Bill Text: CA AB1261 | 2015-2016 | Regular Session | Enrolled
Bill Title: Community-based adult services: adult day health care centers.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Vetoed) 2016-01-15 - Consideration of Governor's veto stricken from file. [AB1261 Detail]
Download: California-2015-AB1261-Enrolled.html
BILL NUMBER: AB 1261 ENROLLED
BILL TEXT
PASSED THE SENATE SEPTEMBER 10, 2015
PASSED THE ASSEMBLY SEPTEMBER 11, 2015
AMENDED IN SENATE SEPTEMBER 4, 2015
AMENDED IN SENATE AUGUST 31, 2015
INTRODUCED BY Assembly Member Burke
(Coauthor: Assembly Member Brown)
FEBRUARY 27, 2015
An act to add Article 7 (commencing with Section 14590.10) to
Chapter 8.7 of Part 3 of Division 9 of the Welfare and Institutions
Code, relating to adult day health care.
LEGISLATIVE COUNSEL'S DIGEST
AB 1261, Burke. Community-based adult services: adult day health
care centers.
Existing law establishes the Medi-Cal program, administered by the
State Department of Health Care Services, under which health care
services are provided to qualified, low-income persons. The Medi-Cal
program is, in part, governed and funded by federal Medicaid Program
provisions. Existing law provides, to the extent permitted by federal
law, that adult day health care (ADHC) be excluded from coverage
under the Medi-Cal program.
This bill would establish the Community-Based Adult Services
(CBAS) program as a Medi-Cal benefit and would require CBAS to be
available as a covered service in contracts with managed health care
plans, as specified. The bill would specify eligibility requirements
for participation in the CBAS program. The bill would require that
CBAS providers be licensed as ADHC centers and certified by the
California Department of Aging as CBAS providers. The bill would
require CBAS providers to meet specified licensing requirements and
to provide care in accordance with specified regulations. The bill
would require that these provisions be implemented only if federal
financial participation is available.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the
following:
(a) California supports the dignity, independence, and choice of
seniors and persons with disabilities to live in the most integrated
setting appropriate, in their own home or a community-based setting,
and to be free from unnecessary institutionalization.
(b) The American population is swiftly aging. According to the
federal Centers for Disease Control and Prevention, in 2007
individuals 65 years of age and over represented 12.6 percent of the
American population; by 2030 it is estimated the older adult
population will reach 20 percent of the whole, with 70 million adults
over 65 years of age. Many of these adults will experience
disability and chronic conditions. The Alzheimer's Association
reports that over five million Americans are living with Alzheimer's
disease and that number will grow to 16 million by 2050, with the
cost of caring for those individuals growing from $203 billion in
2013 to $1.2 trillion by mid-century.
(c) According to the United States Census, California's older
adult population is the country's largest, with over four million
seniors currently residing in the state. The California Department of
Aging reports that one in every five Californians is now 60 years of
age or older and 40 percent of those individuals have a disability.
The state's population is also diverse: just under one-half million
older adults in the state identify as Latino or Hispanic, 354,000
identify as Asian, over 182,000 as African American, and over 100,000
people as Native American, Pacific Islander, or multiracial.
(d) Adult Day Health Care (ADHC) was established in California in
1974 as a service designed to meet the needs of older adults and
adults with disabilities in community settings rather than in
institutional care. ADHC centers are licensed daytime health
facilities that provide integrated services from a multidisciplinary
team including nurses, social workers, occupational therapists, and
other professionals.
(e) ADHC centers serve frail elders and other adults with
disabilities, chronic conditions, and complex care needs, such as
Alzheimer's disease or other dementia, diabetes, high blood pressure,
mental health diagnoses, traumatic brain injury, and people who have
had a stroke or breathing problems or who cannot take medications
properly.
(f) ADHC centers also offer caregiver support, addressing research
findings that identify caregiver stress as a leading cause of
placement in a nursing facility, as well as putting the aging or
disabled adult at increased risk for abuse or neglect.
(g) ADHC services include health, therapeutic, and social services
including transportation; skilled nursing care; physical,
occupational, and speech therapy; medical social work services;
therapeutic exercise activities; protective supervision; activities
of daily living; brain-stimulating activities; and a nutritionally
balanced hot meal. Services are provided in accordance with a
person-centered care plan designed after a three-day
interdisciplinary team assessment that includes a home visit and
communication with the participant's primary care physician.
(h) ADHC participants, who are at risk of institutionalization,
receive services in the center and return to their own homes at
night. According to a 2012 study by the California Medicaid Research
Institute, the statewide weighted average annual per person nursing
home cost for Medi-Cal/Medicare recipients in California is $83,364,
while the average annual expenditure per person for ADHC for this
population is $9,312.
(i) ADHC centers are licensed by the State Department of Public
Health and overseen by the California Department of Aging and the
State Department of Health Care Services.
(j) In 1977, Senator Henry Mello issued a report that identified
the need for 600 ADHC centers statewide to meet the needs of
California's elder population. At its peak in 2004, approximately 360
ADHC centers provided care to over 40,000 medically fragile
Californians. In December 2013, there were a total of 270 open ADHC
centers in California, including 245 serving the Medi-Cal population,
two centers serving private-pay clients, and 23 centers associated
with Programs of All-Inclusive Care for the Elderly. Medi-Cal
recipients receiving services at ADHC centers totaled 28,777 persons.
(k) In 2015, 32 California counties do not have an adult day
health center, including Alpine, Amador, Calaveras, Colusa, Del
Norte, El Dorado, Glenn, Inyo, Kings, Lake, Lassen, Madera, Mariposa,
Mendocino, Modoc, Mono, Nevada, Placer, Plumas, San Benito, San
Joaquin, San Luis Obispo, Sierra, Siskiyou, Sonoma, Stanislaus,
Sutter, Tehama, Trinity, Tulare, Tuolumne, and Yuba.
(l) For many years, ADHC was a state plan optional benefit of the
Medi-Cal program, offering an integrated medical and social services
model of care that helped individuals continue to live outside of
nursing homes or other institutions.
(m) California's adult day services have experienced significant
instability in recent years due to California's fiscal crisis and
subsequent budget reductions. The Budget Act of 2011 and the related
trailer bill, Chapter 3 of the Statutes of 2011, eliminated ADHC as a
Medi-Cal optional state plan benefit.
(n) A class action lawsuit, Esther Darling, et al. v. Toby
Douglas, et al., challenged the elimination of ADHC as a violation of
the Supreme Court decision in Olmstead v. L.C. The state settled the
lawsuit, agreeing to replace ADHC services with a new program called
Community-Based Adult Services (CBAS), effective April 1, 2012, to
provide necessary medical and social services to individuals with
intensive health care needs. CBAS is a managed care benefit,
administered through California's Medi-Cal Managed Care
Organizations. For CBAS-eligible individuals who do not qualify for
managed care enrollment and who have an approved medical exemption or
who reside in a county where managed care is currently not
available, CBAS services are provided as a Medi-Cal fee-for-service
benefit.
(o) The State Department of Health Care Services amended the
"California Bridge to Reform" Section 1115 Waiver to include the new
CBAS program, which was approved by the Centers for Medicare and
Medicaid Services on March 30, 2012, and renewed on November 28,
2014. CBAS is operational under the Section 1115 Bridge to Reform
Waiver through October 31, 2015.
(p) Adult day services and CBAS programs remain a source of
necessary skilled nursing, therapeutic services, personal care,
supervision, health monitoring, and caregiver support. The state's
demographic forecast projects the continued growth of the aging
population at least through the year 2050, thereby increasing the
need and demand for integrated, community-based services.
(q) Continuation of a well-defined and well-regulated system of
CBAS programs is essential in order to meet the rapidly changing
needs of California's diverse and aging population and the state's
goals for the Coordinated Care Initiative.
(r) Ensuring that the key elements of the CBAS program are
codified in state law stabilizes the program's structure and
eligibility framework in order to enable thousands of disabled and
frail Californians who rely upon adult day health programs today, and
those who will need this service in the future, to be able to
continue to receive services that support them in remaining
independent and free of institutionalization for as long as possible.
SEC. 2. Article 7 (commencing with Section 14590.10) is added to
Chapter 8.7 of Part 3 of Division 9 of the Welfare and Institutions
Code, to read:
Article 7. Community-Based Adult Services
14590.10. (a) Notwithstanding the operational period of CBAS as
specified in the Special Terms and Conditions of California's Bridge
to Reform Section 1115(a) Medicaid Demonstration (11-W-00193/9), CBAS
shall be a Medi-Cal benefit and shall be available as a covered
service in contracts with managed health care plans with the
standards, eligibility criteria, and provisions that are described in
the Special Terms and Conditions of California's Bridge to Reform
Section 1115(a) Medicaid Demonstration (11-W-00193/9) and any
successor federal authorities.
(b) CBAS shall be available to beneficiaries who meet all of the
following qualifications:
(1) The beneficiary is 18 years of age or older.
(2) The beneficiary derives his or her Medicaid eligibility from
the state plan and is either aged, blind, or disabled, including
those who are recipients of Medicare.
(3) The beneficiary is a Medi-Cal managed care plan member or is
exempt from enrollment in Medi-Cal managed care.
(4) The beneficiary resides within a geographic service area in
which the CBAS benefit was available as of April 1, 2012, as more
fully described in Special Terms and Conditions 95(b), or is
determined to be eligible for the CBAS benefit by a managed care plan
that contracts with CBAS providers pursuant to Special Terms and
Conditions 95(b) and Special Terms and Conditions 98(a)(ii).
(5) The beneficiary shall meet or exceed the medical necessity
criteria established in Section 14526.1 and for whom one of the
following criteria is present:
(A) The beneficiary meets or exceeds the "Nursing Facility Level
of Care A" (NF-A) criteria as set forth in the California Code of
Regulations.
(B) Both of the following apply to the beneficiary:
(i) The beneficiary has a diagnosed organic, acquired, or
traumatic brain injury or a chronic mental disorder, or both. For the
purpose of this clause, "chronic mental disorder" means that the
beneficiary has one or more of the following diagnoses or their
successor diagnoses included in the most recent version of the
Diagnostic and Statistical Manual of Mental Disorders published by
the American Psychiatric Association:
(I) A pervasive developmental disorder.
(II) An attention deficit and disruptive behavior disorder.
(III) A feeding and eating disorder of infancy, childhood, or
adolescence.
(IV) An elimination disorder.
(V) A schizophrenia and other psychiatric disorder.
(VI) A mood disorder.
(VII) An anxiety disorder.
(VIII) A somatoform disorder.
(IX) A factitious disorder.
(X) A dissociative disorder.
(XI) Paraphilia.
(XII) An eating disorder.
(XIII) An impulse control disorder not elsewhere classified.
(XIV) An adjustment disorder.
(XV) A personality disorder.
(XVI) A medication-induced movement disorder.
(ii) The beneficiary needs assistance or supervision as described
in subclause (I) or (II).
(I) The beneficiary needs assistance or supervision with at least
two of the following:
(ia) Bathing.
(ib) Dressing.
(ic) Self-feeding.
(id) Toileting.
(ie) Ambulating.
(if) Transferring.
(ig) Medication management.
(ih) Hygiene.
(II) The beneficiary needs assistance or supervision with at least
one of the activities identified in subclause (I) and needs
assistance with at least one of the following:
(ia) Money management.
(ib) Accessing community and health resources.
(ic) Meal preparation.
(id) Transportation.
(C) The beneficiary has a moderate to severe cognitive disorder
such as dementia, including dementia characterized by the descriptors
of, or equivalent to, Stages 5, 6, or 7 of the Alzheimer's type.
(D) The beneficiary has a mild cognitive disorder such as
dementia, including dementia of the Alzheimer's type, and needs
assistance or supervision with at least two of the following
activities:
(i) Bathing.
(ii) Dressing.
(iii) Self-feeding.
(iv) Toileting.
(v) Ambulating.
(vi) Transferring.
(vii) Medication management.
(viii) Hygiene.
(E) The beneficiary has a developmental disability. For the
purpose of this subparagraph, "developmental disability" means a
disability that originates before the individual attains 18 years of
age, continues, or can be expected to continue, indefinitely, and
constitutes a substantial disability for that individual as defined
in Section 54001 of Title 17 of the California Code of Regulations.
(c) (1) CBAS providers shall be licensed as adult day health care
centers and certified by the California Department of Aging as CBAS
providers, and shall meet the standards specified in this chapter and
Chapter 5 (commencing with Section 54001) of Division 3 of Title 22
of the California Code of Regulations.
(2) CBAS providers shall meet all applicable licensing and
Medi-Cal standards, including, but not limited to, licensing
provisions in Division 2 (commencing with Section 1200) of the Health
and Safety Code, including Chapter 3.3 (commencing with Section
1570) of Division 2 of the Health and Safety Code, and shall provide
services in accordance with Chapter 10 (commencing with Section
78001) of Division 5 of Title 22 of the California Code of
Regulations.
(3) CBAS providers shall comply with the provisions of California'
s Bridge to Reform Section 1115(a) Medicaid Demonstration
(11-W-00193/9) and any successor federal authorities.
(d) In counties where the State Department of Health Care Services
has implemented Medi-Cal managed care, CBAS shall be available as a
Medi-Cal managed care benefit pursuant to Section 14186.3, except
that for individuals who qualify for CBAS, but who are not qualified
for, or who are exempt from, enrollment in Medi-Cal managed care,
CBAS shall be provided as a fee-for-service Medi-Cal benefit.
(e) For purposes of this section, "Community-Based Adult Services"
or "CBAS" means an outpatient, facility-based program, provided
pursuant to a participant's individualized plan of care, as developed
by the center's multidisciplinary team, that delivers nutrition
services, professional nursing care, therapeutic activities,
facilitated participation in group or individual activities, social
services, personal care services, and, when specified in the
individual plan of care, physical therapy, occupational therapy,
speech therapy, behavioral health services, registered dietician
services, and transportation.
(f) This section shall be implemented only to the extent that any
necessary federal approvals are obtained and federal financial
participation is available and is not jeopardized.
