Bill Text: CA AB574 | 2011-2012 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Program of All-Inclusive Care for the Elderly.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2011-09-30 - Chaptered by Secretary of State - Chapter 367, Statutes of 2011. [AB574 Detail]
Download: California-2011-AB574-Amended.html
Bill Title: Program of All-Inclusive Care for the Elderly.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2011-09-30 - Chaptered by Secretary of State - Chapter 367, Statutes of 2011. [AB574 Detail]
Download: California-2011-AB574-Amended.html
BILL NUMBER: AB 574 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 22, 2011
AMENDED IN ASSEMBLY MARCH 23, 2011
INTRODUCED BY Assembly Member Bonnie Lowenthal
FEBRUARY 16, 2011
An act to amend Sections 1231.5, 1343.1, 1367.63, 1580.1,
1734.5, and 100315 of the Health and Safety Code, and to am
end Sections 14002.5, 14005.12, 14041.1, 14091.3, 14105.19,
14115.75, 14131.10, 14167.1, and 14168.1 of, and to add Chapter
8.75 (commencing with Section 14591) to, and to repeal Chapter 8.75
(commencing with Section 14590) of, Part 3 of Division 9 of ,
the Welfare and Institutions Code, relating to the elderly.
LEGISLATIVE COUNSEL'S DIGEST
AB 574, as amended, Bonnie Lowenthal. Program of All-Inclusive
Care for the Elderly.
Existing law establishes the federal Medicaid Program,
administered by each state, California's version of which is the
Medi-Cal program. The Medi-Cal program, which is administered by the
State Department of Health Care Services under the direction of the
Director of Health Care Services, provides qualified low-income
persons with health care services. Existing federal law establishes
the Program of All-Inclusive Care for the Elderly (PACE), which
provides specified services for older individuals so that they may
continue living in the community. Federal law authorizes states to
implement the PACE program as a Medicaid state option.
Existing state law authorizes the director to establish the
California Program of All-Inclusive Care for the Elderly and contract
with up to 10 demonstration projects to develop risk-based,
long-term care pilot programs. Existing law also establishes PACE
program services as a covered benefit of the Medi-Cal program.
Existing law authorizes the department to enter into specified
contracts for implementation of the PACE program, and also enter into
separate contracts with certain PACE organizations, to fully
implement the single state agency responsibilities assumed by the
department, as specified. Existing law authorizes the department to
enter into separate contracts with up to 10 PACE organizations, but
prohibits certain contracts unless a Medicaid state plan amendment,
electing PACE as a state Medicaid option, has been approved by the
federal Centers for Medicare and Medicaid Services.
This bill would, instead, require the department to establish the
California Program of All-Inclusive Care for the Elderly and would
delete the pilot program and demonstration project requirements in
these provisions. This bill would also provide that the
department may enter into contracts with public or private
nonprofit organizations for implementation of the PACE program and
increase to 20 15 the number of
separate contracts the department may enter into with PACE
organizations, as defined. This bill would make other conforming
changes.
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. Section 1231.5 of the Health
and Safety Code is amended to read:
1231.5. The department may grant to a PACE program, as defined in
Chapter 8.75 (commencing with Section 14590)
14591) of Part 3 of Division 9 of the Welfare and Institutions
Code, exemptions from the provisions contained in this chapter in
accordance with the requirements of Section 100315.
SEC. 2. Section 1343 .1 of the
Health and Safety Code is amended to read:
1343.1. This chapter shall not apply to any program developed
under the authority of Chapter 8.75 (commencing with Section
14590) 14591) of Part 3 of Division 9 of the
Welfare and Institutions Code.
SEC. 3. Section 1367.63 of the Health
and Safety Code is amended to read:
1367.63. (a) Every health care service plan contract, except a
specialized health care service plan contract, that is issued,
amended, renewed, or delivered in this state on or after July 1,
1999, shall cover reconstructive surgery, as defined in subdivision
(c), that is necessary to achieve the purposes specified in
subparagraph (A) or (B) of paragraph (1) of subdivision (c). Nothing
in this section shall be construed to require a plan to provide
coverage for cosmetic surgery, as defined in subdivision (d).
(b) No individual, other than a licensed physician competent to
evaluate the specific clinical issues involved in the care requested,
may deny initial requests for authorization of coverage for
treatment pursuant to this section. For a treatment authorization
request submitted by a podiatrist or an oral and maxillofacial
surgeon, the request may be reviewed by a similarly licensed
individual, competent to evaluate the specific clinical issues
involved in the care requested.
(c) (1) "Reconstructive surgery" means surgery performed to
correct or repair abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma, infection,
tumors, or disease to do either of the following:
(A) To improve function.
(B) To create a normal appearance, to the extent possible.
(2) As of July 1, 2010, "reconstructive surgery" shall include
medically necessary dental or orthodontic services that are an
integral part of reconstructive surgery, as defined in paragraph (1),
for cleft palate procedures.
(3) For purposes of this section, "cleft palate" means a condition
that may include cleft palate, cleft lip, or other craniofacial
anomalies associated with cleft palate.
(d) "Cosmetic surgery" means surgery that is performed to alter or
reshape normal structures of the body in order to improve
appearance.
(e) In interpreting the definition of reconstructive surgery, a
health care service plan may utilize prior authorization and
utilization review that may include, but need not be limited to, any
of the following:
(1) Denial of the proposed surgery if there is another more
appropriate surgical procedure that will be approved for the
enrollee.
(2) Denial of the proposed surgery or surgeries if the procedure
or procedures, in accordance with the standard of care as practiced
by physicians specializing in reconstructive surgery, offer only a
minimal improvement in the appearance of the enrollee.
(3) Denial of payment for procedures performed without prior
authorization.
(4) For services provided under the Medi-Cal program (Chapter 7
(commencing with Section 14000) of Part 3 of Division 9 of the
Welfare and Institutions Code), denial of the proposed surgery if the
procedure offers only a minimal improvement in the appearance of the
enrollee, as may be defined in any regulations that may be
promulgated by the State Department of Health Care Services.
(f) As applied to services described in paragraph (2) of
subdivision (c) only, this section shall not apply to Medi-Cal
managed care plans that contract with the State Department of Health
Care Services pursuant to Chapter 7 (commencing with Section 14000)
of, Chapter 8 (commencing with Section 14200) of, or Chapter 8.75
(commencing with Section 14590) 14591)
of, Part 3 of Division 9 of the Welfare and Institutions Code, where
such contracts do not provide coverage for California Children's
Services (CCS) or dental services.
SEC. 4. Section 1580.1 of the Health
and Safety Code is amended to read:
1580.1. The State Department of Health Care Services, and as
applicable, the State Department of Public Health and the California
Department of Aging, may grant to entities contracting with the State
Department of Health Care Services under the PACE program, as
defined in Chapter 8.75 (commencing with Section 14590)
14591) of Part 3 of Division 9 of the Welfare
and Institutions Code, exemptions from the provisions contained in
this chapter in accordance with the requirements of Section 100315.
SEC. 5. Section 1734.5 of the Health
and Safety Code is amended to read:
1734.5. The department may grant to entities contracting with the
department under the PACE program, as defined in Chapter 8.75
(commencing with Section 14590) 14591)
of Part 3 of Division 9 of the Welfare and Institutions Code,
exemptions from the provisions contained in this chapter in
accordance with the requirements of Section 100315.
SEC. 6. Section 100315 of the Health
and Safety Code is amended to read:
100315. (a) The department and as applicable, the California
Department of Aging, the State Department of Public Health, and the
State Department of Social Services, may grant to a PACE program, as
defined in Chapter 8.75 (commencing with Section 14590)
14591) of Part 3 of Division 9 of the Welfare
and Institutions Code, exemptions from duplicative, conflicting, or
inconsistent requirements in Chapter 1 (commencing with Section
1200), Chapter 3 (commencing with Section 1500), Chapter 3.2
(commencing with Section 1569), Chapter 3.3 (commencing with Section
1570), and Chapter 8 (commencing with Section 1725) of Division 2,
and Divisions 3 and 5 of Title 22 of the California Code of
Regulations, including the use of alternate concepts, methods,
procedures, techniques, space, equipment, personnel, personnel
qualifications, or the conducting of pilot projects, provided that
the exemptions are implemented in a manner that does not jeopardize
the health and welfare of participants receiving services under PACE,
or deprive beneficiaries of rights specified in federal or state
laws or regulations. In determining whether to grant exemptions under
this section, the departments shall consult with each other.
(b) A written request and substantiating evidence supporting the
request for an exemption under subdivision (a) shall be submitted by
the PACE program to the department. A PACE program may submit a
single request for an exemption from the licensing requirements
applicable to two or more licenses held by that organization, so long
as the request lists the locations and license numbers held by that
organization and the requested exemption is the same and appropriate
for all licensed locations. The written request shall include, but
shall not be limited to, all of the following:
(1) A description of how the applicable state requirement
duplicates, conflicts with, or is inconsistent with state or federal
requirements related to the PACE model.
(2) An analysis demonstrating why the duplication, conflict, or
inconsistency cannot be resolved without an exemption.
(3) A description of how the PACE program plans to comply with the
intent of the requirements described in paragraph (1).
(4) A description of how the PACE program will monitor its
compliance with the terms and conditions under which the exemption is
granted.
(c) The department shall approve or deny any request within 60
days of submission. An approval shall be in writing and shall provide
for the terms and conditions under which the exemption is granted. A
denial shall be in writing and shall specify the basis therefor. Any
decision to deny a request shall be a final administrative decision.
(d) If, after investigation, the department determines that a PACE
program that has been granted an exemption under this section is
operating in a manner contrary to the terms and conditions of the
exemption, the department shall immediately suspend or revoke the
exemption. If the exemption is applicable to more than one location
or more than one category of licensure, or both, the department may
suspend or revoke an exemption as to one or more license categories
or locations as deemed appropriate by the department.
SEC. 7. Section 14002.5 of the Welfare
and Institutions Code is amended to read:
14002.5. For the purposes of this article, the following
definitions shall apply:
(a) "Annuity" means a contract that names an annuitant and gives a
person or entity the right to receive periodic payments of a fixed
or variable sum for a described period of time, which may include a
lump-sum payment or periodic payments upon the death of the
annuitant.
(b) "Community spouse" means the spouse of an institutionalized
spouse.
(c) "Home and facility care" means the following services that are
subject to Medi-Cal reimbursement:
(1) Nursing facility care services.
(2) A level of care in any institution equivalent to that of
nursing facility care services.
(3) Home- or community-based care services furnished under a
waiver granted pursuant to subsection (c) or (d) of Section 1396n of
Title 42 of the United States Code.
(d) "Institutionalized spouse" means any individual to whom all of
the following apply:
(1) The individual is in a medical institution or nursing facility
or is a person who is receiving institutional or noninstitutional
services from an organization with a frail elderly demonstration
project waiver pursuant to Chapter 8.75 (commencing with Section
14590) 14591) , and is likely to meet
that requirement for at least 30 consecutive days.
(2) The individual is married to a spouse who is not in a medical
institution or nursing facility, or to a spouse who is not receiving
services from any organization with a frail elderly demonstration
project waiver pursuant to Chapter 8.75 (commencing with Section
14590) 14591) .
(3) Except for purposes of Sections 14005.7, 14005.12, 14005.16,
and 14005.17, an individual who is admitted to a medical institution
or nursing facility on or after September 30, 1989, and who applies
for Medi-Cal benefits on or after January 1, 1990, or a Medi-Cal
recipient who is admitted to a medical institution or nursing
facility on or after January 1, 1990.
(e) "Medical institution" has the same meaning as defined in
Section 435.1010 of Title 42 of the Code of Federal Regulations.
(f) "Nursing facility" has the same meaning as defined in Section
1250 of the Health and Safety Code.
SEC. 8. Section 14005.12 of the Welfare
and Institutions Code is amended to read:
14005.12. (a) For the purposes of Sections 14005.4 and 14005.7,
the department shall establish the income levels for maintenance need
at the lowest levels that reasonably permit medically needy persons
to meet their basic needs for food, clothing, and shelter, and for
which federal financial participation will still be provided under
Title XIX of the federal Social Security Act. It is the intent of the
Legislature that the income levels for maintenance need for
medically needy aged, blind, and disabled adults, in particular,
shall be based upon amounts that adequately reflect their needs.
(1) Subject to paragraph (2), reductions in the maximum aid
payment levels set forth in subdivision (a) of Section 11450 in the
1991-92 fiscal year, and thereafter, shall not result in a reduction
in the income levels for maintenance under this section.
(2) (A) The department shall seek any necessary federal
authorization for maintaining the income levels for maintenance at
the levels in effect June 30, 1991.
(B) If federal authorization is not obtained, medically needy
persons shall not be required to pay the difference between the share
of cost as determined based on the payment levels in effect on June
30, 1991, under Section 11450, and the share of cost as determined
based on the payment levels in effect on July 1, 1991, and
thereafter.
(3) Any medically needy person who was eligible for benefits under
this chapter as categorically needy for the calendar month
immediately preceding the effective date of the reductions in the
minimum basic standards of adequate care for the Aid to Families with
Dependent Children program as set forth in Section 11452.018 made in
the 1995-96 Regular Session of the Legislature shall not be
responsible for paying his or her share of cost if all of the
following apply:
(A) He or she had eligibility as categorically needy terminated by
the reductions in the minimum basic standards of adequate care.
(B) He or she, but for the reductions, would be eligible to
continue receiving benefits under this chapter as categorically
needy.
(C) He or she is not eligible to receive benefits without a share
of cost as a medically needy person pursuant to paragraph (1) or (2).
(b) In the case of a single individual, the amount of the income
level for maintenance per month shall be 80 percent of the highest
amount that would ordinarily be paid to a family of two persons,
without any income or resources, under subdivision (a) of Section
11450, multiplied by the federal financial participation rate.
(c) In the case of a family of two adults, the income level for
maintenance per month shall be the highest amount that would
ordinarily be paid to a family of three persons without income or
resources under subdivision (a) of Section 11450, multiplied by the
federal financial participation rate.
(d) For the purposes of Sections 14005.4 and 14005.7, for a person
in a medical institution or nursing facility, or for a person
receiving institutional or noninstitutional services from an
organization with a frail elderly demonstration project waiver
pursuant to Chapter 8.75 (commencing with Section 14590)
14591) , the amount considered as required for
maintenance per month shall be computed in accordance with, and for
those purposes required by, Title XIX of the federal Social Security
Act, and regulations adopted pursuant thereto. Those amounts shall be
computed pursuant to regulations which include providing for the
following purposes:
(1) Personal and incidental needs in the amount of not less than
thirty-five dollars ($35) per month while a patient. The department
may, by regulation, increase this amount as necessitated by
increasing costs of personal and incidental needs. A long-term health
care facility shall not charge an individual for the laundry
services or periodic hair care specified in Section 14110.4.
(2) The upkeep and maintenance of the home.
(3) The support and care of his or her minor children, or any
disabled relative for whose support he or she has contributed
regularly, if there is no community spouse.
(4) If the person is an institutionalized spouse, for the support
and care of his or her community spouse, minor or dependent children,
dependent parents, or dependent siblings of either spouse, provided
the individuals are residing with the community spouse.
(5) The community spouse monthly income allowance shall be
established at the maximum amount permitted in accordance with
Section 1924(d)(1)(B) of Title XIX of the federal Social Security Act
(42 U.S.C. Sec. 1396r-5(d)(1)(B)).
(6) The family allowance for each family member residing with the
community spouse shall be computed in accordance with the formula
established in Section 1924(d)(1)(C) of Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396r-5(d)(1)(C)).
(e) For the purposes of Sections 14005.4 and 14005.7, with regard
to a person in a licensed community care facility, the amount
considered as required for maintenance per month shall be computed
pursuant to regulations adopted by the department which provide for
the support and care of his or her spouse, minor children, or any
disabled relative for whose support he or she has contributed
regularly.
(f) The income levels for maintenance per month, except as
specified in subdivisions (b) to (d), inclusive, shall be equal to
the highest amounts that would ordinarily be paid to a family of the
same size without any income or resources under subdivision (a) of
Section 11450, multiplied by the federal financial participation
rate.
(g) The "federal financial participation rate," as used in this
section, shall mean 1331/3 percent, or such other rate set forth in
Section 1903 of the federal Social Security Act (42 U.S.C. Sec. 1396
(b)), or its successor provisions.
(h) The income levels for maintenance per month shall not be
decreased to reflect the presence in the household of persons
receiving forms of aid other than Medi-Cal.
(i) When family members maintain separate residences, but
eligibility is determined as a single unit under Section 14008, the
income levels for maintenance per month shall be established for each
household in accordance with subdivisions (b) to (h), inclusive. The
total of these levels shall be the level for the single eligibility
unit.
(j) The income levels for maintenance per month established
pursuant to subdivisions (b) to (i), inclusive, shall be calculated
on an annual basis, rounded to the next higher multiple of one
hundred dollars ($100), and then prorated.
SEC. 9. Section 14041.1 of the Welfare
and Institutions Code is amended to read:
14041.1. (a) Notwithstanding any other provision of law, and to
the extent not otherwise conflicting with federal law, the department
may hold for a period of one month, or direct the medical fiscal
intermediary for the Medi-Cal program to hold for a period of one
month, payments to providers or their designated agents for health
care services that are provided pursuant to this chapter, and
payments to entities that contract with the department pursuant to
this chapter, Chapter 8 (commencing with Section 14200) and Chapter
8.75 (commencing with Section 14590) 14591)
for the delivery of health care services.
(b) The authority described in subdivision (a) shall be limited to
payments for one month only, and only for a month ending prior to
June 30, 2009.
SEC. 10. Section 14091.3 of the Welfare
and Institutions Code is amended to read:
14091.3. (a) For purposes of this section, the following
definitions shall apply:
(1) "Medi-Cal managed care plan contracts" means those contracts
entered into with the department by any individual, organization, or
entity pursuant to Article 2.7 (commencing with Section 14087.3),
Article 2.8 (commencing with Section 14087.5), Article 2.91
(commencing with Section 14089) of this chapter, or Article 1
(commencing with Section 14200) or Article 7 (commencing with Section
14490) of Chapter 8, or Chapter 8.75 (commencing with Section
14590) 14591) .
(2) "Medi-Cal managed care health plan" means an individual,
organization, or entity operating under a Medi-Cal managed care plan
contract with the department under this chapter, Chapter 8
(commencing with Section 14200), or Chapter 8.75 (commencing with
Section 14590) 14591) .
(b) The department shall take all appropriate steps to amend the
Medicaid State Plan, if necessary, to carry out this section. This
section shall be implemented only to the extent that federal
financial participation is available. The department shall adopt
rules and regulations to carry out this section. Until January 1,
2010, any rules and regulations adopted pursuant to this subdivision
may be adopted as emergency regulations in accordance with the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code).
The adoption of these regulations shall be deemed an emergency and
necessary for the immediate preservation of the public peace, health,
and safety or general welfare. The regulations shall become
effective immediately upon filing with the Secretary of State.
(c) Any hospital that does not have in effect a contract with a
Medi-Cal managed care health plan, as defined in paragraph (2) of
subdivision (a), that establishes payment amounts for services
furnished to a beneficiary enrolled in that plan shall accept as
payment in full, from all these plans, the following amounts:
(1) For outpatient services, the Medi-Cal fee-for-service (FFS)
payment amounts.
(2) For emergency inpatient services, the average per diem
contract rate specified in paragraph (2) of subdivision (b) of
Section 14166.245, except that the payment amount shall not be
reduced by 5 percent. For the purposes of this paragraph, this
payment amount shall apply to all hospitals, including hospitals that
contract with the department under the Medi-Cal Selective Provider
Contracting Program described in Article 2.6 (commencing with Section
14081), and small and rural hospitals specified in Section 124840 of
the Health and Safety Code.
(3) For poststabilization services following an emergency
admission, payment amounts shall be consistent with subdivision (e)
of Section 438.114 of Title 42 of the Code of Federal Regulations.
This paragraph shall only be implemented to the extent that contract
amendment language providing for these payments is approved by CMS.
For purposes of this paragraph, this payment amount shall apply to
all hospitals, including hospitals that contract with the department
under the Medi-Cal Selective Provider Contracting Program pursuant to
Article 2.6 (commencing with Section 14081).
(d) Medi-Cal managed care health plans that, pursuant to the
department's encouragement in All Plan Letter 07003, have been paying
out-of-network hospitals the most recent California Medical
Assistance Commission regional average per diem rate as a temporary
rate for purposes of Section 1932(b)(2)(D) of the Social Security Act
(SSA), which became effective January 1, 2007, shall make
reconciliations and adjustments for all hospital payments made since
January 1, 2007, based upon rates published by the department
pursuant to Section 1932(b)(2)(D) of the SSA and effective January 1,
2007, to June 30, 2008, inclusive, and, if applicable, provide
supplemental payments to hospitals as necessary to make payments that
conform with Section 1932(b)(2)(D) of the SSA. In order to provide
managed care health plans with 60 working days to make any necessary
supplemental payments to hospitals prior to these payments becoming
subject to the payment of interest, Section 1300.71 of Title 28 of
the California Code of Regulations shall not apply to these
supplemental payments until 30 working days following the publication
by the department of the rates.
(e) (1) The department shall provide a written report to the
policy and fiscal committees of the Legislature on October 1, 2009,
and May 1, 2010, on the implementation and impact made by this
section, including the impact of these changes on access to hospitals
by managed care enrollees and on contracting between hospitals and
managed care health plans, including the increase or decrease in the
number of these contracts.
(2) Not later than August 1, 2010, the department shall report to
the Legislature on the implementation of this section. The report
shall include, but not be limited to, information and analyses
addressing managed care enrollee access to hospital services, the
impact of this section on managed care health plan capitation rates,
the impact of this section on the extent of contracting between
managed care health plans and hospitals, and fiscal impact on the
state.
(3) For the purposes of preparing the annual status reports and
the final evaluation report required pursuant to this subdivision,
Medi-Cal managed care health plans shall provide the department with
all data and documentation, including contracts with providers,
including hospitals, as deemed necessary by the department to
evaluate the impact of the implementation of this section. In order
to ensure the confidentiality of managed care health plan proprietary
information, and thereby enable the department to have access to all
of the data necessary to provide the Legislature with accurate and
meaningful information regarding the impact of this section, all
information and documentation provided to the department pursuant to
this section shall be considered proprietary and shall be exempt from
disclosure as official information pursuant to subdivision (k) of
Section 6254 of the Government Code as contained in the California
Public Records Act (Division 7 (commencing with Section 6250) of
Title 1 of the Government Code).
(f) This section shall remain in effect only until January 1,
2013, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2013, deletes or extends
that date.
SEC. 11. Section 14105.19 of the
Welfare and Institutions Code is amended to read:
14105.19. (a) Notwithstanding any other provision of law, in
order to implement changes in the level of funding for health care
services, the director shall reduce provider payments as specified in
this section.
(b) (1) Except as provided in subdivision (c), payments shall be
reduced by 10 percent for Medi-Cal fee-for-service benefits for dates
of service on and after July 1, 2008, through and including dates of
service on February 28, 2009.
(2) Except as provided in subdivision (c), payments shall be
reduced by 10 percent for non-Medi-Cal programs described in Article
6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division
106 of the Health and Safety Code, and Section 14105.18 of this
code, for dates of service on and after July 1, 2008, through and
including dates of service on February 28, 2009.
(3) For managed health care plans that contract with the
department pursuant to this chapter, Chapter 8 (commencing with
Section 14200), and Chapter 8.75 (commencing with Section
14590) 14591) , payments shall be reduced by the
actuarial equivalent amount of the payment reduction specified in
this subdivision pursuant to contract amendments or change orders
effective on July 1, 2008.
(4) Notwithstanding paragraphs (1) and (2), payment reductions set
forth in this subdivision shall apply to small and rural hospitals,
as defined in Section 124840 of the Health and Safety Code, for dates
of service on and after July 1, 2008, through and including October
31, 2008.
(c) The services listed in this
subdivision shall be exempt from the payment reductions specified in
subdivision (b):
(1) Acute hospital inpatient services, except for payments to
hospitals not under contract with the State Department of Health Care
Services, as provided in Section 14166.245.
(2) Federally qualified health center services, including those
facilities deemed to have federally qualified health center status
pursuant to a waiver under subdivision (a) of Section 1315 of Title
42 of the United States Code.
(3) Rural health clinic services.
(4) All of the following facilities:
(A) A skilled nursing facility licensed pursuant to subdivision
(c) of Section 1250 of the Health and Safety Code, except a skilled
nursing facility that is a distinct part of a general acute care
hospital. For purposes of this paragraph, "distinct part" has the
same meaning as defined in Section 72041 of Title 22 of the
California Code of Regulations.
(B) An intermediate care facility for the developmentally disabled
licensed pursuant to subdivision (e), (g), or (h) of Section 1250 of
the Health and Safety Code, or a facility providing continuous
skilled nursing care to developmentally disabled individuals pursuant
to the pilot project established by Section 14495.10.
(C) A subacute care unit, as defined in Section 51215.5 of Title
22 of the California Code of Regulations.
(5) Payments to facilities owned or operated by the State
Department of Mental Health or the State Department of Developmental
Services.
(6) Hospice.
(7) Contract services as designated by the director pursuant to
subdivision (e).
(8) Payments to providers to the extent that the payments are
funded by means of a certified public expenditure or an
intergovernmental transfer pursuant to Section 433.51 of Title 42 of
the Code of Federal Regulations.
(9) Services pursuant to local assistance contracts and
interagency agreements to the extent the funding is not included in
the funds appropriated to the department in the annual Budget Act.
(10) Payments to Medi-Cal managed care plans pursuant to Section
4474.5 for services to consumers transitioning from Agnews
Developmental Center into Alameda, San Mateo, and Santa Clara
Counties pursuant to the Plan for the Closure of Agnews Developmental
Center.
(11) Breast and cervical cancer treatment provided pursuant to
Section 14007.71.
(12) The Family Planning, Access, Care, and Treatment (Family
PACT) Waiver Program pursuant to Section 14105.18.
(d) Subject to the exception for services listed in subdivision
(c), the payment reductions required by subdivision (b) shall apply
to the services rendered by any provider who may be authorized to
bill for the service, including, but not limited to, physicians,
podiatrists, nurse practitioners, certified nurse-midwives, nurse
anesthetists, and organized outpatient clinics.
(e) 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 this section by means of a provider
bulletin, or similar instruction, without taking regulatory action.
(f) The reductions described in this section shall apply only to
payments for services when the General Fund share of the payment is
paid with funds directly appropriated to the department in the annual
Budget Act and shall not apply to payments for services paid with
funds appropriated to other departments or agencies.
(g) The department shall promptly seek any necessary federal
approvals for the implementation of this section.
SEC. 12. Section 14115.75 of the
Welfare and Institutions Code is amended to read:
14115.75. (a) As a condition of payment for goods, supplies, and
merchandise provided to Medi-Cal beneficiaries by a provider that
receives or makes annual payments of at least five million dollars
($5,000,000) under the Medi-Cal program, the provider shall comply
with the federal False Claims Act employee training and policy
requirements contained in Section 1902(a) of the federal Social
Security Act (42 U.S.C. Sec. 1396a(a)(68)), and with any requirements
that the United States Secretary of Health and Human Services may
specify. The calculation of the five million dollar ($5,000,000)
threshold shall be based on federal law and regulations and guidance
from the United States Secretary of Health and Human Services.
(b) For purposes of this section, "provider" has the same meaning
as that term is defined in Section 14043.1, and also includes any
Medi-Cal managed care plan authorized under this chapter, Chapter 8
(commencing with Section 14200) , or Chapter 8.75
(commencing with Section 14590) 14591)
.
SEC. 13. Section 14131.10 of the
Welfare and Institutions Code is amended to read:
14131.10. (a) Notwithstanding any other provision of this
chapter, Chapter 8 (commencing with Section 14200), or Chapter 8.75
(commencing with Section 14590) 14591)
, in order to implement changes in the level of funding for health
care services, specific optional benefits are excluded from coverage
under the Medi-Cal program.
(b) (1) The following optional benefits are excluded from coverage
under the Medi-Cal program:
(A) Adult dental services, except as specified in paragraph (2).
(B) Acupuncture services.
(C) Audiology services and speech therapy services.
(D) Chiropractic services.
(E) Optometric and optician services, including services provided
by a fabricating optical laboratory.
(F) Podiatric services.
(G) Psychology services.
(H) Incontinence creams and washes.
(2) Medical and surgical services provided by a doctor of dental
medicine or dental surgery, which, if provided by a physician, would
be considered physician services, and which services may be provided
by either a physician or a dentist in this state, are covered.
(3) Pregnancy-related services and services for the treatment of
other conditions that might complicate the pregnancy are not excluded
from coverage under this section.
(c) The optional benefit exclusions do not apply to either of the
following:
(1) Beneficiaries under the Early and Periodic Screening Diagnosis
and Treatment Program.
(2) Beneficiaries receiving long-term care in a nursing facility
that is both:
(A) A skilled nursing facility or intermediate care facility as
defined in subdivisions (c) and (d) of Section 1250 of the Health and
Safety Code.
(B) Licensed pursuant to subdivision (k) of Section 1250 of the
Health and Safety Code.
(d) This section shall only be implemented to the extent permitted
by federal law.
(e) 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 the provisions of this section by means of
all-county letters, provider bulletins, or similar instructions,
without taking further regulatory action.
(f) This section shall be implemented on the first day of the
month following 90 days after the operative date of this section.
SEC. 14. Section 14167.1 of the Welfare
and Institutions Code is amended to read:
14167.1. For purposes of this article, the following definitions
shall apply:
(a) "Acute psychiatric days" means the total number of Short-Doyle
administrative days, Short-Doyle acute care days, acute psychiatric
administrative days, and acute psychiatric acute days identified in
the Final Medi-Cal Utilization Statistics for the 2008-09 state
fiscal year as calculated by the department on September 15, 2008.
(b) "Converted hospital" means a private hospital that becomes a
designated public hospital or a nondesignated public hospital after
the implementation date, a nondesignated public hospital that becomes
a private hospital or a designated public hospital after the
implementation date, or a designated public hospital that becomes a
private hospital or a nondesignated public hospital after the
implementation date.
(c) "Current Section 1115 Waiver" means California's Medi-Cal
Hospital/Uninsured Care Section 1115 Waiver Demonstration in effect
on the effective date of the article.
(d) "Designated public hospital" shall have the meaning given in
subdivision (d) of Section 14166.1 as that section may be amended
from time to time.
(e) "General acute care days" means the total number of Medi-Cal
general acute care days paid by the department to a hospital in the
2008 calendar year, as reflected in the state paid claims files on
July 10, 2009.
(f) "High acuity days" means Medi-Cal coronary care unit days,
pediatric intensive care unit days, intensive care unit days,
neonatal intensive care unit days, and burn unit days paid by the
department during the 2008 calendar year, as reflected in the state
paid claims files on July 10, 2009.
(g) "Hospital inpatient services" means all services covered under
Medi-Cal and furnished by hospitals to patients who are admitted as
hospital inpatients and reimbursed on a fee-for-service basis by the
department directly or through its fiscal intermediary. Hospital
inpatient services include outpatient services furnished by a
hospital to a patient who is admitted to that hospital within 24
hours of the provision of the outpatient services that are related to
the condition for which the patient is admitted. Hospital inpatient
services do not include services for which a managed health care plan
is financially responsible.
(h) "Hospital outpatient services" means all services covered
under Medi-Cal furnished by hospitals to patients who are registered
as hospital outpatients and reimbursed by the department on a
fee-for-service basis directly or through its fiscal intermediary.
Hospital outpatient services do not include services for which a
managed health care plan is financially responsible, or services
rendered by a hospital-based federally qualified health center for
which reimbursement is received pursuant to Section 14132.100.
(i) (1) "Implementation date" means the latest effective date of
all federal approvals or waivers necessary for the implementation of
this article and Article 5.22 (commencing with Section 14167.31),
including, but not limited to, any approvals on amendments to
contracts between the department and managed health care plans or
mental health plans necessary for the implementation of this article.
The effective date of a federal approval or waiver shall be the
earlier of the stated effective date or the first day of the first
quarter to which the computation of the payments or fee under the
federal approval or waiver is applicable, which may be prior to the
date that the federal approval or waiver is granted or the applicable
contract is amended.
(2) If federal approval is sought initially for only the 2008-09
federal fiscal year and separately secured for subsequent federal
fiscal years, the implementation date for the 2008-09 federal fiscal
year shall occur when all necessary federal approvals have been
secured for that federal fiscal year.
(j) "Individual hospital acute psychiatric supplemental payment"
means the total amount of acute psychiatric hospital supplemental
payments to a subject hospital for a quarter for which the
supplemental payments are made. The "individual hospital acute
psychiatric supplemental payment" shall be calculated for subject
hospitals by multiplying the number of acute psychiatric days for the
individual hospital for which a mental health plan was financially
responsible by four hundred eighty-five dollars ($485) and dividing
the result by 4.
(k) (1) "Managed health care plan" means a health care delivery
system that manages the provision of health care and receives prepaid
capitated payments from the state in return for providing services
to Medi-Cal beneficiaries.
(2) (A) Managed health care plans include county organized health
systems and entities contracting with the department to provide
services pursuant to two-plan models and geographic managed care.
Entities providing these services contract with the department
pursuant to any of the following:
(i) Article 2.7 (commencing with Section 14087.3).
(ii) Article 2.8 (commencing with Section 14087.5).
(iii) Article 2.81 (commencing with Section 14087.96).
(iv) Article 2.91 (commencing with Section 14089).
(B) Managed health care plans do not include any of the following:
(i) Mental health plan contracting to provide mental health care
for Medi-Cal beneficiaries pursuant to Part 2.5 (commencing with
Section 5775) of Division 5.
(ii) Health plan not covering inpatient services such as primary
care case management plans operating pursuant to Section 14088.85.
(iii) Long-Term Care Demonstration Projects for All-Inclusive Care
for the Elderly operating pursuant to Chapter 8.75 (commencing with
Section 14590) 14591) .
(l) "Medi-Cal managed care days" means the total number of general
acute care days, including well baby days, listed for the county
organized health system and prepaid health plans identified in the
Final Medi-Cal Utilization Statistics for the 2008-09 state fiscal
year, as calculated by the department on September 15, 2008, except
that the general acute care days, including well baby days, for the
Santa Barbara Health Care Initiative shall be derived from the Final
Medi-Cal Utilization Statistics for the 2007-08 state fiscal year.
(m) "Medicaid inpatient utilization rate" means Medicaid inpatient
utilization rate as defined in Section 1396r-4 of Title 42 of the
United States Code and as set forth in the final disproportionate
share hospital eligibility list for the 2008-09 state fiscal year
released by the department on October 22, 2008.
(n) "Mental health plan" means a mental health plan that contracts
with the State Department of Mental Health to furnish or arrange for
the provision of mental health services to Medi-Cal beneficiaries
pursuant to Part 2.5 (commencing with Section 5775) of Division 5.
(o) "New hospital" means a hospital that was not in operation
under current or prior ownership as a private hospital, a
nondesignated public hospital, or a designated public hospital for
any portion of the 2008-09 state fiscal year.
(p) "Nondesignated public hospital" means either of the following:
(1) A public hospital that is licensed under subdivision (a) of
Section 1250 of the Health and Safety Code, is not designated as a
specialty hospital in the hospital's annual financial disclosure
report for the hospital's latest fiscal year ending in 2007, and
satisfies the definition in paragraph (25) of subdivision (a) of
Section 14105.98, excluding designated public hospitals.
(2) A tax-exempt nonprofit hospital that is licensed under
subdivision (a) of Section 1250 of the Health and Safety Code, is not
designated as a specialty hospital in the hospital's annual
financial disclosure report for the hospital's latest fiscal year
ending in 2007, is operating a hospital owned by a local health care
district, and is affiliated with the health care district hospital
owner by means of the district's status as the nonprofit corporation'
s sole corporate member.
(q) "Outpatient base amount" means the total amount of payments
for hospital outpatient services made to a hospital in the 2007
calendar year, as reflected in state paid claims files on January 26,
2008.
(r) "Private hospital" means a hospital that meets all of the
following conditions:
(1) Is licensed pursuant to subdivision (a) of Section 1250 of the
Health and Safety Code.
(2) Is in the Charitable Research Hospital peer group, as set
forth in the 1991 Hospital Peer Grouping Report published by the
department, or is not designated as a specialty hospital in the
hospital's Office of Statewide Health Planning and Development Annual
Financial Disclosure Report for the hospital's latest fiscal year
ending in 2007.
(3) Does not satisfy the Medicare criteria to be classified as a
long-term care hospital.
(4) Is a nonpublic hospital, nonpublic converted hospital, or
converted hospital as those terms are defined in paragraphs (26) to
(28), inclusive, respectively, of subdivision (a) of Section
14105.98.
(s) "Subject federal fiscal year" means a federal fiscal year that
ends after the implementation date and begins before December 31,
2010.
(t) "Subject fiscal quarter" means a fiscal quarter beginning on
or after the implementation date and ending before January 1, 2011.
(u) "Subject fiscal year" means a state fiscal year that ends
after the implementation date and begins before December 31, 2010.
(v) "Subject hospital" shall mean a hospital that meets all of the
following conditions:
(1) Is licensed pursuant to subdivision (a) of Section 1250 of the
Health and Safety Code.
(2) Is in the Charitable Research Hospital peer group, as set
forth in the 1991 Hospital Peer Grouping Report published by the
department, or is not designated as a specialty hospital in the
hospital's Office of Statewide Health Planning and Development Annual
Financial Disclosure Report for the hospital's latest fiscal year
ending in 2007.
(3) Does not satisfy the Medicare criteria to be classified as a
long-term care hospital.
(w) "Subject month" means a calendar month beginning on or after
the implementation date and ending before January 1, 2011.
(x) "Upper payment limit" means a federal upper payment limit on
the amount of the Medicaid payment for which federal financial
participation is available for a class of service and a class of
health care providers, as specified in Part 447 of Title 42 of the
Code of Federal Regulations.
SEC. 15. Section 14168.1 of the Welfare
and Institutions Code is amended to read:
14168.1. For the purposes of this article, the following
definitions shall apply:
(a) "Acute psychiatric days" means the total number of Short-Doyle
administrative days, Short-Doyle acute care days, acute psychiatric
administrative days, and acute psychiatric acute days identified in
the Final Medi-Cal Utilization Statistics for the 2008-09 state
fiscal year as calculated by the department on September 15, 2008.
(b) "Converted hospital" means a private hospital that becomes a
designated public hospital or a nondesignated public hospital on or
after January 1, 2011, a nondesignated public hospital that becomes a
private hospital or a designated public hospital on or after January
1, 2011, or a designated public hospital that becomes a private
hospital or a nondesignated public hospital on or after January 1,
2011.
(c) "Days data source" means the following:
(1) For a hospital that did not submit an Annual Financial
Disclosure Report to the Office of Statewide Health Planning and
Development for a fiscal year ending during 2007, but submitted that
report for a fiscal period ending in 2008 that includes at least 10
months of 2007, the Annual Financial Disclosure Report submitted by
the hospital to the Office of Statewide Health Planning and
Development for the fiscal period in 2008 that includes at least 10
months of 2007.
(2) For a hospital owned by Kaiser Foundation Hospitals that
submitted corrections to reported patient days to the Office of
Statewide Health Planning and Development for its fiscal year ending
in 2007 before July 31, 2009, the corrected data.
(3) For all other hospitals, the hospital's Annual Financial
Disclosure Report in the Office of Statewide Health Planning and
Development files as of October 31, 2008, for its fiscal year ending
during 2007.
(d) "Designated public hospital" shall have the meaning given in
subdivision (d) of Section 14166.1 as of January 1, 2011.
(e) "General acute care days" means the total number of Medi-Cal
general acute care days paid by the department to a hospital in the
2008 calendar year, as reflected in the state paid claims files on
July 10, 2009.
(f) "High acuity days" means Medi-Cal coronary care unit days,
pediatric intensive care unit days, intensive care unit days,
neonatal intensive care unit days, and burn unit days paid by the
department during the 2008 calendar year, as reflected in the state
paid claims files on July 10, 2009.
(g) "Hospital inpatient services" means all services covered under
Medi-Cal and furnished by hospitals to patients who are admitted as
hospital inpatients and reimbursed on a fee-for-service basis by the
department directly or through its fiscal intermediary. Hospital
inpatient services include outpatient services furnished by a
hospital to a patient who is admitted to that hospital within 24
hours of the provision of the outpatient services that are related to
the condition for which the patient is admitted. Hospital inpatient
services do not include services for which a managed health care plan
is financially responsible.
(h) "Hospital outpatient services" means all services covered
under Medi-Cal furnished by hospitals to patients who are registered
as hospital outpatients and reimbursed by the department on a
fee-for-service basis directly or through its fiscal intermediary.
Hospital outpatient services do not include services for which a
managed health care plan is financially responsible, or services
rendered by a hospital-based federally qualified health center for
which reimbursement is received pursuant to Section 14132.100.
(i) "Individual hospital acute psychiatric supplemental payment"
means the total amount of acute psychiatric hospital supplemental
payments to a subject hospital for a quarter for which the
supplemental payments are made. The "individual hospital acute
psychiatric supplemental payment" shall be calculated for subject
hospitals by multiplying the number of acute psychiatric days for the
individual hospital for which a mental health plan was financially
responsible by four hundred eighty-five dollars ($485) and dividing
the result by four.
(j) (1) "Managed health care plan" means a health care delivery
system that manages the provision of health care and receives prepaid
capitated payments from the state in return for providing services
to Medi-Cal beneficiaries.
(2) (A) Managed health care plans include county organized health
systems and entities contracting with the department to provide
services pursuant to two-plan models and geographic managed care.
Entities providing these services contract with the department
pursuant to any of the following:
(i) Article 2.7 (commencing with Section 14087.3).
(ii) Article 2.8 (commencing with Section 14087.5).
(iii) Article 2.81 (commencing with Section 14087.96).
(iv) Article 2.91 (commencing with Section 14089).
(B) Managed health care plans do not include any of the following:
(i) Mental health plan contracting to provide mental health care
for Medi-Cal beneficiaries pursuant to Part 2.5 (commencing with
Section 5775) of Division 5.
(ii) Health plan not covering inpatient services such as primary
care case management plans operating pursuant to Section 14088.85.
(iii) Long-Term Care Demonstration Projects for All-Inclusive Care
for the Elderly operating pursuant to Chapter 8.75 (commencing with
Section 14590) 14591) .
(k) "Medi-Cal managed care days" means the total number of general
acute care days, including well baby days, listed for the county
organized health system and prepaid health plans identified in the
Final Medi-Cal Utilization Statistics for the 2008-09 fiscal year, as
calculated by the department on September 15, 2008, except that the
general acute care days, including well baby days, for the Santa
Barbara Health Care Initiative shall be derived from the Final
Medi-Cal Utilization Statistics for the 2007-08 fiscal year.
(l) "Medicaid inpatient utilization rate" means Medicaid inpatient
utilization rate as defined in Section 1396r-4 of Title 42 of the
United States Code and as set forth in the final disproportionate
share hospital eligibility list for the 2008-09 fiscal year released
by the department on October 22, 2008.
(m) "Mental health plan" means a mental health plan that contracts
with the State Department of Mental Health to furnish or arrange for
the provision of mental health services to Medi-Cal beneficiaries
pursuant to Part 2.5 (commencing with Section 5775) of Division 5.
(n) "New hospital" means a hospital operation, business, or
facility functioning under current or prior ownership as a private
hospital that does not have a days data source or a hospital that has
a days data source in whole, or in part, from a previous operator
where there is an outstanding monetary liability owed to the state in
connection with the Medi-Cal program and the new operator did not
assume liability for the outstanding monetary obligation.
(o) "New noncontract hospital" means a private hospital that was a
contract hospital on March 1, 2011, and elects to become a
noncontract hospital at any time between March 1, 2011, and the end
of the program period.
(p) "Nondesignated public hospital" means either of the following:
(1) A public hospital that is licensed under subdivision (a) of
Section 1250 of the Health and Safety Code, is not designated as a
specialty hospital in the hospital's annual financial disclosure
report for the hospital's latest fiscal year ending in 2007, and
satisfies the definition in paragraph (25) of subdivision (a) of
Section 14105.98, excluding designated public hospitals.
(2) A tax-exempt nonprofit hospital that is licensed under
subdivision (a) of Section 1250 of the Health and Safety Code, is not
designated as a specialty hospital in the hospital's annual
financial disclosure report for the hospital's latest fiscal year
ending in 2007, is operating a hospital owned by a local health care
district, and is affiliated with the health care district hospital
owner by means of the district's status as the nonprofit corporation'
s sole corporate member.
(q) "Outpatient base amount" means the total amount of payments
for hospital outpatient services made to a hospital in the 2007
calendar year, as reflected in state paid claims files on January 26,
2008.
(r) "Private hospital" means a hospital that meets all of the
following conditions:
(1) Is licensed pursuant to subdivision (a) of Section 1250 of the
Health and Safety Code.
(2) Is in the Charitable Research Hospital peer group, as set
forth in the 1991 Hospital Peer Grouping Report published by the
department, or is not designated as a specialty hospital in the
hospital's Office of Statewide Health Planning and Development Annual
Financial Disclosure Report for the hospital's latest fiscal year
ending in 2007.
(3) Does not satisfy the Medicare criteria to be classified as
a long-term care hospital.
(4) Is a nonpublic hospital, nonpublic converted hospital, or
converted hospital as those terms are defined in paragraphs (26) to
(28), inclusive, respectively, of subdivision (a) of Section
14105.98.
(s) "Program period" means the period from January 1, 2011, to
June 30, 2011, inclusive.
(t) "Subject fiscal quarter" means a state fiscal quarter
beginning on or after January 1, 2011, and ending before July 1,
2011.
(u) "Subject hospital" shall mean a hospital that meets all of the
following conditions:
(1) Is licensed pursuant to subdivision (a) of Section 1250 of the
Health and Safety Code.
(2) Is in the Charitable Research Hospital peer group, as set
forth in the 1991 Hospital Peer Grouping Report published by the
department, or is not designated as a specialty hospital in the
hospital's Office of Statewide Health Planning and Development Annual
Financial Disclosure Report for the hospital's latest fiscal year
ending in 2007.
(3) Does not satisfy the Medicare criteria to be classified as a
long-term care hospital.
(v) "Subject month" means a calendar month beginning on or after
January 1, 2011, and ending before July 1, 2011.
(w) "Upper payment limit" means a federal upper payment limit on
the amount of the Medicaid payment for which federal financial
participation is available for a class of service and a class of
health care providers, as specified in Part 447 of Title 42 of the
Code of Federal Regulations.
SECTION 1. SEC. 16. Chapter 8.75
(commencing with Section 14590) of Part 3 of Division 9 of the
Welfare and Institutions Code is repealed.
SEC. 2. SEC. 17. Chapter 8.75
(commencing with Section 14591) is added to Part 3 of Division 9 of
the Welfare and Institutions Code, to read:
CHAPTER 8.75. PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY
14591. The Legislature finds and declares all of the following:
(a) Community-based services to the frail elderly are often
uncoordinated, fragmented, inappropriate, or insufficient to meet the
needs of frail elderly who are at risk of institutionalization,
often resulting in unnecessary placement in nursing homes.
(b) Steadily increasing health care costs for the frail elderly
provide incentive to develop programs providing quality services at
reasonable costs.
(c) Capitated "risk-based" financing provides an alternative to
the traditional fee-for-service payment system by providing a fixed,
per capita monthly payment for a package of health care services and
requiring the provider to assume financial responsibility for cost
overruns.
(d) On Lok Senior Health Services began as a federal and state
demonstration program in 1973 to test whether comprehensive
community-based services could be provided to the frail elderly at no
greater cost than nursing home care.
(e) Since 1983, On Lok Senior Health Services of San Francisco has
successfully provided a comprehensive package of services and
operated within a cost-effective, capitated risk-based financing
system.
(f) Recognizing On Lok's success, Congress passed legislation in
1986 and 1987 encouraging the expansion of capitated long-term care
programs by permitting federal Medicare and Medicaid waivers to be
granted indefinitely to On Lok and authorizing the federal Centers
for Medicare and Medicaid Services (CMS) to grant waivers in up to 10
new sites throughout the nation in order to replicate the On Lok
model.
(g) In response, the Legislature authorized the State Department
of Health Care Services to seek a waiver to contract with up to 10
demonstration projects to develop risk-based, long-term care pilot
programs modeled upon On Lok Senior Health Services.
(h) The demonstration projects authorized by the Legislature
proved to be successful at providing comprehensive, community-based
services to frail elderly individuals at no greater cost than
providing nursing home care.
(i) In 1997, Congress passed the Balanced Budget Act of 1997
(Public Law 105-33) authorizing states to offer PACE program services
as optional services under the state's Medicaid state plan.
(j) Based upon the success of the demonstration projects in
California, the state is now providing community-based, risk-based,
and capitated long-term care services under the PACE program as
optional services under California's Medi-Cal State Plan.
14592. (a) For purposes of this chapter, "PACE organization"
means an entity as defined in Section 460.6 of Title 42 of the Code
of Federal Regulations.
(b) The Director of Health Care Services shall establish the
California Program of All-Inclusive Care for the Elderly, to provide
community-based, risk-based, and capitated long-term care services as
optional services under the state's Medi-Cal State Plan and under
contracts entered into between the federal Centers for Medicare and
Medicaid Services, the department, and PACE organizations, meeting
the requirements of the Balanced Budget Act of 1997 (Public Law
105-33) and Part 460 (commencing with Section 460.2) of Title 42 of
the Code of Federal Regulations.
14593. (a) (1) The department may enter into contracts with
public or private nonprofit organizations for implementation of
the PACE program, and also may enter into separate contracts with
PACE organizations, to fully implement the single state agency
responsibilities assumed by the department in those contracts,
Section 14132.94, and any other state requirement found necessary by
the department to provide comprehensive community-based, risk-based,
and capitated long-term care services to California's frail elderly.
(2) The department may enter into separate contracts as specified
in subdivision (a) with up to 20 15
PACE organizations.
(b) The requirements of the PACE model, as provided for pursuant
to Section 1894 (42 U.S.C. Sec. 1395eee) and Section 1934 (42 U.S.C.
Sec. 1396u-4) of the federal Social Security Act, shall not be waived
or modified. The requirements that shall not be waived or modified
include all of the following:
(1) The focus on frail elderly qualifying individuals who require
the level of care provided in a nursing facility.
(2) The delivery of comprehensive, integrated acute and long-term
care services.
(3) The interdisciplinary team approach to care management and
service delivery.
(4) Capitated, integrated financing that allows the provider to
pool payments received from public and private programs and
individuals.
(5) The assumption by the provider of full financial risk.
(6) The provision of a PACE benefit package for all participants,
regardless of source of payment, that shall include all of the
following:
(A) All Medicare-covered items and services.
(B) All Medicaid-covered items and services, as specified in the
state's Medicaid plan.
(C) Other services determined necessary by the interdisciplinary
team to improve and maintain the participant's overall health status.
(c) Sections 14002, 14005.12, 14005.17, and 14006 shall apply when
determining the eligibility for Medi-Cal of a person receiving the
services from an organization providing services under this chapter.
(d) Provisions governing the treatment of income and resources of
a married couple, for the purposes of determining the eligibility of
a nursing-facility certifiable or institutionalized spouse, shall be
established so as to qualify for federal financial participation.
(e) (1) The department shall establish capitation rates paid to
each PACE organization at no less than 90 percent of the
fee-for-service equivalent cost, including the department's cost of
administration, that the department estimates would be payable for
all services covered under the PACE organization contract if all
those services were to be furnished to Medi-Cal beneficiaries under
the fee-for-service Medi-Cal program provided for pursuant to Chapter
7 (commencing with Section 14000).
(2) This subdivision shall be implemented only to the extent that
federal financial participation is available.
(f) Contracts under this chapter may be on a nonbid basis and
shall be exempt from Chapter 2 (commencing with Section 10290) of
Part 2 of Division 2 of the Public Contract Code.
