BILL NUMBER: SB 586INTRODUCED BILL TEXT INTRODUCED BY Senator Hernandez FEBRUARY 26, 2015 An act to amend Section 14094.3 of, and to add Section 14094.24 to, the Welfare and Institutions Code, relating to children's services. LEGISLATIVE COUNSEL'S DIGEST SB 586, as introduced, Hernandez. Children's services. The California Children's Services Program (CCS program) is a statewide program providing medically necessary services required by physically handicapped children whose parents are unable to pay for those services. The State Department of Health Care Services administers the CCS program. Counties, based on population size, are also charged with administering the program, either independently or jointly with the department. The services covered by the CCS program include expert diagnosis, medical treatment, surgical treatment, hospital care, physical therapy, occupational therapy, special treatment, materials, and the supply of appliances and their upkeep, maintenance, and transportation. Funding for the program comes from county, state, and federal sources. In order to be eligible for the CCS program, an applicant must be under 21 years of age, have or be suspected of having a condition covered by the program, and meet certain financial eligibility standards established by the department. Existing law prohibits services covered by the California Children' s Services program (CCS) from being incorporated into a Medi-Cal managed care contract entered into after August 1, 1994, until January 1, 2016, except with respect to contracts entered into for county organized health systems in specified counties. This bill would exempt KIDS contracts, described below, from that prohibition, and would delete the January 1, 2016 time limit. This bill would require the department, no later than January 1, 2018, to contract with one or more Kids Integrated Delivery System (KIDS) plans, as defined, for the purpose of coordinating and managing the provision of Medi-Cal and CCS program services to eligible children, to ensure access to cost-effective quality care. The bill would define "eligible child" and other relevant terms in this regard. The bill would establish criteria the department would be required to consider in selecting a KIDS plan and eligibility standards, as well as the qualifications and exclusions required for KIDS plan contracts. The KIDS plan would be required to coordinate, integrate, and provide or arrange for the full range of Medi-Cal and CCS services. This bill would require the department to seek all necessary federal approvals to ensure federal financial participation for expenditures under the bill and would prohibit implementation of the bill until federal financial participation is obtained. The bill would additionally authorize the department to seek federal approval to require all eligible children to enroll in an available KIDS plan for the length of their CCS eligibility plus 6 months, and if the child remains eligible for Medi-Cal, for up to 12 months following termination of CCS eligibility. 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 California Children's Services (CCS) program is the nation' s oldest Title V Maternal and Child Health Services Block Grant program. (b) The CCS program has provided critical access to specialized medical care for California's most complex and fragile pediatric patients since 1927. (c) The strong standards and credentialing created under the CCS program ensure that eligible children obtain care from experienced providers with appropriate pediatric-specific expertise. (d) CCS providers form a regional backbone for all specialty pediatric care in California, benefitting children of every income level and insurance status. (e) Over the past 20 years, coordinated and integrated health care delivery models have been shown to improve delivery of health care, reduce costs, and improve outcomes. (f) As California expanded the reach of integrated delivery systems in Medi-Cal, CCS services were often excluded from managed care arrangements in recognition of the specialty nature of CCS services and the complicated health status of enrolled children. (g) Accordingly, it is the intent of the Legislature to modernize the CCS program, through development of specialized integrated delivery systems focused on the unique needs of CCS-eligible children, to accomplish the following: (1) Improve coordination and integration of services to meet the needs of the whole child, not just address the CCS-eligible condition. (2) Retain CCS program standards to maintain access to high-quality specialty care for eligible children. (3) Support active participation by parents and families, who are frequently the primary caregivers for CCS-eligible children. (4) Established specialized programs to manage and coordinate the care of CCS-enrolled children. (h) It is further the intent of the Legislature to protect the unique access to pediatric specialty services provided by CCS while promoting modern organized delivery systems to meet the medical care needs of eligible children. SEC. 2. Section 14094.24 is added to the Welfare and Institutions Code, to read: 14094.24. (a) The following definitions shall apply for purposes of this section: (1) "Children's hospital" means a hospital identified in Sections 10727 and 10728. (2) "Kids Integrated Delivery System (KIDS)" means an entity selected by the department to coordinate and manage the provision of Medi-Cal and CCS services for eligible children, on a county or regional basis, consistent with managed care principles, techniques, and practices, to ensure access to cost-effective, quality care for enrolled children. A KIDS plan may include either of the following organizational models: (A) An entity coordinated through a children's hospital with a shared governance structure comprised of providers who are held jointly accountable for achieving measured quality improvements and reductions in the rate of spending growth for Medi-Cal services for enrolled children. (B) An entity coordinated by a CCS-approved provider with a shared governance structure comprised of providers, including participation by at least one children's hospital, who are held jointly accountable for achieving measured quality improvements and reductions in the rate of spending growth for Medi-Cal services for enrolled children. (3) "Eligible child" means either of the following: (A) A minor child under 21 years of age, who is eligible for both Medi-Cal and the California Children's Services Program (Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code), excluding those children eligible under the program for neonatal intensive care services. (B) An individual up to 26 years of age, if the individual was previously treated for a CCS-eligible condition in the twelve months prior to his or her 21st birthday, is eligible for full-scope Medi-Cal services, and voluntarily chooses to remain in a KIDS plan that accepts individuals up to age 26 pursuant to its contract with the department. (4) "Enrollee" means an eligible child enrolled in a KIDS plan and who receives Medi-Cal and CCS services through the KIDS plan. (b) Consistent with Sections 14093.05 and 14093.06 and the requirements of this chapter, no later than January 1, 2018, in counties or regions where there is no demonstration project pursuant to Section 14094.3, the department shall select and enter into contracts with one or more KIDS plans, to provide comprehensive health care services to eligible children. In the selection process, the department shall give special consideration to entities that meet all of the following criteria: (1) Demonstrates experience in effectively serving eligible children and providing services in compliance with CCS program standards and requirements. (2) Includes in the KIDS plan a sufficient number of CCS-paneled providers, including board-certified pediatricians, CCS-approved special care centers, and other providers who have been providing services to eligible children in the proposed KIDS plan service area to ensure continuity of care, timely access to quality services, and the least disruption to existing patient-provider relationships. (3) Develops the KIDS plan through a local collaborative stakeholder process that includes, but is not limited to, families of eligible children, local consumer advocates, CCS providers, and staff of the CCS program in the county or counties in the proposed KIDS plan service area. (4) Incorporates specific strategies to actively engage families as partners in decisions affecting the health care and well-being of children enrolled in the KIDS plan. (c) A KIDS plan shall do all of the following: (1) Contract with the department to coordinate, integrate, and provide or arrange for the full range of Medi-Cal and CCS services to eligible children enrolled in the KIDS plan pursuant to this subdivision. (A) A KIDS plan contract shall exclude, at a minimum, specialty mental health services provided by county mental health plans and neonatal intensive care services. A KIDS contract may exclude other Medi-Cal services, as determined by the department, including, but not limited to, long-term care, transplantation, and dental services. (B) Benefits of the Medical Therapy Program may be provided or coordinated by a KIDS plan, in collaboration and consultation with the designated county CCS agency or agencies in the KIDS plan service area. (2) Operate under a contract with the department that satisfies the requirements of this chapter, including Sections 14093.05 and 14093.06. (3) Provide services to enrollees through a team-based, patient-centered health home model, ensure that enrolled children receive services in the most appropriate and least restrictive setting, and adopt effective strategies to manage and coordinate care and services for enrolled children. (4) Report and comply with quality measures, including, but not limited to, Medi-Cal Healthcare Effectiveness Data and Information Set (HEDIS) measures appropriate for enrolled children, the national Pediatric Quality Measurement System (PQMS) for children's hospitals, and other quality measures developed by the department in consultation with stakeholders. (5) Participate in a nationally recognized pediatric patient safety organization. (6) Comply with readiness criteria, network adequacy standards, and other appropriate standards applicable to Medi-Cal managed care plans, as determined by the department in consultation with stakeholders, and any terms of the federal approvals obtained by the department. (7) Establish and maintain a family advisory council composed of families of eligible children and convene the advisory council at least quarterly. (d) (1) Contracts with KIDS plans may include opportunities to share in the risk of providing services to KIDS enrollees, pursuant to an agreement between the department and the KIDS plan. Any shared savings that result from the implementation of these arrangements shall be reinvested in services provided to children enrolled in the KIDS plan. (2) The department shall not enter into risk-sharing arrangements with a KIDS plan for specific covered services unless the KIDS plan is responsible for the management and authorization of those services. (3) Payments to a KIDS plan that agrees to accept risk-sharing shall be actuarially sound. (e) Eligibility for enrollment in a KIDS plan shall be determined in accordance with all of the following: (1) Children shall be deemed eligible for enrollment in a KIDS plan based on eligibility for the CCS program pursuant to Section 14005.26, except as provided by paragraph (2). (2) A child receiving neonatal intensive care unit (NICU) services shall not be eligible for enrollment until the child is discharged from the NICU and meets the other requirements of this subdivision. (3) (A) To the extent that the department obtains federal approval to require eligible children to enroll in an available KIDS plan in order to receive Medi-Cal and CCS services, eligible children shall be enrolled on a mandatory basis pursuant to this section and the provisions of this chapter applicable to Medi-Cal managed care plan enrollments. (B) Enrollment in a KIDS plan shall be, at a minimum, for the period of a child's CCS eligibility plus an additional six months, provided that the child remains eligible for Medi-Cal. KIDS plan enrollees who continue to remain eligible for Medi-Cal may remain in the KIDS plan for up to 12 months following the termination of CCS eligibility if the KIDS program and the parent, guardian or person responsible for care of the child agree that it is in the best interests of the child. (C) Pursuant to this section, and subject to necessary federal approvals, if a KIDS plan becomes newly available in a service area, or if a child becomes newly eligible for a KIDS plan, the child shall be enrolled in the available KIDS plan. The department shall determine, in consultation with counties, KIDS plans, local KIDS family advisory councils, and existing Medi-Cal managed care plans in the service area and the timing and process for enrollment in KIDS plans to ensure a smooth transition for eligible children. (D) If there is more than one KIDS plan in the county or region in which the child lives, the parent, guardian, or person responsible for the care of the eligible child may select the KIDS plan in which the child will be enrolled. If the family does not select a KIDS plan, the child shall be assigned to a KIDS plan in a manner that ensures the least disruption in existing patient-provider relationships. (E) Upon enrollment of an eligible child in a KIDS plan, the parent, guardian, or person responsible for the care of the child shall be informed that the child may choose to continue an established patient-provider relationship if his or her treating provider is a primary care provider or clinic contracting with the KIDS, has the available capacity, and agrees to continue to treat that eligible child. KIDS plans shall comply with the continuity of care requirements in Section 1373.96 of the Health and Safety Code. (4) Within 30 days of notice that a child is no longer eligible for a KIDS plan pursuant to this section, a child who continues to be eligible for Medi-Cal shall be enrolled in the Medi-Cal delivery system in the county in which he or she resides. The department shall ensure that families receive information about the Medi-Cal delivery systems available in their county and the process for enrolling in and selecting among the available options. Children disenrolling from a KIDS plan because they are no longer eligible shall be enrolled in county Medi-Cal delivery systems as follows: (A) If there is a Medi-Cal managed care plan in the county of the child's residence, the child shall be enrolled in the managed care plan. In counties where there is more than one Medi-Cal managed care plan, if the family does not choose a plan for the child within 30 days of notice of disenrollment from the KIDS, the child shall be enrolled into the Medi-Cal managed care health plan that contains his or her primary care provider. If the primary care provider participates in more than one managed care health plan in the county, the child shall be assigned to one of the health plans containing his or her primary care provider in accordance with the assignment process applicable in the county. (B) In a county that is not a managed care county, children no longer eligible for the KIDS plan shall be provided services under the Medi-Cal fee-for-service delivery system. (5) The department shall instruct KIDS plans, counties, and managed care plans, by means of all-county and all-plan letters or similar instruction, as to the processes to be used to enroll and disenroll children in KIDS plans and to re-enroll eligible children in local Medi-Cal coverage options, to ensure each child experiences a smooth transition among coverage types with no gap in coverage or care. (6) A child who is enrolled in a KIDS plan shall retain all rights to CCS program appeals and fair hearings of denials of medical eligibility or of service authorizations. (f) The department shall seek all necessary federal approvals to ensure federal financial participation in expenditures under this section. This section shall not be implemented until necessary federal approvals have been obtained. (g) The department may seek federal approval to require all eligible children to enroll in an available KIDS plan during the length of their eligibility for CCS plus an additional six months, and, if the child remains eligible for Medi-Cal, to voluntarily remain in the KIDS for up to 12 months following termination of CCS eligibility. SEC. 3. Section 14094.3 of the Welfare and Institutions Code is amended to read: 14094.3. (a) Notwithstanding this article or Section 14093.05 or 14094.1, CCS covered services shall not be incorporated into any Medi-Cal managed care contract entered into after August 1, 1994, pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.8 (commencing with Section 14087.5), Article 2.9 (commencing with Section 14088), Article 2.91 (commencing with Section 14089), Article 2.95 (commencing with Section 14092); or either Article 2 (commencing with Section 14200), or Article 7 (commencing with Section 14490) of Chapter 8,until January 1, 2016,except forcontracts entered into for county organized health systems or Regional Health Authority in the Counties of San Mateo, Santa Barbara, Solano, Yolo, Marin, and Napa.either or both of the following: (1) Contracts entered into for county organized health systems or Regional Health Authority in the Counties of San Mateo, Santa Barbara, Solano, Yolo, Marin, and Napa. (2) Contracts entered into pursuant to Section 14094.24. (b) Notwithstanding any other provision of this chapter, providers serving children under the CCS program who are enrolled with a Medi-Cal managed care contractor but who are not enrolled in a pilot project pursuant to subdivision (c) shall continue to submit billing for CCS covered services on a fee-for-service basis until CCS covered services are incorporated into the Medi-Cal managed care contracts described in subdivision (a). (c) (1) The department may authorize a pilot project in Solano County in which reimbursement for conditions eligible under the CCS program may be reimbursed on a capitated basis pursuant to Section 14093.05, and provided all CCS program's guidelines, standards, and regulations are adhered to, and CCS program's case management is utilized. (2) During the time period described in subdivision (a), the department may approve, implement, and evaluate limited pilot projects under the CCS program to test alternative managed care models tailored to the special health care needs of children under the CCS program. The pilot projects may include, but need not be limited to, coverage of different geographic areas, focusing on certain subpopulations, and the employment of different payment and incentive models. Pilot project proposals from CCS program-approved providers shall be given preference. All pilot projects shall utilize CCS program-approved standards and providers pursuant to Section 14094.1. (d) For purposes of this section, CCS covered services include all program benefits administered by the program specified in Section 123840 of the Health and Safety Code regardless of the funding source. (e) Nothing in this section shall be construed to exclude or restrict CCS eligible children from enrollment with a managed care contractor, or from receiving from the managed care contractor with which they are enrolled primary and other health care unrelated to the treatment of the CCS eligible condition.