in California by the appropriate California regulatory agency, acting within the scope of his or her license or certificate as defined in the Business and Professions Code.

(2) Except as provided in subparagraph (A) or (B) or subdivision (c), the certification shall be received prior to service authorization, and services shall not be authorized in the absence of the certification.

(3) Services shall not be denied due to a lack of medical certification to any applicant who provides good cause for not submitting the certification required by this section. Such good cause shall include lack of transportation and/or an inability to pay for transportation, or being asked to pay for the completion of the certification form by a health professional. Under such circumstances, the county shall complete the eligibility determination process without requiring the certification form.

(A) Services may be authorized prior to receipt of the certification when the services have been requested on behalf of an individual being discharged from a hospital or nursing home and services are needed to enable the individual to return safely to their home or into the community.

(B) Services may be authorized temporarily pending receipt of the certification when the county determines that there is a risk of out-of-home placement.

(3) The county shall consider the certification as one indicator of the need for in-home supportive services, but the certification shall not be the sole determining factor.

(4) The health care professional’s certification shall include, at a minimum, both of the following:

(A) A statement by the professional, as defined in subdivision (a), that the individual is unable to independently perform one or more activities of daily living, and that one or more of the services available under the IHSS program is recommended for the applicant or recipient, in order to prevent the need for out-of-home care.

(B) A description of any condition or functional limitation that has resulted in, or contributed to, the applicant’s or recipient’s need for assistance.

(b) The department, in consultation with the State Department of Health Care Services and with stakeholders, including, but not limited to, representatives of program recipients, providers, and counties, shall develop a standard certification form for use in all counties that includes, but is not limited to, all of the conditions in paragraph (4) of subdivision (a). The form shall include a description of the In-Home Supportive Services program and the services the program can provide when authorized after a social worker’s assessment of eligibility. The form shall not, however, require health care professionals to certify the applicant’s or recipient’s need for each individual service.

(c) The department, in consultation with the State Department of Health Care Services and stakeholders, as defined in subdivision (b), shall identify alternative documentation that shall be accepted by counties to meet the requirements of this section, including, but not limited to, hospital or nursing facility discharge plans, minimum data set forms, individual program plans, or other documentation that contains the necessary information, consistent with the requirements specified in subdivision (a).

(d) The department shall develop a letter for use by counties to inform recipients of the requirements of subdivision (a). The letter shall be understandable to the recipient, and shall be translated into all languages spoken by a substantial number of the public served by the In-Home Supportive Services program, in accordance with Section 7295.2 of the Government Code.

(e) This section shall not apply to a recipient who is receiving services in accordance with this article or Section 14132.95 or 14132.952 on the operative date of this section until the date of the recipient’s first reassessment following the operative date of this section, as provided in subdivision (f).

(1) The recipient shall be notified of the certification requirement before or at the time of the reassessment, and shall submit the certification within 45 days following the reassessment in order to continue to be authorized for receipt of services.

(2) A county may extend the 45-day period for a recipient to submit the medical certification on a case-by-case basis, if the county determines that good cause for the delay exists.

(f) This section shall become operative on the first day of the first month following 90 days after the effective date of Chapter 8 of the Statutes of 2011, or July 1, 2011, whichever is later.

(g) (h) The State Department of Health Care Services shall provide notice to all Medi-Cal managed care plans, directing the plans to assess all Medi-Cal recipients applying for or receiving in-home supportive services, in order to make the certifications required by this section.

(h) (i) If the Director of Health Care Services determines that a Medicaid State Plan amendment is necessary to implement subdivision (b) of Section 14132.95, this section shall not be implemented until federal approval is received.

(j) The State Department of Social Services shall, in consultation with interested stakeholders, including but not limited to the California State Association of Counties, the County Welfare Directors Association, and the Coalition of California Welfare Rights Organizations, develop, or otherwise identify, both of the following by February 1, 2021:

(1) An alternative to the current medical certification form as described in this section.

(A)The alternative shall consider where medical expertise from a licensed healthcare professional may be helpful to eligibility staff in making IHSS determinations.

(2) A proposed method and timeline for implementing the alternative to the current medical certification form in the In-Home Supportive Services program, which shall include consideration of necessary county staff training and automation changes to support implementation.

(A) The department shall convene its first meeting with the interested stakeholders no later than February 1, 2020.

PRIOR VOTES

POSITIONS

Support:

Coalition of California Welfare Rights Organizations (Sponsor)

Association of Regional Center Agencies

Disability Rights California

UDW/AFSCME Local 3930

Oppose:

None received

-- END --

Date of Hearing: March 12, 2019

ASSEMBLY COMMITTEE ON HUMAN SERVICES

Eloise Gómez Reyes, Chair

ABPCA Bill Id:AB 426 (

Author:Maienschein) – As Amended Ver:March 4, 2019

SUBJECT: In-Home Supportive Services program

SUMMARY: Delete in-home supportive services (IHSS) medical certification requirements and require, in certain circumstances, the reduction of an IHSS recipient’s authorized number of hours to be based solely on one of a specified number of factors. Specifically, this bill:

1. Requires, in instances where there has been a county-initiated reassessment of an IHSS recipient’s need for services due to a social worker having obtained information indicating that such need is expected to decrease in less than a year, that any reduction of the recipient’s monthly authorized number of hours be based solely on: a verified change of the recipient’s medical condition; a change in the recipient’s living arrangements, functionality, or circumstances; a change in the law; or an error in computing the recipient’s monthly authorized number of services hours.
   
2. Removes IHSS medical certification requirements by deleting provisions of current law that, as specified:
   
   1. Require an IHSS applicant or recipient to, as a condition of receiving IHSS, obtain certification from a licensed health care professional that: contains certain information, including a description of any condition or functional limitation that has contributed to or resulted in the individual’s need for assistance; declares the applicant’s or recipient’s inability to independently perform some activities of daily living; and states that, without services to assist them with such activities, the applicant or recipient is at risk of placement in out-of-home care.
      
   2. Require the county to consider the medical certification as one indicator of need of IHSS, but prohibit the certification from being the sole determining factor.
      
   3. Require the California Department of Social Services (CDSS), in consultation with the Department of Health Care Services (DHCS) and stakeholders, to develop a standard medical certification form for use in all counties, to contain certain information and, further, prohibit this form from requiring a health care professional to certify an applicant’s or recipient’s need for each individual IHSS service.
      
   4. Require CDSS, in consultation with DHCS and stakeholders, to identify alternative documentation to be accepted by counties as a way to meet medical certification requirements and, further, require CDSS to develop a letter for counties to use to inform IHSS recipients about the medical certification requirements.
      
   5. Require DHCS to provide notice directing all Medi-Cal managed care plans to assess all Medi-Cal recipients who are applying for or receiving IHSS in order to make the required medical certifications.
      
3. Makes technical amendments.

EXISTING LAW:

1. Establishes the IHSS program to provide supportive services, including domestic, protective supervision, personal care, and paramedical services as specified, to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. (Welfare and Institutes Code [WIC] Section 12300 et seq.)
   
2. Authorizes counties to choose to contract with a nonprofit consortium or establish a public authority for the provision of IHSS services. Requires nonprofit consortia and public authorities to, among other things, establish a registry to assist recipients in locating IHSS providers, and to investigate the background and qualifications of potential providers, as specified. (WIC 12301.6)
   
3. Maintains an IHSS recipient’s right to hire, fire, and supervise the work of any IHSS provider, regardless of the employer responsibilities of a public authority or nonprofit consortium, as specified. (WIC 12301.6 (c))
   
4. Requires an IHSS applicant to, as a condition of receiving IHSS, obtain certification from a licensed health care professional that: contains certain information, including a description of any condition or functional limitation that has contributed to or resulted in the individual’s need for assistance; declares the applicant’s or recipient’s inability to independently perform some activities of daily living; and states that, without services to assist them with such activities, the applicant or recipient is at risk of placement in out-of-home care. Further, requires the county to consider the medical certification as one indicator of need for IHSS, but prohibits the certification from being the sole determining factor. (WIC 12309.1)
   
5. Requires CDSS to adopt regulations establishing a uniform range of services available to all eligible IHSS recipients based on individual needs. (WIC 12301.1 (a))
   
6. Requires a county welfare department to assess each IHSS recipient’s ongoing monthly need for services at least once every 12 months in order to establish a recipients weekly authorized number of hours of IHSS, as specified. (WIC 12301.1 (b))
   
7. Authorizes a county to reassess a recipient’s need for services at a time interval of less than 12 months from a recipient’s initial intake or last reassessment if the county social worker has information indicating that the recipient’s need for services is expected to decrease in under 12 months. (WIC 12301.1 (c)(3)(A))
   

FISCAL EFFECT: Unknown

COMMENTS:

In-home supportive services: Eligible low-income individuals in California who are at least 65 years old, living with disabilities, or blind may access services through the IHSS program that enable them to remain in their own homes. IHSS program providers are paid to assist with personal care services (such as bathing, toileting, and grooming), domestic and related services (meal preparation, housecleaning, and the like), paramedical services, and protective supervision. There are currently over 593,000 Californians who receive IHSS; over 98% of these individuals receive IHSS services as a Medicaid benefit.

CDSS oversees the IHSS program, but it is administered at the county level. Once individuals apply for IHSS, they are assessed during home visits by a county social worker for eligibility and need. If an individual is determined to be eligible for IHSS, they are authorized for certain services and for a specified number of hours of care. IHSS recipients have their needs reassessed by county social workers on at least an annual basis. However, a recipient may request a reassessment at any time if their circumstances or needs change. Additionally, should a social worker have information indicating that the recipient’s need for services is expected to decrease in under 12 months, the county may reassess a recipient’s need for services at a time interval of less than 12 months.

IHSS recipients are responsible for selecting, hiring, firing, directing, and supervising their IHSS workers, and for certain administrative duties, such as scheduling and signing timesheets – however, the state handles payroll. There are currently almost 507,000 IHSS providers in California; 71.6% of these providers are relatives and 53.3% of these providers live in the same residence as the recipient.

Medical certification for IHSS: SB 72 (Senate Committee on Budget and Fiscal Review), Chapter 8, Statutes of 2011, the human services trailer bill, established the requirement that an individual applying for IHSS obtain certification from a licensed health care professional declaring that they are unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the individual is at risk of placement in out-of-home care (this requirement also applied to recipients already receiving IHSS who had not yet obtained this medical certification). For purposes of complying with this requirement, applicants may obtain medical certification from a broad range of licensed health care professionals including, but not limited to, a physician, physician assistant, regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist, psychologist, optometrist, ophthalmologist, or public health nurse.

Need for this bill: This bill seeks to repeal the medical certification requirement as a condition of initial IHSS eligibility. It also seeks to ensure that, in instances where a social worker initiates a reassessment triggered by that worker having obtained information indicating that need is expected to decrease in less than 12 months, any resulting reduction in an IHSS recipient’s authorized hours be based on certain factors, such as a change in the recipient’s functionality.

Writing in support, Disability Rights California (DRC) states that, “Requiring medical approval is inappropriate for several reasons. First, there is a delay for the necessity of obtaining the approval. Second is the cost of the medical visit in order to obtain the approval. Third is the burden of a medical visit for a person who may find it difficult (if not impossible) to leave home for an office visit. Fourth, a person’s home is the best place from which to assess needs. Are there stairs? Are the kitchen, bathroom, and other parts of the home usable and accessible so that it can be determined whether the applicant needs assistance with cooking, toileting, and related functions? The list goes on. Finally, DRC supports a requirement that hours not be reduced or eliminated absent a verified justification.”

According to the author, “The SOC 873 form [the IHSS health care certification form] is not used as a sole determining factor in determining if an applicant is eligible for IHSS. Requiring that applicants consult their doctors to attain the form acts as an unnecessary financial burden on the applicant, and clogs up the system with additional paperwork.”

Recommended amendments: As currently written, the provisions of this bill that establish necessary bases for a reduction in a recipient’s authorized number of IHSS hours leave a few implementation questions unanswered, including: Is verifying a recipient’s medical condition appropriate for this purpose? Who would request this verification, and who would complete it? Would this verification take place in the recipient’s home? Additionally, these provisions could benefit from additional clarity intended to: require that only changes in household composition or other household members’ use of services that would impact prorated services (e.g., domestic services and heavy cleaning, related services, and protective supervision) could provide a basis for reduction in hours; require change in functionality to be documented; delete “a change in the recipient’s circumstances” as a basis because it is vague and unclear what additional circumstances might apply; clarify that “a change in law” includes only those changes in law that impact the assessment of need for services; and clarify that “an error in computing a recipient’s monthly authorized number of service hours” needs to have been documented by the county. In order to address the questions and need for clarification described above, committee staff recommend the following amendments beginning on line 12 of page 5 of the bill:

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(3) (A)  A county may reassess a recipient’s need for services

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at a time interval of less than 12 months from a recipient’s initial

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intake or last assessment if the county social worker has

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information indicating that the recipient’s need for services is

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expected to decrease in less than 12 months.

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(B) A reduction of a recipient’s monthly authorized number of

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service hours shall be based solely on a verified change of a

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recipient’s medical condition, a change in the recipient’s living

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arrangements household composition or other household member’s or members’ use of services that impacts the calculation of prorated services, a documented change in the recipient’s functionality, a change

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in the recipient’s circumstances, a change in the law that affects assessment of need for services, or an error

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in computing a recipient’s monthly authorized number of service

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hours that has been documented by the county.

PRIOR LEGISLATION:

SB 72 (Senate Committee on Budget and Fiscal Review), Chapter 8, Statutes of 2011, the human services trailer bill that, among many other changes, adopted the requirement that applicants for and recipients of IHSS obtain certification from a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the applicant or recipient is at risk of placement in out-of-home care.

REGISTERED SUPPORT / OPPOSITION:

Support

Coalition of California Welfare Rights Organizations, Sponsor
Disability Rights California
Educate. Advocate.
Empower Family California

United Domestic Workers of America-AFSCME Local 3930/AFL-CIO

Opposition

None on file

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089

ASSEMBLY THIRD READING

ATR Bill Id:AB 426

Author:(Maienschein)

As Amended Ver:May 16, 2019

Majority vote

SUMMARY:

Deletes in-home supportive services (IHSS) medical certification requirements.

Major Provisions

1. Deletes provisions of current law requiring an IHSS applicant or recipient to, as a condition of receiving IHSS, obtain certification from a licensed health care professional that: contains certain information, including a description of any condition or functional limitation that has contributed to or resulted in the individual's need for assistance; declares the applicant's or recipient's inability to independently perform some activities of daily living; and states that, without services to assist them with such activities, the applicant or recipient is at risk of placement in out-of-home care.
2. Deletes provisions of current law related to the administration of IHSS medical certification requirements.

COMMENTS:

Medical certification for IHSS: SB 72 (Budget and Fiscal Review Committee), Chapter 8, Statutes of 2011, the human services trailer bill, established the requirement that an individual applying for IHSS obtain certification from a licensed health care professional declaring that they are unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the individual is at risk of placement in out-of-home care (this requirement also applied to recipients already receiving IHSS who had not yet obtained this medical certification). For purposes of complying with this requirement, applicants may obtain medical certification from a broad range of licensed health care professionals including, but not limited to, a physician, physician assistant, regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist, psychologist, optometrist, ophthalmologist, or public health nurse.

Need for this bill: This bill, recognizing the burden that obtaining medical certification may place on many IHSS applicants, seeks to repeal the requirement as a condition of initial IHSS eligibility.

According to the Author:

"The SOC 873 form [the IHSS health care certification form] is not used as a sole determining factor in determining if an applicant is eligible for IHSS. Requiring that applicants consult their doctors to attain the form acts as an unnecessary financial burden on the applicant, and clogs up the system with additional paperwork."

Arguments in Support:

Writing in support, UDW/AFSCME Local 3930 states that, "Generally, applicants take the healthcare certification form to their doctors, who can charge up to $100 to complete the paperwork. As completing a form is not classified as a medical service, Medi-Cal does not cover this fee for applicants. [This bill] seeks to eliminate this excessive and unnecessary bureaucratic form from the documents required to apply for the IHSS program. For all practical purposes it is the social worker's assessment that controls the determination of whether or not the applicant is eligible for IHSS. For each case, the social worker is required to complete an assessment of a recipient's need any time the county is notified of a request to adjust authorized hours. These consistent checkups render form SOC 873 useless, leaving the paperwork to clog up the system and provide an inconvenience for the aged, blind or disabled in need of IHSS care."

Arguments in Opposition:

None on file

FISCAL COMMENTS:

According to the Assembly Appropriations Committee, this bill may result in the following costs: 1) Ongoing administrative costs in the mid-millions of dollars (General Fund [GF]/county funds) for county social workers to assess additional applicants (this assumes approximately 60,000 additional applicants will be assessed based on the number of applicants denied in 2018 because they lacked a medical certification form); and, 2) One-time automation costs of $750,000 (GF) for changes to the CMIPS II, the case management and payroll system for the IHSS program.

VOTES:

ASM HUMAN SERVICES: 6-0-2

YES: Reyes, Choi, Friedman, Gipson, Maienschein, Mark Stone

ABS, ABST OR NV: Mathis, Arambula

ASM APPROPRIATIONS: 15-0-3

YES: Gonzalez, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bigelow, Fong, Obernolte

UPDATED:

VERSION: May 16, 2019

CONSULTANT: Daphne Hunt / HUM. S. / (916) 319-2089 FN: 0000876

Date of Hearing: April 3, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 426

Author:(Maienschein) – As Amended Ver:March 25, 2019

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

SUMMARY:

This bill deletes in-home supportive services (IHSS) medical certification requirements and requires, in certain circumstances, the reduction of an IHSS recipient’s authorized number of hours be based solely on one of a specified number of factors.

FISCAL EFFECT:

1. Ongoing administrative costs in the mid-millions of dollars (GF/county funds) for county social workers to assess additional applicants. This assumes approximately 60,000 additional applicants will be assessed based on the number of applicants denied in 2018 because they lacked a medical certification form.
2. One-time automation costs of $750,000 (GF) for changes to the CMIPS II, the case management and payroll system for the IHSS program.

COMMENTS:

1. Purpose. This bill seeks to repeal the medical certification requirement as a condition of initial IHSS eligibility and to ensure that, in reassessment situations, a reduction in an IHSS recipient’s authorized hours be based solely on a verified justification.

According to the author, “Requiring that applicants consult their doctors to attain the [medical certification] form acts as an unnecessary financial burden on the applicant, and clogs up the system with additional paperwork.”

1. Medical certification for IHSS. As part of a package of cost-savings measures to address the state’s budget shortfall, SB 72 (Senate Committee on Budget and Fiscal Review), Chapter 8, Statutes of 2011 -- the human services trailer bill -- required an applicant for IHSS obtain certification from a licensed health care professional declaring the applicant is unable to perform one or more activities of daily living independently, and that without one or more IHSS services, the individual is at risk of placement in out-of-home care. This requirement also applied to recipients already receiving IHSS who had not yet obtained this medical certification.

To comply with this requirement, applicants may obtain medical certification from a broad range of licensed health care professionals including, but not limited to, a physician, physician assistant, regional center clinician or clinician supervisor, occupational therapist, physical therapist, psychiatrist, psychologist, optometrist, ophthalmologist, or public health nurse.

This bill deletes this requirement, thereby restoring program eligibility to its pre-2011 condition.

1. IHSS Assessment. The IHSS program provides eligible low-income individuals in California who are at least 65 years old, living with disabilities or blind access to assistance with daily living activities to enable them to remain in their own homes. These activities may include bathing, dressing, meal preparation and housecleaning, among others. There are over 593,000 Californians who receive IHSS.

The IHSS program is overseen by DSS and administered at the county level. IHSS applicants are assessed by a county social worker for eligibility and need. The medical certification is used to help a social worker evaluate the applicant’s present condition and needs. If an individual is determined to be eligible, they are authorized for certain services and for a specified number of hours of care. IHSS recipients have their needs reassessed by county social workers on at least an annual basis. However, a recipient may request a reassessment at any time if their circumstances or needs change.

Additionally, should a social worker have information indicating that the recipient’s need for services is expected to decrease in less than 12 months, the county may reassess a recipient’s need for services sooner than 12 months. This bill requires that any reduction in hours resulting from this type of reassessment be only for specified, documented reasons.

Analysis Prepared by: Jennifer Swenson / APPR. / (916) 319-2081