Today's Law As Amended

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AB-2266 Medi-Cal: Health Homes for Medi-Cal Enrollees and 1115 Waiver Demonstration Populations with Chronic and Complex Conditions.(2011-2012)

As Amends the Law Today

 The Legislature finds and declares all of the following:
(a) The Health Homes for Enrollees with Chronic Conditions option (Health Homes option) under Section 2703 of the federal Patient Protection and Affordable Care Act (Affordable Care Act) (42 U.S.C. Sec. 1396w-4) offers an opportunity for California to address complex and chronic health conditions, as well as social determinants of poor health outcomes and high costs among Medi-Cal beneficiaries.
(b) For example, people who frequently use hospitals for reasons that could have been avoided with more appropriate care incur high Medi-Cal costs and suffer poor health outcomes due to the complexity of their conditions and, often, their negative social determinants of health. Frequent users have difficulties accessing regular or preventive care and complying with treatment protocols, and the significant number who are homeless have no place to store medications, cannot adhere to a healthy diet or maintain appropriate hygiene, face frequent victimization, and lack rest when recovering from illness.
(c) Increasingly, health providers are partnering with community behavioral health and social services providers to offer a person-centered interdisciplinary system of care that effectively addresses the needs of enrollees with multiple chronic or complex conditions, including frequent hospital users and people experiencing chronic homelessness. These health homes help people with chronic and complex conditions to access better care and better health, while decreasing costs.
(d) Federal guidelines allow the state to access enhanced federal matching rates for health home services under the Health Homes option for multiple target populations to achieve more than one policy goal.

SEC. 2.

 Article 3.9 (commencing with Section 14127) is added to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to read:

Article  3.9. Health Homes for Medi-Cal Enrollees and 1115 Waiver Demonstration Populations with Chronic and Complex Conditions
 For the purposes of this article, the following definitions shall apply:
(a) “Department” means the State Department of Health Care Services.
(b) “Eligible individual” means an individual who meets the criteria defined by the department, consistent with subdivision (b) of Section 14127.2.
(c) “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.
(d) (1) “Health home” means a provider or team of providers designated by the department that satisfies all of the following:
(A) Meets the criteria described in federal guidelines.
(B) Offers a whole person approach, including, but not limited to, coordinating health home services and linkages to other available services for the needs affecting the health of an eligible individual.
(C) Offers services in a range of settings, as appropriate, to meet the needs of an eligible individual for health home services.
(2) Health home partners may include, but are not limited to, a health plan, community clinic, a mental health plan, a hospital, physicians, a clinical practice or clinical group practice, rural health clinic, community health center, community mental health center, home health agency, nurse practitioners, social workers, and paraprofessionals.
(3) For purposes of serving eligible individuals, the department may require a lead provider to be a community clinic, a mental health plan, or a hospital.
(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.
(e) “Homeless” has the same meaning as that term is defined in Section 91.5 of Title 24 of the Code of Federal Regulations. “Chronic homelessness” means the state of an individual whose conditions limit his or her activities of daily living and who has experienced homelessness for longer than a year or for four or more episodes over three years.
  Subject to federal approval, the department may do all of the following to create a health home program, as authorized under Section 2703 of the Affordable Care Act:
(a) Design, with opportunity for public comment, a program to provide health home services to Medi-Cal beneficiaries and Section 1115 waiver demonstration populations with chronic conditions.
(b) Contract with new providers, new managed care plans, existing Medi-Cal providers, existing managed care plans, or counties to provide health home services, as provided in Section 14128.
(c) Submit any necessary applications to the federal Centers for Medicare and Medicaid Services for a state plan amendment and Section 1115 waiver demonstration amendment to provide health home services to Medi-Cal beneficiaries, to newly eligible Medi-Cal beneficiaries upon Medicaid expansion under the Affordable Care Act, and, if applicable, to Low Income Health Program (LIHP) enrollees in counties with LIHPs willing to match federal funds.
(d) Define the populations of eligible individuals.
(e) Develop a payment methodology, including, but not limited to, fee-for-service or per member, per month payment structures that may include tiered payment rates that take into account the intensity of services necessary to outreach to, engage, and serve the populations the department identifies.
(f) Identify health home services, consistent with federal guidelines.
(g) The department may submit applications and operate, to the extent permitted by federal law and to the extent federal approval is obtained, more than one health home program for distinct populations, different providers or contractors, or multiple geographic areas.
 (a) The department may create one or more health home programs for children and adults pursuant to Section 14127.1, and, in consultation with stakeholders, shall develop the geographic criteria, beneficiary eligibility criteria, and provider eligibility criteria for each program.
(b) The health home program identified in Section 14127.1 shall include, but not be limited to, an eligible individual who is an adult who meets both of the following criteria:
(1) Current diagnosis of chronic, cooccurring physical health and mental health or substance use disorders prevalent among frequent hospital users at an acuity level to be determined by the department.
(2) One or more of the following indicators of severity, at a level to be determined by the department:
(A) Frequent inpatient hospital admissions, including long-term hospitalization for medical, psychiatric, or substance abuse-related conditions.
(B) Excessive use of crisis or emergency services or inpatient hospital care.
(C) Chronic homelessness.
(c) The department shall design program elements specific to the eligible individuals after consultation with stakeholder groups who have expertise in engagement and services for those individuals.
(d) (1) Subject to federal approval for receipt of the enhanced federal match, services provided under the program established pursuant to this section shall include all of the following:
(A) Comprehensive and individualized care management.
(B) Care coordination and health promotion, including connection to medical, mental health, and substance abuse care.
(C) Comprehensive transitional care from inpatient to other settings, including appropriate followup.
(D) Individual and family support, including authorized representatives.
(E) If relevant, referral to other community and social services supports, including transportation to appointments needed to manage health needs, connection to housing for participants who are homeless or unstably housed, and peer and recovery support.
(F) Health information technology to identify eligible individuals and link services, if feasible and appropriate.
(2) According to beneficiary needs, the department may provide less intensive services or graduate the beneficiary completely from the program upon stabilization.
(e) In addition to selecting providers to serve other populations, for the purposes of providing health home services to the eligible individuals, the department shall select designated health home providers, managed care organizations subcontracting with providers, and counties subcontracting with providers operating with a team of health care professionals that have all of the following:
(1) Demonstrated experience working with frequent hospital users.
(2) Demonstrated experience working with people experiencing chronic homelessness.
(3) The capacity and administrative infrastructure to participate in the program, including the ability to meet requirements of federal guidelines.
(4) A viable plan, with roles identified among providers of the health home, to do all of the following:
(A) Reach out to and engage frequent hospital users and chronically homeless eligible individuals.
(B) Link eligible individuals who are homeless or experiencing housing instability to permanent housing, such as supportive housing.
(C) Ensure coordination and linkages to services needed to access and maintain health stability, including medical, mental health, substance abuse care, and social services to address social determinants of health.
(D) Identify appropriate funding sources for the nonfederal share of costs of services.
(f) The department may design additional provider criteria to those identified in subdivision (e) after consultation with stakeholder groups who have expertise in engagement and services for eligible individuals.
(g) The department shall design a health home program with specific elements to engage and serve eligible individuals, and health home program outreach and enrollment shall specifically focus on these populations.
 (a) The department shall administer this article in a manner that attempts to maximize federal financial participation, consistent with federal law.
(b) This article shall not be construed to preclude local governments or foundations from contributing the nonfederal share of costs for services provided under this program, so long as those contributions are permitted under federal law. The department, and counties contracting with the department, may also enter into risk-sharing and social impact bond program agreements to fund services under this article.
(c) In accordance with federal guidelines, the state may limit availability of health home or enhanced health home services geographically.
 (a) If the department implements a health home program, the department shall ensure that an evaluation of the program identified in this article is completed and shall, within two years after implementation, submit a report to the appropriate policy and fiscal committees of the Legislature.
(b) The requirement for submitting the report imposed under subdivision (a) is inoperative four years after the date the report is due, pursuant to Section 10231.5 of the Government Code.
 (a) This article shall be implemented only if federal financial participation is available and the federal Centers for Medicare and Medicaid Services approves the state plan amendment and any necessary waivers sought pursuant to this article.
(b) Except as provided in subdivisions (c) and (d), this article shall be implemented only if additional state general funds are not used to fund the administration and service costs.
(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 state 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 state general fund costs for the Medi-Cal program, the department may use state general funds to fund any program costs.
(e) The department may use new funding in the form of enhanced federal financial participation for health home services that are currently funded to fund any additional costs for new health home program services.
(f) The department shall seek to fund the creation, implementation, and administration of the program with funding other than state general funds.
(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.
 (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 is allowed temporary authority as necessary to implement program changes until completion of the regulatory process.
(2) The department shall adopt emergency regulations no later than two years after implementation of this article. The department may readopt, up to two times, any emergency regulation authorized by this section that is the same as or substantially equivalent to an emergency regulation previously adopted pursuant to this section.
(3) The adoption of emergency regulations implementing this article authorized by this subdivision shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, safety, or general welfare. Emergency regulations authorized by this section shall be exempt from review by the Office of Administrative Law. The emergency regulations authorized by this section shall be submitted to the Office of Administrative Law for filing with the Secretary of State and shall remain in effect for no more than 180 days, by which time final regulations may be adopted.