Bill Text: CA AB2266 | 2011-2012 | Regular Session | Amended
Bill Title: Medi-Cal: Health Homes for Medi-Cal Enrollees and 1115
Spectrum: Partisan Bill (Democrat 4-0)
Status: (Engrossed - Dead) 2012-08-29 - Ordered to inactive file at the request of Senator Alquist. [AB2266 Detail]
Download: California-2011-AB2266-Amended.html
BILL NUMBER: AB 2266 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 24, 2012
AMENDED IN SENATE AUGUST 21, 2012
AMENDED IN SENATE JUNE 25, 2012
AMENDED IN ASSEMBLY MAY 25, 2012
AMENDED IN ASSEMBLY APRIL 17, 2012
AMENDED IN ASSEMBLY MARCH 20, 2012
INTRODUCED BY Assembly Member Mitchell
(Principal coauthor: Assembly Member Atkins)
(Coauthors: Assembly Members Wieckowski and Williams)
FEBRUARY 24, 2012
An act to add Article 3.9 (commencing with Section 14127) to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 2266, as amended, Mitchell. Medi-Cal: Health Homes for Medi-Cal
Enrollees and 1115 Waiver Demonstration Populations with Chronic and
Complex Conditions.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
The Medi-Cal program is, in part, governed and funded by federal
Medicaid Program provisions. Existing federal law authorizes a state,
subject to federal approval of a state plan amendment, to offer
health home services, as defined, to eligible individuals with
chronic conditions.
This bill would authorize the department, subject to federal
approval, to create a health home program for enrollees with chronic
conditions, as prescribed, as authorized under federal law.
If the department exercises its authority to create a health home
program for enrollees with chronic conditions, this bill would
require the department to, subject to federal approval, also create
an enhanced health home program for enrollees with complex
conditions, as prescribed. This bill would provide
that those provisions shall not be implemented unless federal
financial participation is available and additional state general
funds are not used to fund the administration and service costs,
except as specified. This bill would require the department to
ensure that an evaluation of the program is completed, if created by
the department, and would require that the department submit a report
to the appropriate policy and fiscal committees of the Legislature
within 2 years after implementation of the program.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the
following:
(a) The Health Homes for Enrollees with Chronic Conditions option
(Health Homes option) under Section 2703 of the federal Patient
Protection and Affordable Care Act (Affordable Care Act) (42 U.S.C.
Sec. 1396w-4) offers an opportunity for California to address complex
and chronic health conditions, as well as social determinants of
poor health outcomes and high costs among Medi-Cal beneficiaries.
(b) For example, people who frequently use hospitals for reasons
that could have been avoided with more appropriate care incur high
Medi-Cal costs and suffer poor health outcomes due to the complexity
of their conditions and, often, their negative social determinants of
health. Frequent users have difficulties accessing regular or
preventive care and complying with treatment protocols, and the
significant number who are homeless have no place to store
medications, cannot adhere to a healthy diet or maintain appropriate
hygiene, face frequent victimization, and lack rest when recovering
from illness.
(c) Increasingly, health providers are partnering with community
behavioral health and social services providers to offer a
person-centered interdisciplinary system of care that effectively
addresses the needs of enrollees with multiple chronic or complex
conditions, including frequent hospital users and people experiencing
chronic homelessness. These health homes help people with chronic
and complex conditions to access better care and better health, while
decreasing costs.
(d) Federal guidelines allow the state to access enhanced federal
matching rates for health home services under the Health
Homes option for multiple target populations to achieve more than one
policy goal.
SEC. 2. Article 3.9 (commencing with Section 14127) is added to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions
Code, to read:
Article 3.9. Health Homes for Medi-Cal Enrollees and 1115
Waiver Demonstration Populations with Chronic and Complex Conditions
14127. For the purposes of this article, the following
definitions shall apply:
(a) "Department" means the State Department of Health Care
Services.
(b) "Eligible individual" means an individual who meets the
criteria defined by the department. "Individual eligible for
enhanced health home services" means an individual who meets the
criteria defined by the department, consistent with
subdivision (c) (b) of Section 14127.2.
(c) (1) "Enhanced health home" means a provider so designated by
the department that satisfies all of the following:
(A) Meets the criteria described in federal guidelines.
(B) Offers a whole person approach, such as, but not limited to,
coordinating services for all of the needs affecting the health of an
individual eligible for enhanced health home services.
(C) Elects to participate in the program pursuant to this article.
(D) Offers services in a range of settings as appropriate to meet
the needs of an individual eligible for enhanced health home
services.
(2) An enhanced health home includes a lead provider that is a
community clinic, a mental health plan, or a hospital, and may
include a physician, clinical practice or clinical group practice,
rural health clinic, community health center, community mental health
center, home health agency, nurse care coordinators, nutritionists,
social workers, behavioral health professionals, and
paraprofessionals, or any other entity or provider.
(d)
( c) "Federal guidelines" means all federal
statutory guidance statutes , and all
regulatory and policy guidelines issued by the federal Centers for
Medicare and Medicaid Services regarding the Health Homes for
Enrollees with Chronic Conditions option under Section 2703 of the
federal Patient Protection and Affordable Care Act (Affordable Care
Act) (42 U.S.C. Sec. 1396w-4), including the State Medicaid Director
Letter issued on November 16, 2010.
(d) (1) "Health home" means a provider or team of providers
designated by the department that satisfies all of the following:
(A) Meets the criteria described in federal guidelines.
(B) Offers a whole person approach, including, but not limited to,
coordinating health home services and linkages to other available
services for the needs affecting the health of an eligible
individual.
(C) Offers services in a range of settings, as appropriate, to
meet the needs of an eligible individual for health home services.
(2) Health home partners may include, but are not limited to, a
health plan, community clinic, a mental health plan, a hospital,
physicians, a clinical practice or clinical group practice, rural
health clinic, community health center, community mental health
center, home health agency, nurse practitioners, social workers, and
paraprofessionals.
(3) For purposes of serving eligible individuals, the department
may require a lead provider to be a community clinic, a mental health
plan, or a hospital.
(e) "Health home" means a provider or team of providers the
department designates that meets federal guidelines as a health home.
The
(4) The department may determine
the model of health home it intends to create, including any entity,
provider, or group of providers operating as a health team, as a team
of health care professionals, or as a designated provider, as those
terms are defined in Sections 3502(c)(2) and 1945(h)(5) and (h)(6) of
the Affordable Care Act, respectively.
(f)
( e) "Homeless" has the same meaning as that
term is defined in Section 91.5 of Title 24 of the Code of Federal
Regulations. "Chronic homelessness" means the state of an individual
whose conditions limit his or her activities of daily living and who
has experienced homelessness for longer than a year or for four or
more episodes over three years.
14127.1. Health homes for enrollees with chronic
conditions. Subject to federal approval, the department may
do all of the following to create a health home program, as
authorized under Section 2703 of the Affordable Care Act:
(a) Design, with opportunity for public comment, a program to
provide health home services to Medi-Cal beneficiaries and Section
1115 waiver demonstration populations with chronic conditions.
(b) Contract with new providers, new managed care plans, existing
Medi-Cal providers, existing managed care plans, or counties to
provide health home services, as provided in Section 14128.
(c) Submit any necessary applications to the federal Centers for
Medicare and Medicaid Services for a state plan amendment and Section
1115 waiver demonstration amendment to provide health home services
to Medi-Cal beneficiaries, to newly eligible Medi-Cal beneficiaries
upon Medicaid expansion under the Affordable Care Act, and, if
applicable, to Low Income Health Program (LIHP) enrollees in counties
with LIHPs willing to match federal funds.
(d) Define the populations of eligible individuals.
(e) Develop a payment methodology, including, but not limited to,
fee-for-service or per member, per month payment structures that
may include tiered payment rates that take into account
the intensity of services necessary to outreach to, engage, and serve
the populations the department identifies .
(f) Identify health home services, consistent with federal
guidelines.
(g) The department may submit applications and operate, to the
extent permitted by federal law and to the extent federal approval is
obtained, more than one health home program for distinct
populations, different providers or contractors, or multiple
geographic areas.
14127.2. Enhanced health homes for enrollees with complex
conditions. If the department creates a health home program pursuant
to Section 14127.1, it shall include an enhanced health home program,
subject to federal approval under Section 2703 of the Affordable
Care Act.
(a) In creating an enhanced health home program, the department
shall do all of the following:
(1) Design, with opportunity for public comment, a program to
provide enhanced health home services identified in subdivision (g)
to persons at high risk of avoidable and frequent use of hospital
services due to complex co-occurring health and behavioral health
conditions.
(2) Contract with new and existing providers, new and existing
managed care plans, or counties in accordance with the selection
criteria identified in subdivision (h), as designated enhanced health
homes.
(3) Include an enhanced health home program in an application to
the federal Centers for Medicare and Medicaid Services for a state
plan amendment under the Health Homes option to provide enhanced
health home services .
(b) The program established pursuant to this section shall provide
services to Medi-Cal beneficiaries, to newly enrolled Medi-Cal
beneficiaries upon implementation of Medicaid expansion under the
Affordable Care Act, and, if applicable, in counties with a LIHP
willing to match federal funds, to enrollees of the LIHP.
(c) Designated enhanced health home providers shall determine
whether an individual is eligible for enhanced health home services.
An individual is eligible for enhanced health home services if the
individual is a Medi-Cal beneficiary or, if applicable, a LIHP
beneficiary who meets both of the following criteria:
(1) Two or more of the following current diagnoses:
(A) Mental health disorders identified by the department as
prevalent among frequent hospital users.
(B) Substance abuse or substance dependence disorders.
(C) Chronic or life-threatening medical conditions identified by
the department as prevalent among frequent hospital users.
(D) Significant cognitive impairments associated with traumatic
brain injury, dementia, or other causes.
(2) Two or more of the following indicators of severity:
(A) Frequent inpatient hospital admissions, including long-term
hospitalization for medical, psychiatric, or substance abuse related
conditions.
(B) Excessive use of crisis or emergency services or inpatient
hospital care with failed linkages to primary care or behavioral
health care.
(C) Chronic homelessness.
(D) History of inadequate followthrough, related to risk factors,
with elements of a treatment plan, including lack of followthrough in
taking medications, following a crisis plan, or achieving stable
housing.
(E) Two or more episodes of use of detoxification services.
(F) Medication resistance due to intolerable side effects, or
illness interfering with consistent self-management of medications.
(G) Self-harm or threats of harm to others.
(H) Evidence of significant complications in health conditions.
(d) The department may establish other criteria to allow
additional Medi-Cal or LIHP beneficiaries to be eligible for enhanced
health home services.
(e) This section shall not be construed to permit providers to
determine whether an individual is eligible for Medi-Cal or LIHP.
(f) The department may develop a payment methodology other than a
fee-for-service payment, including, but not limited to, a per member,
per month payment to designated providers.
(g)
14127.2. (a) The department may create one or
more health home programs for children and adults pursuant to Section
14127.1, and, in consultation with stakeholders, shall develop the
geographic criteria, beneficiary eligibility criteria, and provider
eligibility criteria for each program.
(b) The health home program identified in Section 14127.1 shall
include, but not be limited to, an eligible individual who is an
adult who meets both of the following criteria:
(1) Current diagnosis of chronic, cooccurring physical health and
mental health or substance use disorders prevalent among frequent
hospital users at an acuity level to be determined by the department.
(2) One or more of the following indicators of severity, at a
level to be determined by the department:
(A) Frequent inpatient hospital admissions, including long-term
hospitalization for medical, psychiatric, or substance abuse-related
conditions.
(B) Excessive use of crisis or emergency services or inpatient
hospital care.
(C) Chronic homelessness.
(c) The department shall design program elements specific to the
eligible individuals after consultation with stakeholder groups who
have expertise in engagement and services for those individuals.
(d) (1) Subject to federal approval for
receipt of the enhanced federal match, services provided under the
program established pursuant to this section shall include all of the
following:
(A) Comprehensive and individualized case
care management.
(B) Care coordination and health promotion, including connection
to medical, mental health, and substance abuse care.
(C) Comprehensive transitional care from inpatient to other
settings, including appropriate followup.
(D) Individual and family support, including authorized
representatives.
(E) If relevant, referral to other community and social services
supports, including transportation to appointments needed to manage
health needs, connection to housing for participants who are homeless
or unstably housed, and peer and recovery support.
(F) Health information technology to identify eligible individuals
and link services, if feasible and appropriate.
(2) Beneficiaries According to
beneficiary needs, the department may require
provide less intensive services or graduate
the beneficiary completely from the program upon stabilization.
(h) For purposes of implementing this section, the department
shall ensure that designated
(e) In addition to selecting providers
to serve other populations, for the purposes of providing health home
services to the eligible individuals, the department shall select
designated health home providers, managed care organizations
subcontracting with providers, or and
counties subcontracting with providers offer
operating with a team of health care professionals that have
all of the following:
(1) A designated lead provider that is a community clinic, a
mental health plan pursuant to Section 14712, or a hospital.
(2)
( 1) Demonstrated experience working with
frequent hospital users , with documentation of experience
reducing emergency department visits and hospital inpatient days
among the population served .
(3)
( 2) Demonstrated experience working with
people experiencing chronic homelessness.
(4)
( 3) The capacity and administrative
infrastructure to participate in the program, including the ability
to meet requirements of federal guidelines.
(5) Documented ability to provide or to link clients with
appropriate community-based services, including intensive
individualized face-to-face care coordination, primary care,
specialty care, mental health treatment, substance abuse treatment,
peer and recovery support, permanent or transitional housing, and
transportation.
(6) Experience working with supportive or other permanent housing
providers.
(7) Current partnership with essential community hospitals.
(8)
( 4) A viable plan, with roles identified
among providers of the enhanced health home, to do
all of the following:
(A) Reach out to and engage frequent hospital users and
chronically homeless eligible individuals.
(B) Connect Link eligible
individuals who are homeless or experiencing housing instability to
permanent housing, including such as
supportive housing.
(C) Ensure eligible individuals receive integrated
coordination and linkages to services needed to
access and maintain health stability , including medical, mental
health, substance abuse care, and social services to address social
determinants of health .
(D) Track, maintain, and provide outcome data as required by the
department for purposes of the evaluation required pursuant to
Section 14127.4.
(E)
( D) Identify appropriate funding sources
for the nonfederal share of costs of services for the first
eight quarters of implementation of the program .
(F) Identify appropriate funding sources for the nonfederal share
of costs of services to sustain program funding beyond the first
eight quarters of implementation of the program. Identifying sources
may include a plan to partner with managed care organizations,
counties, hospitals, private funders, or others.
(f) The department may design additional provider criteria to
those identified in subdivision (e) after consultation with
stakeholder groups who have expertise in engagement and services for
eligible individuals.
(g) The department shall design a health home program with
specific elements to engage and serve eligible individuals, and
health home program outreach and enrollment shall specifically focus
on these populations.
14127.3. (a) The department shall administer this article in a
manner that attempts to maximize federal financial participation,
consistent with federal law.
(b) This article shall not be construed to preclude local
governments or foundations from contributing the nonfederal share of
costs for services provided under this program , so long as
those contributions are permitted under federal law . The
department , and counties contracting with the department,
may also enter into risk-sharing and social impact bond program
agreements to fund services under this article.
(c) In accordance with federal guidelines, the state may limit
availability of health home or enhanced health home services
geographically.
14127.4. (a) If the department implements a health home
or enhanced health home program, the department shall
ensure that an evaluation of the program identified in this article
is completed and shall, within two years after implementation, submit
a report to the appropriate policy and fiscal committees of the
Legislature.
(b) The requirement for submitting the report imposed under
subdivision (a) is inoperative four years after the date the report
is due, pursuant to Section 10231.5 of the Government Code.
14127.5. (a) This article shall be implemented only if federal
financial participation is available and the federal Centers for
Medicare and Medicaid Services approves the state plan amendment
and any necessary waivers sought pursuant to this article
, and the department expects the programs to be cost neutral
to the state .
(b) Except as provided in subdivision
subdivisions (c) and (d) , this article shall be
implemented only if nonstate public funds or private
additional state general funds are
available to fully not used to fund the
administration and service costs during the first eight
quarters of implementation, and thereafter .
(c) Notwithstanding subdivision (b), prior to and during the
first eight quarters of implementation, if the department
finds, after the first eight quarters of implementation,
that Medi-Cal costs avoided by the participants of the enhanced
health home program are adequate to fully fund the program costs
projects, based on analysis of current and projected
expenditures for health home services, that this article can be
implemented in a manner that does not result in a net increase in
ongoing state general fund costs for the Medi-Cal program , the
department may use state funds to fund the
any program costs.
(d) Notwithstanding subdivision (b), if the department projects,
after the first eight quarters of implementation, that implementation
of this article has not resulted in a net increase in ongoing state
general fund costs for the Medi-Cal program, the department may use
state general funds to fund any program costs.
(e) The department may use new funding in the form of enhanced
federal financial participation for health home services that are
currently funded to fund any additional costs for new health home
program services.
(f) The department shall seek to fund the creation,
implementation, and administration of the program with funding other
than state general funds.
(d)
( g) The department may revise or terminate
the enhanced health home program any time after
the first eight quarters of implementation if the department finds
that the program fails to result in improved health outcomes or
results in substantial General Fund expense without commensurate
decreases in Medi-Cal costs among program participants.
14128. (a) In the event of a judicial challenge of the provisions
of this article, this article shall not be construed to create an
obligation on the part of the state to fund any payment from state
funds due to the absence or shortfall of federal funding.
(b) For the purposes of implementing this article, the department
shall establish and use a competitive process to select or
amend existing contracts may enter into exclusive or
nonexclusive contracts on a bid or negotiated basis, and may amend
existing managed care contracts to provide or arrange for
services under this article. Contracts may be statewide or on a more
limited geographic basis. Contracts entered into or amended under
this section shall be exempt from the provisions of Chapter 2
(commencing with Section 10290) of Part 2 of Division 2 of the Public
Contract Code and Chapter 6 (commencing with Section 14825) of Part
5.5 of Division 3 of the Government Code, and shall be exempt from
the review or approval of any division of the Department of General
Services.
(c) (1) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement, interpret, or make specific the
process set forth in this article by means of all-county
letters, plan letters, plan or provider bulletins, or similar
instructions, without taking regulatory action, until such time as
regulations are adopted. It is the intent of the Legislature that the
department is allowed temporary authority as necessary to implement
program changes until completion of the regulatory process.
(2) The department shall adopt emergency regulations no later than
two years after implementation of this article. The department may
readopt, up to two times, any emergency regulation authorized by this
section that is the same as or substantially equivalent to an
emergency regulation previously adopted pursuant to this section.
(3) The adoption of emergency regulations implementing this
article authorized by this subdivision shall be deemed an emergency
and necessary for the immediate preservation of the public peace,
health, safety, or general welfare. Emergency regulations authorized
by this section shall be exempt from review by the Office of
Administrative Law. The emergency regulations authorized by this
section shall be submitted to the Office of Administrative Law for
filing with the Secretary of State and shall remain in effect for no
more than 180 days, by which time final regulations may be adopted.
