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AB-1223 Medi-Cal: audit of PACE organizations.(2023-2024)

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Date Published: 03/09/2023 09:00 PM
AB1223:v98#DOCUMENT

Amended  IN  Assembly  March 09, 2023

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill
No. 1223

Introduced by Assembly Member Hoover

February 16, 2023

An act to amend Section 5003 14593 of the Welfare and Institutions Code, relating to mental health. Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 1223, as amended, Hoover. Mental health services. Medi-Cal: audit of PACE organizations.
Existing federal law establishes the Program of All-Inclusive Care for the Elderly (PACE), which provides specified services for older individuals at a PACE center so that they may continue living in the community. Federal law authorizes states to implement PACE as a Medicaid state option. Existing state law establishes 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. Existing law authorizes the State Department of Health Care Services to enter into contracts with public or private organizations for implementation of the PACE program and sets out mandatory requirements of the PACE model, as provided under federal law.
This bill would require the department to perform program audits of PACE organizations and to develop and maintain standards, rules, and auditing protocols. The bill would require the protocol to include data collection procedures and formal decision rules and procedures for enforcement consequences when the requirements of law are not met.

Existing law, the Lanterman-Petris-Short Act, authorizes the involuntary commitment and treatment of persons with specified mental health disorders for the protection of the persons so committed. The act also authorizes the appointment of a conservator for a person who is gravely disabled. Existing law specifies that the act does not limit the right of a person to voluntarily apply, at any time, to a public or private agency or practitioner for mental health services, as specified.

This bill would make technical, nonsubstantive changes to those provisions.

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: NOYES   Local Program: NO  

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


SECTION 1.

 Section 14593 of the Welfare and Institutions Code is amended to read:

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) (1) The department shall perform program audits of PACE organizations pursuant to Section 460.192 of Title 42 of the Code of Federal Regulations and shall develop and maintain a consistent set of standards, rules, and auditing protocols. The department, or other public or private audit agency with which the department contracts, shall make available to all providers, in writing, any standards, rules, and auditing protocols to be used in any PACE organization audit.
(2) The protocol shall include data collection procedures so that state review and reporting may occur. The protocol shall also include a procedure for the provision of technical assistance and formal decision rules and procedures for enforcement consequences when the requirements of law and regulations are not met.

(b)

(c) 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)

(d) 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)

(e) 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)

(f) (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)

(g) 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)

(h) (1) Notwithstanding subdivision (b), (c), 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.

SECTION 1.Section 5003 of the Welfare and Institutions Code is amended to read:
5003.

This part shall not be construed in any way as limiting the right of a person to voluntarily apply, at any time, to a public or private agency or practitioner for mental health services, either by direct application in person, or by referral from another public or private agency or practitioner.