Code Section Group

Welfare and Institutions Code - WIC

DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.81]

  ( Division 9 added by Stats. 1965, Ch. 1784. )

PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771]

  ( Part 3 added by Stats. 1965, Ch. 1784. )

CHAPTER 8.75. Program of All-Inclusive Care for the Elderly [14591 - 14594]
  ( Chapter 8.75 repealed and added by Stats. 2011, Ch. 367, Sec. 19. )

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.

(Added by Stats. 2011, Ch. 367, Sec. 19. (AB 574) Effective January 1, 2012.)

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 shall establish the California Program of All-Inclusive Care for the Elderly (PACE program) 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 any other applicable law or regulation.

(c) A primary care clinic, as defined in paragraph (1) of subdivision (b) of Section 1200 of the Health and Safety Code, an adult day health care center, as defined in subdivision (b) of Section 1570.7 of the Health and Safety Code, or a home health agency, as defined in subdivision (a) of Section 1727 of the Health and Safety Code, that exclusively serves PACE participants, as defined in Section 460.6 of Title 42 of the Code of Federal Regulations, is exempt from licensure by the State Department of Public Health. A primary care clinic, an adult day health care center, or a home health agency that exclusively serves PACE participants shall be overseen and regulated by the department.

(1) A primary care clinic, adult day health care center, or home health agency approved by the department pursuant to this section to operate exclusively as part of a PACE organization may provide services to individuals who are being assessed for eligibility to enroll in the PACE program for not more than 60 calendar days after an individual submits an application for enrollment.

(2) If the department determines that a primary care clinic, adult day health care center, or home health agency approved to operate exclusively as part of a PACE organization has provided services to individuals other than those enrolled in the PACE program, or who are being assessed for eligibility pursuant to paragraph (1), the clinic, adult day health care center, or home health agency shall apply for licensure with the State Department of Public Health. A primary care clinic, adult day health care center, or home health agency required to obtain licensure from the State Department of Public Health pursuant to this paragraph shall apply for the license not later than 60 calendar days following the determination by the department described in this paragraph. The clinic, adult day health care center, or home health agency shall not accept any new participants in the PACE program until licensure is obtained.

(3) This subdivision shall become operative only if the director determines, and communicates that determination in writing to the State Department of Public Health, that operating standards compliance programs consistent with subdivisions (d) and (e) have been established for implementation of this section. A primary care clinic, adult day health care center, or home health agency, as defined in this subdivision, shall remain under the oversight and regulatory authority of the State Department of Public Health until the director communicates their written determination to the State Department of Public Health.

(d) In order to provide services to PACE participants, PACE organizations exempt from licensure pursuant to this section shall be in compliance with all of the operating standards:

(1) A primary care clinic that exclusively serves PACE participants, or that also serves individuals who are being assessed for eligibility to enroll in a PACE program for not more than 60 calendar days after an individual submits an application for enrollment, shall be in compliance with the clinic operating standards set forth in Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code, except as modified by the department, to meet the needs of PACE participants or those individuals being assessed.

(2) An adult day health care center that exclusively serves PACE participants, or that also serves individuals who are being assessed for eligibility to enroll in a PACE program for not more than 60 calendar days after an individual submits an application for enrollment, shall be in compliance with the center operating standards set forth in Chapter 3.3 (commencing with Section 1570) of Division 2 of the Health and Safety Code, except as modified by the department, to meet the needs of PACE participants or those individuals being assessed.

(3) A home health agency that exclusively serves PACE participants, or that also serves individuals who are being assessed for eligibility to enroll in a PACE program for not more than 60 calendar days after an individual submits an application for enrollment, shall be in compliance with the agency operating standards set forth in Chapter 8 (commencing with Section 1725) of Division 2 of the Health and Safety Code, except as modified by the department, to meet the needs of PACE participants or those individuals being assessed.

(e) A PACE organization exempt from licensure pursuant to this section shall cooperate with the department’s evaluation, oversight, and ongoing monitoring and shall comply with the operating standards, as described in subdivision (d). The PACE organization’s cooperation shall include, but shall not be limited to, all of the following:

(1) Permitting the department or its agent immediate access to inspect any physical locations involved with the PACE organization’s services.

(2) Immediately providing the department or its agent with copies of any requested records regarding the PACE organization and services offered to PACE participants.

(3) Immediately providing the department or its agent with requested information regarding the PACE organization’s operations.

(f) The department may refuse to enter into, or may terminate, a contract with a PACE organization exempt from licensure pursuant to this section, based on the PACE organization’s failure to comply with the operating standards as described in subdivision (d), or based on the PACE organization’s failure to cooperate as described in subdivision (e).

(g) If a PACE organization exempt from licensure pursuant to this section fails to comply with subdivision (c), (d), or (e), the department may require the PACE organization to submit a corrective action plan to bring the PACE organization into compliance with the requirements of those subdivisions. If the department approves the corrective action plan, the PACE organization shall complete the corrective action plan to the satisfaction of the department. If the PACE organization fails to satisfactorily complete the corrective action plan within the time specified by the department, the department may take other action as specified in the PACE organization’s contract with the department.

(h) For purposes of implementing this section, the department may enter into exclusive or nonexclusive contracts, or may amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services.

(i) 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 this section, in whole or in part, by means of letters, bulletins, or other similar instructions, without taking regulatory action.

(j) This section shall be implemented only to the extent any necessary federal approvals are obtained and federal financial participation is available.

(k) The department shall implement the amendments made to this section by the act that added this subdivision no later than January 1, 2021, but only to the extent any necessary federal approvals are obtained and federal financial participation is available.

(l) (1) The department shall establish an administrative fee to be paid by each PACE organization exempt from licensure upon enrollment as a PACE provider, and annually thereafter, in an amount necessary to pay for reasonable costs of implementing and administering subdivisions (c) through (j), inclusive.

(2) (A) The fee described in this subdivision shall not be greater than the corresponding fee or fees otherwise imposed on a primary care clinic, home health agency, or adult day health care center pursuant to laws and regulations relating to licensing and regulation by the State Department of Public Health.

(B) It is the intent of the Legislature that the fee described in this subdivision is not an additional cost to a PACE organization because PACE organizations exempt from licensure are not subject to fees otherwise imposed for purposes of licensing and regulation by the State Department of Public Health.

(C) All fees paid to, and received by, the department pursuant to this subdivision shall be deposited in the State Treasury and shall be credited to a special fund that is hereby created as the PACE Oversight Fund of the State Department of Health Care Services. Moneys deposited in this fund shall be expended by the department for the purposes of implementing and administering subdivisions (c) through (j), inclusive, upon appropriation by the Legislature. No surplus in the PACE Oversight Fund of the State Department of Health Care Services shall be deposited in, or transferred to, the General Fund or any other fund.

(m) The amendments made to this section by the act that added this subdivision shall be supported entirely by federal funds and special funds, unless otherwise specified in statute or unless specifically appropriated from the General Fund in the annual Budget Act or other enacted legislation.

(Amended by Stats. 2019, Ch. 821, Sec. 8. (AB 1128) Effective January 1, 2020.)

14593.
  

(a) (1) The department may enter into contracts with public or private 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 paragraph (1) with up to 15 PACE organizations. This paragraph shall become inoperative upon federal approval of a capitation rate methodology, pursuant to subdivision (n) of Section 14301.1.

(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 95 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.

(3) This subdivision shall become inoperative upon federal approval of a capitation rate methodology, pursuant to subdivision (n) of Section 14301.1.

(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.

(g) (1) Notwithstanding subdivision (b), and only to the extent federal financial participation is available, the department, in consultation with PACE organizations, shall seek increased federal regulatory flexibility from the federal Centers for Medicare and Medicaid Services to modernize the PACE program, which may include, but is not limited to, addressing all of the following:

(A) Composition of PACE interdisciplinary teams (IDT).

(B) Use of community-based physicians.

(C) Marketing practices.

(D) Development of a streamlined PACE waiver process.

(2) This subdivision shall be operative upon federal approval of a capitation rate methodology pursuant to subdivision (n) of Section 14301.1.

(Amended (as amended by Stats. 2016, Ch. 30, Sec. 34) by Stats. 2017, Ch. 52, Sec. 77. (SB 97) Effective July 10, 2017.)

14594.
  

(a) For the purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply.

(b) It is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the health care provider.

(c) No PACE organization shall require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the PACE organization, and between the PACE organization and its participating providers or provider groups.

(d) No PACE organization shall limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the PACE organization, and between the PACE organization and its participating providers or provider groups.

(e) Notwithstanding any other provision, this section shall not be interpreted to authorize a PACE organization to require the use of telehealth when the health care provider has determined that it is not appropriate.

(Added by Stats. 2012, Ch. 782, Sec. 14. (AB 1733) Effective January 1, 2013.)

WICWelfare and Institutions Code - WIC