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AB-2233 Medi-Cal: Assisted Living Waiver program.(2017-2018)

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Date Published: 03/23/2018 09:00 PM
AB2233:v98#DOCUMENT

Revised  April 04, 2018
Amended  IN  Assembly  March 23, 2018

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Assembly Bill No. 2233


Introduced by Assembly Member Kalra
(Coauthor: Assembly Member Wood)

February 13, 2018


An act to add Section 14132.265 to the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 2233, as amended, Kalra. Medi-Cal: Assisted Living Waiver program.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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 law requires the State Department of Health Care Services to develop a federal waiver program program, known as the Assisted Living Waiver program, to test the efficacy of providing an assisted living benefit to beneficiaries under the Medi-Cal program. Existing law requires that the benefit include, but not be limited to, the care and supervision activities specified for residential care facilities for the elderly. Existing law requires implementation of the program only to the extent federal financial participation is available and funds are appropriated or otherwise available for the program.
This bill would require the department to submit submit, in 2019, to the federal Centers for Medicare and Medicaid Services a request for renewal of the Assisted Living Waiver program with specified amendments. The bill would require, as part of the amendments, additional slots, as specified, in the 15 counties where the waiver program is currently in operation. The waiver amendments would also require the department to expand the program on a statewide basis, as specified. The waiver amendments would, among other things, authorize assessments to be conducted by trained individuals, visits to be conducted on an as-needed and quarterly basis, and the provision of certain accommodations to account for the needs of dementia care residents. existing waiver counties, expansion of the program beyond those counties on a regional basis, and modification to the provider reimbursement tiers while also maintaining the program’s budget-neutral provisions. The bill would require the department, before the submission of the waiver renewal request, to notify specified legislative committees about certain information relating to the additional slots and the regional expansion, to conduct open in-person meetings with stakeholders, as specified, and to release a draft of the proposed waiver renewal for stakeholder comment.

The bill would also require the department to authorize eligibility for share-of-cost Medi-Cal beneficiaries, and to modify its provider reimbursement tier, as specified, while also maintaining the waiver program’s budget-neutral provisions.

The bill would condition implementation of the waiver amendments on obtaining the necessary federal approvals and on the availability of federal financial participation. The bill would require implementation of the waiver amendments to commence within 6 months of the department’s receipt of authorization for the necessary resources, as specified.
The bill would also make legislative findings and declarations relating to the Assisted Living Waiver program.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   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) In 1999, the United States Supreme Court ruled in the case of Olmstead v. L.C. (1999) 527 U.S. 581, finding that the unnecessary institutionalization of people with disabilities is a violation of the Americans with Disabilities Act of 1990 (ADA), thereby establishing the right of individuals with disabilities to receive services in the most integrated setting.
(b) To meet the intent of the Olmstead decision, it is the state’s obligation to ensure that individuals have access to an array of necessary services and supports that meet each person’s needs and preferences, regardless of age or degree of disability.
(c) The Assisted Living Waiver program has provided a valuable alternative to institutionalization for individuals who would otherwise reside in a facility but prefer to remain in a community-based setting and cannot afford the costs of assisted living. whose care needs qualify them for Medicaid coverage of nursing facility care and who meet the criteria for admission to a licensed residential care facility for the elderly. Demand for the Assisted Living Waiver program has outpaced supply and operates with a waiting list of approximately 2500 individuals across 15 counties, including counties: the Counties of Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, and Sonoma.
(d) Despite the demand for the Assisted Living Waiver program, a number of challenges prevent the program from realizing its potential, including lack a dearth of available providers, lack of little awareness of the program, low reimbursement rates that hamper provider participation, lack of availability across the remaining 43 counties that do not participate in the program, and ineffective administrative requirements.
(e) According to the 2017 Long-Term Services and Supports Scorecard, almost 11 percent of California’s 101,000 nursing home residents, or 11,000 individuals, are identified as having low-care needs. These individuals could be cared for in the community, or in assisted living settings, as an alternative to institutionalization. However, for many of those individuals, either the opportunities to transition do not exist or these individuals are unaware of the alternatives.
(f) As part of California’s efforts to realize its commitment to the Olmstead decision, availability of “slots” under the Assisted Living Waiver program should be increased, while also addressing the programmatic issues impacting its effectiveness.
SEC. 2.Section 14132.265 is added to the Welfare and Institutions Code, immediately following Section 14132.26, to read:
14132.265.

(a)The department shall submit to the federal Centers for Medicare and Medicaid Services a request for renewal of the Assisted Living Waiver program described in Section 14132.26, with all of the following amendments to the program components:

(1)Additional slots in the 15 counties where the waiver program is currently in operation. The department shall increase the number of slots beyond the currently authorized 3,700 to 10,000, to address the waiting list, while expanding the number of available slots on an annual basis. Before submission of the waiver renewal request, the department shall notify the appropriate fiscal and policy committees of the Legislature of the number of waiver slots included in the waiver renewal request along with supportive data for those slots. A report submitted to the Legislature pursuant to this paragraph shall be submitted in compliance with Section 9795 of the Government Code.

(2)Geographic availability of slots on a statewide basis. The department shall expand the waiver program beyond the existing counties to enable its availability on a statewide basis. The statewide expansion shall be phased in on a scheduled basis throughout the waiver program’s five-year term.

(3)Administrative and provider requirements. The department shall include within the waiver renewal request all of the following provisions:

(A)Authorize assessments to be conducted by trained individuals, including registered nurses, licensed vocational nurses, individuals with a Master’s degree in social work, geriatric care managers, or a related field.

(B)Authorize visits be conducted on an as-needed and quarterly basis, instead of a monthly basis.

(C)Authorize semi-private bedrooms and bathrooms or kitchenettes in order to account for the needs of dementia care residents.

(D)Consider revising the requirement that nursing staff be either on call or employed by the facility, in order to allow for greater provider participation.

(4)Eligibility. The department shall permit eligibility for share-of-cost Medi-Cal beneficiaries who do not qualify for full-scope Medi-Cal eligibility.

(5)Provider reimbursement. The department shall modify its provider reimbursement tier to ensure sufficient participation from providers with the daily rate for each tier not less than the rate in 2017–18 fiscal year, while also maintaining the waiver program’s budget-neutral provisions. The provider reimbursement methodology shall include a tier specific to provision of memory care.

(b)(1)The department shall implement this section only to the extent federal financial participation is available and only if any necessary federal approvals have been obtained.

(2)Upon federal approval of the waiver renewal request with the amendments described in this section, implementation of the amended waiver program shall commence within six months of the department receiving authorization for the necessary resources to provide the services to additional waiver program participants.

SEC. 2.

 Section 14132.265 is added to the Welfare and Institutions Code, immediately following Section 14132.26, to read:

14132.265.
 (a) In 2019, the department shall submit to the federal Centers for Medicare and Medicaid Services a request for renewal of the Assisted Living Waiver program described in Section 14132.26, with all of the following amendments to the program components:
(1) The department shall increase the number of slots beyond the currently authorized 3,700 to at least 18,500 slots.
(2) The department shall phase in the 18,500 slots over the waiver program renewal’s five-year term, with the initial phase of additional slots prioritized for the 15 existing waiver counties.
(3) Geographic availability of slots on a regional basis. The department shall outline a process to expand the waiver program beyond the 15 existing waiver counties to enable the waiver program’s availability on a regional basis in the state’s northern, central, and southern regions that currently are without access to the program. The regional expansion shall be phased in throughout the waiver program renewal’s five-year term. As part of the minimum 18,500 slots, slots beyond those authorized for the 15 existing waiver counties shall be phased in on a regional basis.
(4) Before submission of the waiver renewal request, the department shall notify the appropriate fiscal and policy committees of the Legislature of the methodology for allotting the waiver slots among the 15 existing waiver counties and the process for regional expansion, along with supportive data for those slots.
(5) The department shall address all of the following components within the waiver renewal process:
(A) Accommodations. The department shall consider the appropriateness of requiring participating residential care facilities for the elderly to provide private or semi-private bedrooms and bathrooms, and refrigerators and microwave ovens. That consideration shall include the program participant’s quality of life, provider participation in the program, and other relevant concerns. The consideration shall be included in the stakeholder process described in paragraph (6).
(B) Financial eligibility and exploration of expansion of the waiver.
(i) In the 2019 waiver renewal request, the department shall provide for financial eligibility standards that are no more restrictive than the financial eligibility standards currently employed by the department for the Assisted Living Waiver program.
(ii) As part of the stakeholder process described in paragraph (6), the department shall provide written clarification regarding the department’s Assisted Living Waiver financial eligibility standards for all waiver eligibility categories indicated on the federally approved current waiver document, including eligibility for recipients under the Supplemental Security Income program, recipients under the State Supplementary Payment program, aged or disabled persons with eligibility based on the federal poverty level, medically needy persons, and persons in the special home and community-based waiver group under Section 435.217 of Title 42 of the Code of Federal Regulations.
(iii) During the same stakeholder process, the department shall also explore and explain options to expand financial eligibility to include persons not currently eligible, or to make participation in the waiver program more financially feasible to persons who, under current eligibility rules, may be eligible but are without adequate resources to pay for room and board and other essential expenses.
(C) Provider reimbursement. The department shall modify its provider reimbursement tiers to ensure sufficient participation from providers, while also maintaining the waiver program’s budget-neutral provisions. The modification shall include, but not be limited to, all of the following:
(i) An adjustment to account for the increase in California’s minimum hourly wage from six dollars and seventy-five cents ($6.75) to ten dollars ($10) that occurred from January 1, 2007, through January 1, 2016.
(ii) A 15-percent increase to tier levels one, two, three, and four, applied after the adjustment described in clause (i).
(iii) An augmented reimbursement rate at the tier three and tier four levels of care when program participants in those tier levels have been admitted to hospice care as a federal Medicare benefit.
(D) The department shall establish requirements and procedures so that any person on the waiver program’s waiting list each month is able to know his or her position on the waiting list and when he or she is likely to reach the top of the waiting list. The department shall clearly indicate all methodologies and prioritizations used in selecting persons from the waiting list, including, but not limited to, any priorities based on imminent risk of institutionalization, current residence in a nursing home, care needs, or county of residence.
(6) (A) As part of the waiver renewal process, the department shall conduct open in-person meetings in the northern, central, and southern areas of the state with stakeholders, including, but not limited to, consumers, providers, and families of consumers, and shall receive input on the design and oversight of the Assisted Living Waiver program. The department shall also seek written feedback from stakeholders on the provisions included within the waiver program. The department shall give at least a 30-day notice of each of the in-person meetings, and at least a 30-day notice of the opportunity to submit written feedback.
(B) Before submission of the waiver renewal request, the department shall release a draft of the proposed waiver renewal for stakeholder comment. The release of the draft shall allow for at least a 30-day comment period, and shall precede the submission of the waiver renewal request to the federal Centers for Medicare and Medicaid Services by at least 60 days.
(b) (1) The department shall implement this section only to the extent federal financial participation is available and only if any necessary federal approvals have been obtained.
(2) Upon federal approval of the waiver renewal request with the amendments described in this section, implementation of the amended waiver program shall commence within six months of the department receiving authorization for the necessary resources to provide the services to additional waiver program participants.

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REVISIONS:
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