Bill Text: CA AB2266 | 2011-2012 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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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

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BILL NUMBER: AB 2266	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  MARCH 20, 2012

INTRODUCED BY   Assembly Member Mitchell

                        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
Enrollees with Chronic 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 require the department, upon approval of a state
plan amendment, to establish a  pilot  program in at
least 5 counties to provide health home services to frequent users
of health services, as defined.
   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 Home for Enrollees with Chronic Conditions option
under Section 2703 of the federal Patient Protection and Affordable
Care Act (42 U.S.C. Sec. 1396w-4) is an opportunity for California to
address the needs of people who frequently use emergency departments
for reasons that could have been avoided with earlier or primary
care, as well as the overlapping population of people experiencing
chronic homelessness.
   (b) Almost half of frequent emergency department users are
homeless. Frequent users who are homeless face significant
difficulties accessing regular or preventive care and complying with
treatment protocols with no place to store medications, an inability
to adhere to a healthy diet or maintain appropriate hygiene, frequent
victimization, and  an inability to rest sufficiently
  a lack of rest  to recover from illness. Homeless
Medi-Cal enrollees will, in fact, continue to use costly acute care
services and actually increase their inpatient days, even if
receiving medical home services to reduce their return to the
hospital.
   (c) Increasingly, health providers are partnering with community
social services or housing providers to offer a person-centered
interdisciplinary system of care that includes intensive
paraprofessional care coordination or case management. Programs that
offer intensive care coordination to frequent emergency department
users integrate primary care, behavioral health care, and social
services, and facilitate coordination of care among health systems,
making this model an ideal health home that fosters a "whole person"
orientation.
   (d) Data show that programs providing intensive care coordination,
including  connection   connecting homeless
people  to housing, decrease Medicaid costs within a year. A
randomized study of chronically homeless frequent users receiving
intensive care coordination in housing demonstrated that every 100
participants experienced 270 fewer hospitalizations, 116 fewer
emergency department visits, and 2,000 fewer nursing home days.
Medi-Cal beneficiaries participating in foundation-funded frequent
user programs experienced reductions in Medi-Cal hospital costs of
three thousand eight hundred forty-one dollars ($3,841) per
beneficiary after one year and seven thousand five hundred nineteen
dollars ($7,519) per beneficiary per year after two years, while
drastically improving clinical outcomes.
  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 Home for Enrollees with Chronic 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 program" means  a team comprised of  a
nonprofit organization or entity, including a private hospital,
 or a unit of local government, including  a public
hospital or county,  a community clinic, and social service
providers,  that elects to participate in the  pilot
 program pursuant to this article and that meets the
criteria described in federal guidelines. For the purposes of this
article, "eligible program" shall include health home teams that
 include multiple providers, including  
incorporate  social service providers.
   (c) "Federal guidelines" means all federal statutory guidance, 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 (42 U.S.C. Sec.
1396w-4), including the State Medicaid Director Letter issued on
November 16, 2010.
   (d) "Frequent user of health services" means an adult who has
undergone emergency department treatment on five or more occasions in
the past 12 months or on eight or more occasions in the last 24
months, who would benefit from the provision of multidisciplinary
services, and who has two or more of the following risk factors:
   (1) On one or more occasions within the last 24 months, the
individual was diagnosed with  a   two or more
 chronic  or life-threatening condition  
conditions  that  requires   require 
management of symptoms, medications, health care, or changes in
lifestyle or risk-related behaviors. These conditions may include
specific conditions the department identifies based on data collected
pursuant to Section 14127.1.
   (2) On one or more occasions within the last 24 months, the
individual was diagnosed, or, in the judgment of an emergency
department physician, would likely be diagnosed, if provided a mental
assessment, with an Axis I or Axis II mental disorder identified in
the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition.
   (3) On one or more occasions within the last 24 months, the
individual was diagnosed, or, in the judgment of an emergency
department physician, would likely be diagnosed, if provided an
assessment, with a substance use disorder, including substance
dependence and substance use problems, that interferes with the
individual's health or appropriate utilization of health services.
   (4) The individual is homeless.
   (e) "Homeless" has the same meaning as that term is defined in
Section 91.5 of Title 24 of the Code of Federal Regulations.
   (f) "Stakeholders" includes, but is not limited to, the Frequent
Users of Health Services Initiative program participants,  other
frequent user programs the department selects,  the Corporation
for Supportive Housing, the California Mental Health Directors
Association, community clinic representatives,  the California
Hospital Association or the California Association of Public
Hospitals,  and representatives from other disciplines that
represent the needs of frequent users of health services.
   14127.1.  (a) No later than July 1, 2013, the department shall do
all of the following:
   (1) Collect data to determine conditions that are most prevalent
among frequent users of health services, as defined in subdivision
(d) of Section 14127, whose high costs could be avoided with more
appropriate care.
   (2) Design, in consultation with stakeholders, a program to
provide  Medi-Cal   health home  services
to frequent users of health care services.
   (3) Submit any necessary application to the federal Centers of
Medicare and Medicaid Services for a state plan amendment under
Section 2703 of the federal Patient Protection and Affordable Care
Act (42 U.S.C. Sec. 1396w-4), the Health Homes for Enrollees with
Chronic Conditions option, to provide health home services to
Medi-Cal beneficiaries  and Low Income Health Program (LIHP)
enrollees  who are frequent users of health services.
   (b) The department shall commence implementation of a 
pilot  program in accordance with the Health Homes for
Enrollees with Chronic Conditions option (42 U.S.C. Sec. 1396w-4) on
the first day of the third month following the month in which federal
approval of the state plan amendment sought pursuant to subdivision
(a) is received.
   (c) The  pilot  program established pursuant to
this article shall provide services to Medi-Cal beneficiaries in
addition to an individual's existing Medi-Cal benefits,  and, in
counties with LIHPs that are willing to provide state matching funds,
to enrollees of the LIHP implemented through California's Bridge to
Reform Section 1115(a) Medicaid Demonstration,  and shall be
designed to reduce a participating individual's use of hospital
emergency departments when more effective care, including primary,
specialty, and social services, can be provided in less costly
settings.
   14127.2.  (a) In accordance with federal guidelines, the state may
limit the availability of services geographically, but shall
implement the  pilot  program in at least five
counties; provided, however, that providers meet federal criteria in
each county designated. Providers may include nonlicensed
professional or paraprofessional staff, including social workers.
   (b) (1) Services provided under the  pilot 
program established pursuant to this article shall include, but need
not be limited to, all of the following:
   (A) Individualized intensive face-to-face outreach, care
coordination, and case management.
   (B) Money management services and education.
   (C) Transportation.
   (D) Life skills training.
   (E) Peer and recovery support.
   (F) Prevocational and vocational services.
   (G) Employment support services.
   (H) Housing location services  , when needed 
 for participants who are homeless or unstably housed  .
   (2) Beneficiaries may require less intensive services or graduate
completely from the program upon stabilization.
   (c) The selection of the eligible programs shall be based on
criteria that shall be developed by the department pursuant to
federal guidelines and in consultation with stakeholders. 
The department may consult with existing frequent user projects in
developing selection criteria.  The criteria for
participation as a program shall include at least all of the
following:
   (1) Demonstrated experience working with the frequent users of
health services population.
   (2) The capacity and administrative infrastructure to participate
in the  pilot  program, including the ability to
meet requirements of federal guidelines identified in the State
Medicaid Director letter dated November 16, 2010, regarding Health
Homes for Enrollees with Chronic Conditions.
   (3) 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,
transportation, money management, prevocational and vocational
services, and employment support.
   (4) A plan to offer services to a point-in-time caseload of at
least 100 clients on a voluntary basis.
   (5) Support of essential community hospitals, particularly the
hospital or hospitals serving a high proportion of Medi-Cal patients,
such as disproportionate share hospitals.
   14127.3.  (a) The state shall provide for the nonfederal share of
costs for services provided to individuals under this article.
   (b) This section shall not be construed to preclude local
entities, health plans, or foundations from contributing the
nonfederal share of costs for services provided under this program.
   (c) This article shall not be construed to limit the department in
targeting  other   additional  populations
 or creating additional programs  under the Health Homes
for Enrollees with Chronic Conditions option.
   14127.4.  (a) The department shall prepare, or contract for the
preparation of, an evaluation of the frequent users program. The
department shall seek out and utilize only private funds to fund the
evaluation. The department, within  one year  
18 months after programs have been selected and have begun to
seek reimbursement, shall complete the evaluation and 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.  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
sought pursuant Section 14427.1, and only to the extent nonstate
funds are available for use as the nonfederal share during the first
eight quarters of implementation.