Bill Text: CA AB361 | 2013-2014 | 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

Spectrum: Partisan Bill (Democrat 6-0)

Status: (Passed) 2013-10-08 - Chaptered by Secretary of State - Chapter 642, Statutes of 2013. [AB361 Detail]

Download: California-2013-AB361-Amended.html

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BILL NUMBER: AB 361	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 4, 2013

INTRODUCED BY   Assembly Member Mitchell
    (   Principal coauthor:   Assembly Member
  Atkins   ) 
    (   Coauthor:   Assembly Member  
Ammiano   ) 
    (   Coauthor:  Senator   Beall
  ) 

                        FEBRUARY 14, 2013

   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 361, as amended, Mitchell. Medi-Cal: Health Homes for Medi-Cal
Enrollees and Section 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. This bill
would provide that those provisions shall not be implemented unless
federal financial participation is available and additional General
Fund moneys 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 chronic
and complex health conditions, including social determinants that
lead to 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 high rates of early  morality
  mortality  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 Section
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) "Federal guidelines" means all federal 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.
   (c) (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 other available services that address needs affecting a
participating individual's health.
   (C) Offers services in a range of settings, as appropriate, to
meet the needs of an individual eligible 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,
paraprofessionals, housing navigators, and housing providers.
   (3) For purposes of serving  the population  
targeted beneficiaries  identified in  subdivision (c) of
 Section 14127.3, the department shall require a lead provider
to be a  physician, a  community clinic, a mental health
plan, a community-based nonprofit organization, a county health
system, or a hospital.
   (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.
   (d) "Homeless" has the same meaning as that term is defined in
Section 91.5 of Title 24 of the Code of Federal Regulations. A
"chronically homeless individual" means 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. An individual who is currently residing in
transitional housing or who has been residing in permanent
supportive housing for less than two years shall be considered a
chronically homeless individual if the individual was chronically
homeless prior to his or her residence. 
   (e) "Targeted beneficiary" means an individual who meets the
criteria specified in subdivision (c) of Section 14127.3. 
   14127.1.  Subject to federal approval, the department may do all
of the following to create a California 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 one or more state plan amendments
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)  Except as specified in Section 14127.3, define
  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
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 specific
geographic areas.
   14127.2.  (a) The department may design one or more state plan
amendments to provide health home services to 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 state plan
amendment.
   (b) (1) Subject to federal approval for receipt of the enhanced
federal match, services provided under the program established
pursuant to this article shall include all of the following:
   (A) Comprehensive and individualized care management.
   (B) Care coordination and health promotion, including connection
to medical, mental health, and substance use care.
   (C) Comprehensive transitional care from inpatient to other
settings, including appropriate followup.
   (D) Individual and family support, including authorized
representatives.
   (E) Referral to relevant community and social services supports,
including, but not limited to, connection to housing for participants
who are homeless or unstably housed, transportation to appointments
needed to managed health needs, and peer recovery support.
   (F) Health information technology to identify eligible individuals
and link services, if feasible and appropriate.
   (2) According to beneficiary needs, the health home provider may
provide less intensive services or graduate the beneficiary
completely from the program upon stabilization. 
   (c) (1) 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.  
   (2) The department shall design program elements, including
provider rates specific to eligible populations defined by the
department pursuant to subdivision (d) of Section 14127.1 and
targeted beneficiaries described in Section 14127.3, if applicable,
after consultation with stakeholder groups who have expertise in
engagement and services for those individuals. The department shall
design the health home program with specific elements to engage and
serve these populations, and these populations shall be a specific
focus for health home program outreach and enrollment. 
   14127.3.  (a) If the department creates a health home program
pursuant to this article, the department shall determine whether a
health home program that targets adults is operationally viable.
   (b) (1) In determining whether a health home program that targets
adults is operationally viable, the department shall consider whether
a state plan amendment could be designed in a manner that minimizes
the impact on the General Fund, whether the department has the
capacity to administer the program, and whether a sufficient provider
network exists for providing health home services to  the
population described in this section   targeted
beneficiaries described in subdivision (c)  .
   (2) If the department determines that a health home program that
targets adults is operationally viable pursuant to paragraph (1),
then the department shall design a state plan amendment to target
beneficiaries who meet the criteria specified in subdivision (c).
   (3) (A) If the department determines a health home program that
targets adults is not operationally viable, then the department shall
report the basis for this determination, as well as a plan to
address the  health  needs of  the 
chronically homeless  beneficiaries  and frequent hospital
users to the appropriate policy and fiscal committees of the
Legislature.
   (B) The requirement for submitting the report and plan under
subparagraph (A) is inoperative four years after the date the report
is due, pursuant to Section 10231.5 of the Government Code.
   (c) A state plan amendment  designed  
submitted  pursuant to this section shall target  adult
 beneficiaries who meet both of the following criteria:
   (1) Have current diagnoses of chronic, co-occurring physical
health, mental health, or substance use disorders prevalent among
frequent hospital users  at an acuity level to be determined
by the department  . 
   (2) Have one or more of the following indicators of severity, at a
level to be determined by the department:  
   (2) Have a level of severity in conditions established by the
department, based on one or more of the following factors: 
   (A) Frequent inpatient hospital admissions, including
hospitalization for medical, psychiatric, or substance use related
conditions.
   (B) Excessive use of crisis or emergency services.
   (C) Chronic homelessness.
   (d) (1) For the purposes of providing health home services to
targeted beneficiaries who meet the criteria in subdivision (c), the
department shall select designated health home providers, managed
care organizations subcontracting with providers, or counties acting
as or subcontracting with providers operating as a health home team
that have all of the following:
   (A) Demonstrated experience working with frequent hospital users.
   (B) Demonstrated experience working with people who are
chronically homeless.
   (C) The capacity and administrative infrastructure to participate
in the program, including the ability to meet requirements of federal
guidelines.
   (D) A viable plan, with roles identified among providers of the
health home, to do all of the following:
   (i) Reach out to and engage frequent hospital users and
chronically homeless eligible individuals.
   (ii) Link eligible individuals who are homeless or experiencing
housing instability to permanent housing, such as supportive housing.

   (iii) Ensure coordination and linkages to services needed to
access and maintain health stability, including medical, mental
health, substance use care, and social services to address social
determinants of health.
   (2) The department may design additional provider criteria to
those identified in paragraph (1) after consultation with stakeholder
groups who have expertise in engagement and services for targeted
beneficiaries described in this section.
   (3) The department may authorize health home providers eligible
under this subdivision to serve Medi-Cal enrollees through a
fee-for-service or managed care delivery system, and shall allow for
both county-operated and private providers to participate in the
California Health Home program. 
   (4) The department shall design strategies to outreach to, engage,
and provide health home services to the targeted beneficiaries
identified in subdivision (c), based on consultation with
stakeholders groups who have expertise in engaging and providing
services to these targeted beneficiaries.  
   (5) The department shall design other health home elements,
including provider rates specific to targeted beneficiaries described
in subdivision (c), after consultation with stakeholder groups who
have expertise in engaging and providing services to these targeted
beneficiaries.  
   (6) If the department creates a health home program that targets
adults described in subdivision (c), the department may also submit
state plan amendments targeting other adult populations. 
   14127.4.  (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, or
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.
   14127.5.  (a) If the department creates a health home program, the
department shall ensure that an evaluation of the program 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 under subdivision
(a) is inoperative four years after the date the report is due,
pursuant to Section 10231.5 of the Government Code.
   14127.6.  (a) This article shall be implemented only if and to the
extent federal financial participation is available and the federal
Centers for Medicare and Medicaid Services approves any state plan
amendments sought pursuant to this article.
   (b) Except as provided in subdivisions (c) and (d), this article
shall be implemented only if no additional General Fund moneys are
used to fund the administration and costs of services.
   (c) Notwithstanding subdivision (b), prior to and during the first
eight quarters of implementation, if the department 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 General Fund costs for the
Medi-Cal program, the department may use state funds to fund 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
General Fund costs for the Medi-Cal program, the department may use
state 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.
   (g) The department may revise or terminate the 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
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 be
provided 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 initial adoption of emergency regulations implementing
this article and the readoptions of emergency regulations authorized
by this section shall be deemed an emergency and necessary for the
immediate preservation of the public peace, health, safety, or
general welfare. Initial emergency regulations and readoptions
authorized by this section shall be exempt from review by the Office
of Administrative Law. The initial emergency regulations and
readoptions 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.