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AB-1230 Medi-Cal and Medicare: dual eligible beneficiaries: special needs plans.(2023-2024)

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Date Published: 02/16/2023 09:00 PM
AB1230:v99#DOCUMENT


CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill
No. 1230

Introduced by Assembly Member Valencia

February 16, 2023

An act to add Section 14132.278 to the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 1230, as introduced, Valencia. Medi-Cal and Medicare: dual eligible beneficiaries: special needs plans.
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 federal law establishes the Medicare Program, which is a public health insurance program for persons who are 65 years of age or older and specified persons with disabilities who are under 65 years of age.
Existing law sets forth various provisions, including within the Coordinated Care Initiative (CCI) and the California Advancing and Innovating Medi-Cal (CalAIM) initiative, relating to beneficiaries who are dually eligible for the Medicare Program and the Medi-Cal program, for purposes of promoting more integrated care through those beneficiaries’ aligned enrollment in a Medicare Advantage Dual Eligible Special Needs Plan (D-SNP), as defined.
This bill would require the department, commencing no later than January 1, 2025, to offer contracts to health care service plans for Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNPs) and Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs), as defined, to provide care to dual eligible beneficiaries.
The bill would require that a HIDE-SNP or FIDE-SNP contract authorize a beneficiary to select from a number of available options and to maintain their established or selected health care providers. The bill would also require a contracting plan to perform all applicable required care coordination and data-sharing functions, and to provide documentation demonstrating the care integration that dual eligible beneficiaries receive through a HIDE-SNP or FIDE-SNP contract.
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) California currently has more than 1.6 million individuals who are eligible for both Medicare and Medicaid services. These individuals suffer greater health disparities and have a higher prevalence of chronic conditions and disabilities. Dual eligible beneficiaries are among the highest cost enrollees in each program. Although they make up 20 percent of the total Medicare population, they account for 34 percent of the total Medicare expenditures and have an annual per capita cost of $36,080.
(b) California has dedicated several years to improving the health outcomes of dual eligible beneficiaries. To that end, a recent study by the United States Department of Health and Human Services found that beneficiaries enrolled in a Dual Eligible Special Needs Plan (D-SNP), a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP), or a Program of All-Inclusive Care for the Elderly (PACE) were less likely to be hospitalized or institutionalized — an important goal in complying with the decision of the United States Supreme Court in Olmstead v. L.C. ex rel. Zimring (1999) 527 U.S. 581. Moreover, these specialized plans for dual eligible beneficiaries helped to increase the use of home- and community-based services.
(c) According to the Kaiser Family Foundation, seniors continue to enroll in a Medicare Advantage plan. In 2022, more than 28 million individuals were enrolled, accounting for nearly one-half of the eligible Medicare population. Of these enrollees, more than 4.6 million Medicare beneficiaries are enrolled in Special Needs Plans (SNPs), with the vast majority of those individuals (89 percent) enrolled in D-SNPs.
(d) California must continue to offer highly specialized services to low-income individuals with Medicare and Medicaid coverage. Offering Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNPs) and FIDE-SNPs will enhance the state’s current options under the existing Medi-Cal managed care program and will increase patient choice as well as quality outcome measures.

SEC. 2.

 Section 14132.278 is added to the Welfare and Institutions Code, immediately following Section 14132.277, to read:

14132.278.
 (a) (1) Commencing no later than January 1, 2025, the department shall offer contracts to health care service plans for Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNPs) and Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) to provide care to dual eligible beneficiaries.
(2) A HIDE-SNP or FIDE-SNP contract offered under paragraph (1) shall be in accordance with Section 14087.3.
(b) A HIDE-SNP or FIDE-SNP contract entered into pursuant to this section shall meet all of the following conditions:
(1) A dual eligible beneficiary may select from a number of options of plans available under the federal Medicare Program that have consistently high Medicare star ratings and other quality metrics.
(2) A dual eligible beneficiary may maintain their established or selected health care providers.
(3) A contracting plan shall perform all applicable required care coordination and data-sharing functions, as determined by the department.
(4) A contracting plan shall provide all applicable documentation demonstrating the care integration that dual eligible beneficiaries receive through a HIDE-SNP or FIDE-SNP contract.
(c) For purposes of this section, the following definitions apply:
(1) “Dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or both, and is eligible for medical assistance under the Medi-Cal State Plan.
(2) “Fully Integrated Dual Eligible Special Needs Plan” or “FIDE-SNP” means a Medicare Advantage plan that fully integrates care for dual eligible beneficiaries under a single managed care organization, pursuant to the federal Patient Protection and Affordable Care Act (Public Law 111-148), the federal Bipartisan Budget Act of 2018 (Public Law 115-123), and any successor amendments to those acts or other applicable laws.
(3) “Highly Integrated Dual Eligible Special Needs Plan” or “HIDE-SNP” means a Medicare Advantage plan that has a higher level of integration than a standard Dual Eligible Special Needs Plan (D-SNP), pursuant to the federal Bipartisan Budget Act of 2018 (Public Law 115-123) and any successor amendments to that act or other applicable laws.