BILL NUMBER: AB 2266INTRODUCED BILL TEXT INTRODUCED BY Assembly Member Mitchell FEBRUARY 24, 2012 An act to add Article 3.9 (commencing with Section 14127) to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, relating to Medi-Cal. LEGISLATIVE COUNSEL'S DIGEST AB 2266, as introduced, Mitchell. Medi-Cal: Health Homes for Enrollees with Chronic Conditions. Existing law provides for 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 federal law authorizes a state, subject to federal approval of a state plan amendment, to offer health home services, as defined, to eligible individuals with chronic conditions. This bill would require the department, upon approval of a state plan amendment, to establish a pilot program in at least 5 counties to provide health home services to frequent users of health services, as defined. Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated 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) The Health Home for Enrollees with Chronic Conditions option under Section 2703 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 1396w-4) is an opportunity for California to address the needs of people who frequently use emergency departments for reasons that could have been avoided with earlier or primary care, as well as the overlapping population of people experiencing chronic homelessness. (b) Almost half of frequent emergency department users are homeless. Frequent users who are homeless face significant difficulties accessing regular or preventive care and complying with treatment protocols with no place to store medications, an inability to adhere to a healthy diet or maintain appropriate hygiene, frequent victimization, and an inability to rest sufficiently to recover from illness. Homeless Medi-Cal enrollees will, in fact, continue to use costly acute care services and actually increase their inpatient days, even if receiving medical home services to reduce their return to the hospital. (c) Increasingly, health providers are partnering with community social services or housing providers to offer a person-centered interdisciplinary system of care that includes intensive paraprofessional care coordination or case management. Programs that offer intensive care coordination to frequent emergency department users integrate primary care, behavioral health care, and social services, and facilitate coordination of care among health systems, making this model an ideal health home that fosters a "whole person" orientation. (d) Data show that programs providing intensive care coordination, including connection to housing, decrease Medicaid costs within a year. A randomized study of chronically homeless frequent users receiving intensive care coordination in housing demonstrated that every 100 participants experienced 270 fewer hospitalizations, 116 fewer emergency department visits, and 2,000 fewer nursing home days. Medi-Cal beneficiaries participating in foundation-funded frequent user programs experienced reductions in Medi-Cal hospital costs of three thousand eight hundred forty-one dollars ($3,841) per beneficiary after one year and seven thousand five hundred nineteen dollars ($7,519) per beneficiary per year after two years, while drastically improving clinical outcomes. SEC. 2. Article 3.9 (commencing with Section 14127) is added to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to read: Article 3.9. Health Home for Enrollees with Chronic Conditions 14127. For the purposes of this article, the following definitions shall apply: (a) "Department" means the State Department of Health Care Services. (b) "Eligible program" means a nonprofit organization or entity, including a private hospital, or a unit of local government, including a public hospital or county, that elects to participate in the pilot program pursuant to this article and that meets the criteria described in federal guidelines. For the purposes of this article, "eligible program" shall include health home teams that include multiple providers, including social service providers. (c) "Federal guidelines" means all federal statutory guidance, and all regulatory and policy guidelines issued by the federal Centers for Medicare and Medicaid Services regarding the Health Homes for Enrollees with Chronic Conditions option under Section 2703 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 1396w-4), including the State Medicaid Director Letter issued on November 16, 2010. (d) "Frequent user of health services" means an adult who has undergone emergency department treatment on five or more occasions in the past 12 months or on eight or more occasions in the last 24 months, who would benefit from the provision of multidisciplinary services, and who has two or more of the following risk factors: (1) On one or more occasions within the last 24 months, the individual was diagnosed with a chronic or life-threatening condition that requires management of symptoms, medications, health care, or changes in lifestyle or risk-related behaviors. These conditions may include specific conditions the department identifies based on data collected pursuant to Section 14127.1. (2) On one or more occasions within the last 24 months, the individual was diagnosed, or, in the judgment of an emergency department physician, would likely be diagnosed, if provided a mental assessment, with an Axis I or Axis II mental disorder identified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (3) On one or more occasions within the last 24 months, the individual was diagnosed, or, in the judgment of an emergency department physician, would likely be diagnosed, if provided an assessment, with a substance use disorder, including substance dependence and substance use problems, that interferes with the individual's health or appropriate utilization of health services. (4) The individual is homeless. (e) "Homeless" has the same meaning as that term is defined in Section 91.5 of Title 24 of the Code of Federal Regulations. (f) "Stakeholders" includes, but is not limited to, the Frequent Users of Health Services Initiative program participants, the Corporation for Supportive Housing, the California Mental Health Directors Association, community clinic representatives, and representatives from other disciplines that represent the needs of frequent users of health services. 14127.1. (a) No later than July 1, 2013, the department shall do all of the following: (1) Collect data to determine conditions that are most prevalent among frequent users of health services, as defined in subdivision (d) of Section 14127, whose high costs could be avoided with more appropriate care. (2) Design, in consultation with stakeholders, a program to provide Medi-Cal services to frequent users of health care services. (3) Submit any necessary application to the federal Centers of Medicare and Medicaid Services for a state plan amendment under Section 2703 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 1396w-4), the Health Homes for Enrollees with Chronic Conditions option, to provide health home services to Medi-Cal beneficiaries who are frequent users of health services. (b) The department shall commence implementation of a pilot program in accordance with the Health Homes for Enrollees with Chronic Conditions option (42 U.S.C. Sec. 1396w-4) on the first day of the third month following the month in which federal approval of the state plan amendment sought pursuant to subdivision (a) is received. (c) The pilot program established pursuant to this article shall provide services to Medi-Cal beneficiaries in addition to an individual's existing Medi-Cal benefits, and shall be designed to reduce a participating individual's use of hospital emergency departments when more effective care, including primary, specialty, and social services, can be provided in less costly settings. 14127.2. (a) In accordance with federal guidelines, the state may limit the availability of services geographically, but shall implement the pilot program in at least five counties; provided, however, that providers meet federal criteria in each county designated. Providers may include nonlicensed professional or paraprofessional staff, including social workers. (b) (1) Services provided under the pilot program established pursuant to this article shall include, but need not be limited to, all of the following: (A) Individualized intensive face-to-face outreach, care coordination, and case management. (B) Money management services and education. (C) Transportation. (D) Life skills training. (E) Peer and recovery support. (F) Prevocational and vocational services. (G) Employment support services. (H) Housing location services, when needed. (2) Beneficiaries may require less intensive services or graduate completely from the program upon stabilization. (c) The selection of the eligible programs shall be based on criteria that shall be developed by the department pursuant to federal guidelines and in consultation with stakeholders. The department may consult with existing frequent user projects in developing selection criteria. The criteria for participation as a program shall include at least all of the following: (1) Demonstrated experience working with the frequent users of health services population. (2) The capacity and administrative infrastructure to participate in the pilot program, including the ability to meet requirements of federal guidelines identified in the State Medicaid Director letter dated November 16, 2010, regarding Health Homes for Enrollees with Chronic Conditions. (3) Documented ability to provide or to link clients with appropriate community-based services, including intensive individualized face-to-face care coordination, primary care, specialty care, mental health treatment, substance abuse treatment, peer and recovery support, permanent or transitional housing, transportation, money management, prevocational and vocational services, and employment support. (4) A plan to offer services to a point-in-time caseload of at least 100 clients on a voluntary basis. (5) Support of essential community hospitals, particularly the hospital or hospitals serving a high proportion of Medi-Cal patients, such as disproportionate share hospitals. 14127.3. (a) The state shall provide for the nonfederal share of costs for services provided to individuals under this article. (b) This section shall not be construed to preclude local entities, health plans, or foundations from contributing the nonfederal share of costs for services provided under this program. (c) This article shall not be construed to limit the department in targeting other populations under the Health Homes for Enrollees with Chronic Conditions option. 14127.4. (a) The department shall prepare, or contract for the preparation of, an evaluation of the frequent users program. The department shall seek out and utilize only private funds to fund the evaluation. The department, within one year after programs have been selected and have begun to seek reimbursement, shall complete the evaluation and submit a report to the appropriate policy and fiscal committees of the Legislature. (b) The requirement for submitting the report imposed under subdivision (a) is inoperative four years after the date the report is due, pursuant to Section 10231.5 of the Government Code. 14127.5. This article shall be implemented only if federal financial participation is available and the federal Centers for Medicare and Medicaid Services approves the state plan amendment sought pursuant Section 14427.1, and only to the extent nonstate funds are available for use as the nonfederal share during the first eight quarters of implementation.