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AB-180 Medi-Cal.(2017-2018)

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Date Published: 05/26/2017 09:00 PM
AB180:v97#DOCUMENT

Amended  IN  Senate  May 26, 2017
Amended  IN  Senate  May 18, 2017

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Assembly Bill No. 180


Introduced by Assembly Member Wood
(Coauthor: Senator Hernandez)

January 18, 2017


An act to amend Sections 14094.18 and 14102.5 of the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 180, as amended, Wood. Medi-Cal.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law requires the department to develop and prepare one or more reports issued on at least a quarterly basis and make the reports public within 30 days for the purpose of informing the California Health and Human Services Agency, the California Health Benefit Exchange, the Legislature, and the public about the enrollment process for all insurance affordability programs. Existing law further requires the department to collect the data for these reports pursuant to specified administrative procedures.
This bill would instead require this report these ongoing reports to be issued on at least a biannual basis and would make a conforming change. be made public within 90, rather than 30, days. The bill would further require the data within the reports to be aggregated and calculated on at least a quarterly basis. The bill would delete the requirement for the department to collect the data pursuant to the specified administrative procedures.
Existing law provides for the California Children’s Services (CCS) program, which is a statewide program that provides medically necessary services for physically handicapped children whose parents are unable to pay for those services. Existing law authorizes the department to establish, no sooner than July 1, 2017, a Whole Child Model program, under which managed care plans served by a county organized health system or Regional Health Authority in designated counties would provide CCS program services to Medi-Cal-eligible CCS children and youth. Existing law requires the department to contract with an independent entity that has experience in performing robust program evaluations to conduct an evaluation to assess Medi-Cal managed care plan performance and the outcomes and experience of CCS-eligible children and youth participating in the Whole Child Model program. Existing law requires the department to provide a report on the results of that evaluation by January 1, 2021.
This bill would instead require the department to provide that report by January 1, 2021, or 3 years from the date when all counties in which the department is authorized to establish the Whole Child Model program are fully operational under the program, whichever is later.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

The people of the State of California do enact as follows:


SECTION 1.

 Section 14094.18 of the Welfare and Institutions Code is amended to read:

14094.18.
 (a) (1) The department shall contract with an independent entity that has experience in performing robust program evaluations to conduct an evaluation to assess Medi-Cal managed care plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the Whole Child Model program, including access to primary and specialty care, and youth transitions from Whole Child Model program to adult Medi-Cal coverage.
(2) The department shall provide a report on the results of this evaluation required pursuant to this section to the Legislature by January 1, 2021, or three years from the date when all counties described in Section 14094.5 are fully operational under the Whole Child Model program pursuant to this article, whichever is later. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code.
(b) The evaluation required by this section, at a minimum, shall evaluate the performance of the plans participating in the Whole Child Model program as compared to the performance of the CCS program prior to the implementation of the Whole Child Model program in those same counties. The evaluation shall evaluate whether the inclusion of CCS services in a managed care delivery system improves access to care, quality of care, and the patient experience by analyzing all of the following, and when possible, disaggregating the results, based on the child’s or youth’s race, ethnicity, and primary language spoken at home:
(1) Access to specialty and primary care, and in particular, utilization of CCS-paneled providers.
(2) The type and location of CCS services and the extent to which CCS services are provided in-network compared to out of network.
(3) Utilization rates of inpatient admissions, outpatient services, durable medical equipment, behavioral health services, home health, pharmacy, and other ancillary services.
(4) Patient and family satisfaction.
(5) Appeals and grievances, including the number of petitions to the plan to extend the continuity of care period for durable medical equipment and CCS providers, the results of those appeals, whether any subsequent appeals were made to the department, and the results of those appeals to the department.
(6) Authorization of CCS-eligible services.
(7) Network and provider participation, including participation of pediatricians, pediatric specialists, and pediatric subspecialists, by specialty and subspecialty.
(8) The ability of a child or youth who ages out of CCS and remains in the same Medi-Cal managed care plan to retain his or her existing providers, to the extent possible or known.
(c) The evaluation required by this section shall also evaluate managed care plans participating in the Whole Child Model program as compared to the CCS program in counties where CCS services are not incorporated into managed care, and collect appropriate data to evaluate all of the following:
(1) The rate of new CCS enrollment in each county.
(2) The percentage of CCS-eligible children and youth with a diagnosis requiring a referral to a CCS special care center who have been seen by a CCS special care center.
(3) The percentage of CCS children and youth discharged from a hospital who had at least one followup contact or visit within 28 days after discharge.
(4) Appeals and grievances.
(d) The department shall consult with stakeholders, including, but not limited to, the Whole Child Model program stakeholder advisory group, regarding the scope and structure of the review.

SEC. 2.

 Section 14102.5 of the Welfare and Institutions Code is amended to read:

14102.5.
 (a) The department shall, in collaboration with the Exchange, the counties, consumer advocates, and the Statewide Automated Welfare System consortia, develop and prepare one or more reports that shall be issued on at least a biannual basis and shall be made publicly available within 30 90 days following the end of each reporting period, for the purpose of informing the California Health and Human Services Agency, the Exchange, the Legislature, and the public about the enrollment process for all insurance affordability programs. The data within the reports shall be aggregated and calculated on at least a quarterly basis. The reports shall comply with federal reporting requirements and shall, at a minimum, include the following information, to be derived from, as appropriate depending on the data element, CalHEERS, MEDS, or the Statewide Automated Welfare System:
(1) For applications received for insurance affordability programs through any venue, all of the following:
(A) The number of applications received through each venue.
(B) The number of applicants included on those applications.
(C) Applicant demographics, including, but not limited to, gender, age, race, ethnicity, and primary language.
(D) The disposition of applications, including all of the following:
(i) The number of eligibility determinations that resulted in an approval for coverage.
(ii) The program or programs for which the individuals in clause (i) were determined eligible.
(iii) The number of applications that were denied for any coverage and the reason or reasons for the denials.
(E) The number of days for eligibility determinations to be completed.
(2) With regard to health plan selection, all of the following:
(A) The health plans that are selected by applicants enrolled in an insurance affordability program, reported by the program.
(B) The number of Medi-Cal enrollees who do not select a health plan but are defaulted into a plan.
(3) For annual redeterminations conducted for beneficiaries, all of the following:
(A) The number of redeterminations processed.
(B) The number of redeterminations that resulted in continued eligibility for the same insurance affordability program.
(C) The number of redeterminations that resulted in a change in eligibility to a different insurance affordability program.
(D) The number of redeterminations that resulted in a finding of ineligibility for any program and the reason or reasons for the findings of ineligibility.
(E) The number of days for redeterminations to be completed.
(4) With regard to disenrollments not related to a redetermination of eligibility, all of the following:
(A) The number of beneficiary disenrollments.
(B) The reasons for the disenrollments.
(C) The number of disenrollments that are caused by an individual disenrolling from one insurance affordability program and enrolling into another.
(5) The number of applications for insurance affordability programs that were filed with the help of an assister or navigator.
(6) The total number of grievances and appeals filed by applicants and enrollees regarding eligibility for insurance affordability programs, the basis for the grievance, and the outcomes of the appeals.
(b) The department shall collect the information necessary for these reports and develop these reports using data obtained from the Statewide Automated Welfare System, CalHEERS, MEDS, and any other appropriate state information management systems.
(c) For purposes of this section, the following definitions shall apply:
(1) “CalHEERS” means the California Healthcare Eligibility, Enrollment, and Retention System developed under Section 15926.
(2) “Exchange” means the California Health Benefit Exchange established pursuant to Title 22 (commencing with Section 100500) of the Government Code.
(3) “Statewide Automated Welfare System” means the system developed pursuant to Section 10823.
(4) “MEDS” means the Medi-Cal Eligibility Data System that is maintained by the department.

(d)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. Thereafter, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Beginning six months after the effective date of this section, and notwithstanding Section 10231.5 of the Government Code, the department shall provide a status report to the Legislature on a semiannual basis until regulations have been adopted.