California Assembly Bill AB1310 Introduced / Bill

 BILL NUMBER: AB 1310INTRODUCED BILL TEXT INTRODUCED BY Assembly Member Brown FEBRUARY 22, 2013 An act to amend Section 14132.25 of the Welfare and Institutions Code, relating to Medi-Cal. LEGISLATIVE COUNSEL'S DIGEST AB 1310, as introduced, Brown. Medi-Cal: pediatric subacute care. 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 law requires the department to establish a subacute care program in health facilities in order to more effectively use limited Medi-Cal dollars while ensuring needed services for patients who meet subacute care criteria, as established by the department. For the purposes of the subacute care program, existing law defines pediatric subacute services as the health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function. Existing law also provides that, for the purposes of the subacute care program, medical necessity for pediatric subacute care services, as defined, shall be substantiated in one of 5 ways. This bill would expand the definition of pediatric subacute services to include the health care services needed by a person between 21 and 22 years of age who uses a medical technology that compensates for the loss of a vital bodily function and to include the health care services needed by a person under 22 years of age who requires treatment for one or more active complex medical conditions or requires the administration of one or more technically complex treatments. This bill would also provide that one of the ways that medical necessity for pediatric subacute care services shall be substantiated is by dependence on complex wound care management or the presence of a medical condition and necessity of care such that his or her health care needs may be satisfied by placement in a facility providing pediatric subacute care services, but, in the absence of access to a pediatric subacute care service, the only alternative in patient care sufficient to meet the patient's medical needs is an acute care hospital bed. The bill would also provide that medical necessity may be shown solely by dependence on total parenteral nutrition or other intravenous nutritional support, without a showing of dependence on additional treatments, and by dependence on tracheostomy care, as specified, in conjunction with dependence on tube feeding by means of a jejunostomy tube. 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. Section 14132.25 of the Welfare and Institutions Code is amended to read: 14132.25. (a) On or before July 1, 1983, the State Department of Health Care Services shall establish a subacute care program in health facilities in order to more effectively use the limited Medi-Cal dollars available while at the same time ensuring needed services for these patients. The subacute care program shall be available to patients in health facilities who meet subacute care criteria. Subacute care may be provided by any facility designated by the director as meeting the subacute care criteria that has an approved provider participation agreement with the department. (b) The department shall develop a rate of reimbursement for this subacute care program. Reimbursement rates shall be determined in accordance with methodology developed by the department, specified in regulation, and may include the following: (1) All-inclusive per diem rates. (2) Individual patient-specific rates according to the needs of the individual subacute care patient. (3) Other rates subject to negotiation with the health facility. (c) Reimbursement at subacute care rates, as specified in subdivision (b), shall only be implemented if funds are available for this purpose pursuant to the annual Budget Act. (d) The department may negotiate and execute an agreement with any health facility that meets the standards for providing subacute care. An agreement may be negotiated or established between the health facility and the department for subacute care based on individual patient assessment. The department shall establish level of care criteria and appropriate utilization controls for patients eligible for the subacute care program. (e) For the purposes of this section, pediatric subacute services are the health care services needed by a person under  21   22  years of age who uses a medical technology that compensates for the loss of a vital bodily  function.   function, requires treatment for one or more active complex medical conditions, or requires the administration of one or more technically complex treatments.  (f) Medical necessity for pediatric subacute care services shall be substantiated in any one of the following ways: (1) A tracheostomy with dependence on mechanical ventilation for a minimum of six hours each day. (2) Dependence on tracheostomy care requiring suctioning at least every six hours, and room air mist or oxygen as needed, and dependence on one of the five treatment procedures listed in subparagraphs (B) to (F), inclusive: (A) Dependence on intermittent suctioning at least every eight hours and room air mist and oxygen as needed. (B) Dependence on continuous intravenous therapy, including administration of a therapeutic agent necessary for hydration or of intravenous pharmaceuticals, or intravenous pharmaceutical administration of  more than one agent,   one or more agents,  via a peripheral or central line, without continuous infusion. (C) Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours. (D) Dependence on tube feeding by means of a  nasogastric or gastrostomy   nasogastric, gastrostomy, or jejunostomy  tube. (E) Dependence on other medical technologies required continuously,  which   that  , in the opinion of the attending physician and the Medi-Cal consultant, require the services of a  professional   licensed registered  nurse. (F) Dependence on biphasic positive airway pressure at least six hours a day, including assessment or intervention every three hours and lacking either cognitive or physical ability of the patient to protect his or her airway. (3) Dependence on total parenteral nutrition or other intravenous nutritional  support, and dependence on one of the treatment procedures specified in subparagraphs (A) to (F), inclusive, of paragraph (2).  support.  (4) Dependence on skilled nursing care in the administration of any three of the  following  six treatment  procedures specified in subparagraphs (A) to (F), inclusive, of paragraph (2).   procedures:   (A) Dependence on intermittent suctioning at least every eight hours and room air mist and oxygen as needed.   (B) Dependence on continuous intravenous therapy, including administration of a therapeutic agent necessary for hydration or of intravenous pharmaceuticals, or intravenous pharmaceutical administration of one or more agents, via a peripheral or central line, without continuous infusion.   (C) Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours.   (D) Dependence on tube feeding by means of a nasogastric, gastrostomy, or jejunostomy tube.   (E) Dependence on other medical technologies required continuously that in the opinion of the attending physician and the Medi-Cal consultant, require the services of a licensed registered nurse.   (F) Dependence on biphasic positive airway pressure at least six hours a day, including assessment or intervention every three hours for a patient lacking either cognitive or physical ability of the patient to protect his or her airway.  (5) Dependence on biphasic positive airway pressure or continuous positive airway pressure at least six hours a day, including assessment or intervention every three hours  and   , for a patient  lacking either cognitive or physical ability  of the patient  to protect his or her airway  ,  and dependence on one of the  following  five treatment  procedures specified in subparagraphs (A) to (E), inclusive, of paragraph (2).   procedures:   (A) Dependence on intermittent suctioning at least every eight hours and room air mist and oxygen as needed.   (B) Dependence on continuous intravenous therapy, including administration of a therapeutic agent necessary for hydration or of intravenous pharmaceuticals, or intravenous pharmaceutical administration of one or more agents, via a peripheral or central line, without continuous infusion.   (C) Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours.   (D) Dependence on tube feeding by means of a nasogastric, gastrostomy, or jejunostomy tube.   (E) Dependence on other medical technologies required continuously that in the opinion of the attending physician and the Medi-Cal consultant, require the services of a licensed registered nurse.   (6) Dependence on complex wound care management, including daily assessment or intervention by a licensed registered nurse and daily dressing changes, wound packing, debridement, negative pressure wound therapy, or a special mattress.   (7) The patient has a medical condition and requires an intensity of medical or skilled nursing care such that his or her health care needs may be satisfied by placement in a facility providing pediatric subacute care services, but, in the absence of a facility providing pediatric subacute care services, the only other inpatient care appropriate to meet the patient's health care needs under the Medi-Cal program is in an acute care licensed hospital bed.  (g) The medical necessity determination outlined in subdivision (f) is intended solely for the evaluation of a patient who is potentially eligible and meets the criteria to be transferred from an acute care setting to a subacute level of care.