California Senate Bill SB586 Amended / Bill

 BILL NUMBER: SB 586AMENDED BILL TEXT AMENDED IN ASSEMBLY JUNE 8, 2016 AMENDED IN ASSEMBLY MAY 4, 2016 AMENDED IN SENATE APRIL 28, 2015 INTRODUCED BY Senator Hernandez (Coauthors: Assembly Members Alejo, Bonta, and Chvez) FEBRUARY 26, 2015 An act to amend Section 14094.3 of, and to add  Section 14094.4 to,   Article 2.985 (commencing with Section 14094.4) to Chapter 7 of Part 3 of Division 9 of,  the Welfare and Institutions Code, relating to children's services. LEGISLATIVE COUNSEL'S DIGEST SB 586, as amended, Hernandez. Children's services. The California Children's Services  Program (CCS 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   CCS  program  (CCS)  from being incorporated into a Medi-Cal managed care contract entered into after August 1, 1994, until January 1, 2017, except with respect to contracts entered into for county organized health systems or Regional Health Authority in specified counties. This bill would exempt contracts entered into under the Whole Child Model program, described below, from that prohibition and would extend to January 1, 2025, and until the evaluation required under the Whole Child Model program has been completed, the termination of the prohibition against CCS covered services being incorporated in a Medi-Cal managed care contract entered into after August 1, 1994. The bill would authorize the department, no sooner than July 1, 2017, to establish a Whole Child Model program, under which managed care plans under county organized health systems or Regional Health Authority that elect, and are selected, to participate would provide CCS services under a capitated payment model to Medi-Cal and  S-CHIP   State Children's Health Insurance   Program (S-CHIP)  eligible CCS children and youth. The bill would limit the number of managed care plans under a county organized health system or Regional Health Authority that are eligible to participate in the program. The bill would require the department to establish an application process and would require a managed care plan to provide the department with a written application of interest that contains specified information, including evidence that the managed care plan received written support from specified individuals and entities, including CCS providers, as defined, that serve a preponderance of CCS children and youth in the county. The bill would prohibit the department from approving the application of a managed care plan until the Director of Health Care Services has verified the readiness of the managed care plan to address the unique needs of CCS-eligible beneficiaries, including, among other things, that the managed care contractor demonstrates the availability of an appropriate provider network to serve the needs of children and youth with CCS conditions and complies with all CCS program guidelines. The bill would prohibit the department from implementing the program in any county until it has developed and implemented specific CCS monitoring and oversight standards for managed care plans. The bill would require the department to establish a statewide Whole Child Model stakeholder advisory group comprised of specified stakeholders, including representatives from health plans and family resource centers, and would require the department to consult with the Whole Child Model stakeholder advisory group on the implementation of the program, as specified. The bill would require the department to contract with an independent entity to conduct an evaluation to assess health plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the program, and would require the department to provide a report on the results of this evaluation to the Legislature no later than January 1, 2023.  This bill would provide that its provisions are not intended to permit any reduction in benefits or eligibility levels under the existing CCS program.  The bill would require the department, by July 1, 2018, to adopt regulations and, commencing July 1, 2017, would require the department to provide a status report to the Legislature until regulations have been adopted.  The bill would authorize the Director of Health Care Services to   enter into exclusive or nonexclusive contracts on a bid, nonbid, or negotiated basis and   amend   existing managed care contracts to provide or arrange for services provided under the bill.  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, benefiting 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) Establish specialized programs to manage and coordinate the care of CCS-enrolled children. (5) Ensure that children with CCS-eligible conditions receive care in the most appropriate, least restrictive setting. (6) Maintain existing patient-provider relationships, whenever possible. (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 14094.3 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 1 (commencing with Section 14200), or Article 7 (commencing with Section 14490) of Chapter 8, until January 1, 2025, and until the evaluation required pursuant to  subdivision (j) of Section 14094.4   Section 14094.18  has been completed, except for contracts entered into pursuant to the Whole Child Model program, as described in  Section 14094.4,   Article 2.985 (commencing with Section 14094.4),  or for county organized health systems or Regional Health Authority in the Counties of San Mateo, Santa Barbara, Solano, Yolo, Marin, and Napa. (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.  SEC. 3.   Section 14094.4 is added to the Welfare and Institutions Code, to read: 14094.4. (a) For the purposes of this section, the following definitions shall apply: (1) "CCS Provider" means a provider that is approved by the CCS program to treat a CCS-eligible condition pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code. (2) "County organized health system" or "COHS" means a county organized health system contracting with the department to provide Medi-Cal services to beneficiaries pursuant to Article 2.8 (commencing with Section 14087.5). (3) "Whole Child Model site" means a managed care plan under a county organized health system or Regional Health Authority that is selected to participate in the Whole Child Model program under a capitated payment model. (b) The department may establish a Whole Child Model program for Medi-Cal and S-CHIP eligible CCS children and youth enrolled in a managed care plan under a county organized health system or Regional Health Authority in up to __ counties no sooner than July 1, 2017. (c) The goals for the Whole Child Model program for children and youth under 21 years of age who meet the eligibility requirements of Section 123805 of the Health and Safety Code and are enrolled in a managed care plan under a county organized health system or Regional Health Authority shall include all of the following: (1) Improving the coordination of primary and preventive services with specialty care services, medical therapy units, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), long-term services and supports (LTSS), and regional center services, and home- and community-based services using a child and youth and family-centered approach. (2) Maintaining or exceeding CCS program standards and specialty care access, including access to appropriate subspecialties. (3) Ensuring the continuity of child and youth access to expert, CCS dedicated case management and care coordination, provider referrals, and service authorizations through contracting with or the employment of county CCS staff to perform these functions. (4) Improving the transition of youth from CCS to adult Medi-Cal managed systems of care through better coordination of medical and nonmedical services and supports and improved access to appropriate adult providers for youth who age out of CCS. (5) Identifying, tracking, and evaluating the transition of children and youth from CCS to the Whole Child Model program to inform future CCS program improvements. (d) (1) No sooner than July 1, 2017, the department shall establish an application process by which up to __ managed care plans under a county organized health system, including the county organized health systems and Regional Health Authority that have incorporated CCS covered services into their contracts pursuant to Section 14094.3, may participate in the Whole Child Model program established under this section, pursuant to the criteria described in this section. The director shall consult with the Legislature, the federal Centers for Medicare and Medicaid Services, counties, CCS providers, and CCS families when determining the implementation date for this section. (2) In order to apply to become a Whole Child Model site, a managed care plan under a county organized health system or Regional Health Authority shall provide a written application of interest that provides the director with evidence of all of the following: (A) Written approval by the county board of supervisors to partner with the managed care plan for the integration of CCS medical and case management and service authorizations for CCS Medi-Cal beneficiaries into the managed care plan. (B) Written support from the local bargaining units representing affected CCS worker classifications. (C) Written support from CCS providers that serve a preponderance of the CCS children and youth in the county, home- and community-based services networks, and the regional center or centers that serve CCS children and youth in that county. (D) Establishment and demonstration of a local stakeholder process with the meaningful engagement of a diverse group of families that represent a range of conditions, disabilities, and demographics, and local providers, including, but not limited to, the parent centers, such as family resource centers, family empowerment centers, and parent training and information centers, that support families in the affected county. (E) Written support from the family resource center or family empowerment center serving the affected county. (3) The department shall post its written approval of an application of interest on its Internet Web site at least 90 days before CCS services are incorporated into the managed care plan under the Whole Child Model program pursuant to this section. (e) A managed care plan shall not be approved to participate in the Whole Child Model program unless all of the following conditions have been satisfied: (1) The managed care plan has obtained written approval from the director of its application of interest. (2) The department has obtained all necessary federal approvals and waivers. (3) The director has verified the readiness of the managed care plan to address the unique needs of CCS-eligible beneficiaries, including, but not limited to, the requirements set forth in subdivision (b) of Section 14087.48, subdivisions (b) to (f), inclusive, of Section 14093.05, and all of the following: (A) Timely and appropriate communication with affected CCS-eligible children and youth and their parents or guardians. Communication shall be tested for readability by a health literacy and readability professional and targeted at a 6th grade reading level. Plan communications to families and providers shall also be shared with the plan's local family advisory group established pursuant to clause (xx) of subparagraph (E) for feedback and approval. (B) That the managed care contractor demonstrates the availability of an appropriate provider network to serve the needs of children and youth with CCS conditions, including primary care physicians, pediatric specialists and subspecialists, professional, allied, and medical supportive personnel, and an adequate number of accessible facilities within each CCS service area. (C) That the managed care contractor has established and maintains an updated and accessible listing of providers and their specialties and subspecialties and makes it available to CCS-eligible children and youth and their parents or guardians, at a minimum by phone, written material, and Internet Web site. (D) That the managed care contractor has entered into an agreement with the county CCS program or the state, or both, for the provision of CCS care coordination and service authorization and how the plan will work with the CCS program to ensure continuity and consistency of CCS program expertise for that role, in accordance with this section. (E) That the managed care contractor serving children and youth with CCS-eligible conditions under the CCS program shall do all of the following: (i) Comply with continuity of care requirements in Section 1373.96 of the Health and Safety Code and Section 14185. (ii) Coordinate with each regional center operating within the plan's service area to assist CCS-eligible children and youth with developmental disabilities and their families in understanding and accessing services and act as a central point of contact for questions, access and care concerns, and problem resolution. (iii) Coordinate with the local CCS Medical Therapy Unit (MTU) to ensure appropriate access to MTU services. (iv) Create and maintain a clinical advisory committee composed of the managed care contractor's Chief Medical Officer, the county CCS medical director, and at least four CCS-paneled providers to review treatment authorizations and other clinical issues relating to CCS conditions. (v) (I) Establish and maintain a process by which families may maintain access to any CCS providers for up to the length of the child's or youth's CCS qualifying condition or 12 months, whichever is longer, under the following conditions: (ia) The CCS-eligible child or youth has an ongoing relationship with a provider who is a CCS-approved provider. (ib) The provider will accept the health plan's rate for the service offered or the applicable Medi-Cal or CCS fee-for-service rate, whichever is higher. (ic) The managed care plan determines that the provider meets applicable CCS standards and has no disqualifying quality of care issues, in accordance with guidance from the department, including all-plan letters and CCS numbered letters or other administrative communication. (id) The provider shall provide treatment information to the health plan, to the extent authorized by the state and federal patient privacy provisions. (II) This clause shall apply to out-of-network and out-of-county primary care and specialist providers. (III) A managed care plan, at its discretion, may extend the continuity of care period beyond the length of time specified in this clause. (vi) Facilitate communication among a CCS child's or youth's health care and personal care providers, including in-home supportive services and behavioral health providers, when appropriate, with the CCS-eligible child or youth, parent, or guardian. (vii) Facilitate timely access to primary care, specialty care, medications, and other health services needed by the CCS child or youth, including referrals to address any physical or cognitive barriers to access. (viii) Provide training for families about managed care processes and how to navigate a health plan, including their rights to appeal any service denials. The managed care plan shall partner with a family empowerment center or family resource center in its service area to provide this training. (ix) Provide a mechanism for a CCS-eligible child's and youth's parent or caregiver to request a specialist or clinic as a primary care provider. A specialist or clinic may serve as a primary care provider if the specialist or clinic agrees to serve in a primary care provider role and is qualified to treat the required range of CCS-eligible conditions of the CCS child or youth. (x) Provide that communication to, and services for, the CCS-eligible children or youth and their families are available in alternative formats that are culturally, linguistically, and physically appropriate through means, including, but not limited to, assistive listening systems, sign language interpreters, captioning, written communication, plain language, and written translations in at least the Medi-Cal threshold languages. (xi) Provide that materials are available and provided to inform CCS children and youth and their families of procedures for obtaining CCS specialty services and Medi-Cal primary care and mental health benefits, including grievance and appeals procedures that are offered by the managed care plan or are available through the Medi-Cal program. (xii) Identify and track children and youth with CCS-eligible conditions for the duration of the child's or youth's participation in the Whole Child Model program and for children and youth who age into adult Medi-Cal systems, for at least 10 years into adulthood. (xiii) Provide timely processes for accepting and acting upon complaints, grievances, and disenrollment requests, including procedures for appealing decisions regarding coverage or benefits. The grievance process shall comply with Section 14450, and Sections 1368 and 1368.01 of the Health and Safety Code. (xiv) Establish an assessment process that, at a minimum, does all of the following: (I) Ensures that families have access to ongoing information, education, and support so they understand the care plan, course of treatment, and expected outcomes for their child or youth, the assessment process, what it means, their role in the process, and what services their child or youth may be eligible for. (II) Assesses each CCS child's or youth's risk level and needs by performing a risk assessment process using means such as telephonic or in-person communication, review of utilization and claims processing data, or by other means as determined by the department. The risk assessment process shall be performed in accordance with all applicable federal and state laws. (III) Assesses, in accordance with the agreement with the county CCS program specified in paragraph (3) of subdivision (b), the care needs of CCS-eligible children and youth and coordinates their CCS specialty services, Medi-Cal primary care services, mental health and behavioral health benefits, and regional center services across all settings, including coordination of necessary services within and, when necessary, outside of the managed care health plan's provider network. (IV) Reviews historical CCS fee-for-service utilization data for CCS-eligible children and youth upon transition of CCS services to managed care contractors so that the managed care plans are better able to assist CCS-eligible children and youth and prioritize assessment and care planning. (V) Follows timeframes for reassessment of risk pursuant to this clause and, if necessary, circumstances or conditions that require redetermination of risk level, which shall be set by the department. (xv) Work with the state or county CCS program, as appropriate, to ensure that, at a minimum, and in addition to other statutory and contractual requirements, care coordination and care management activities do all of the following: (I) Reflect a CCS child or youth family-centered, outcome-based approach to care planning. (II) Ensure families have access to ongoing information, education, and support so that they understand the vision of care for their child or youth and their role in the individual care process, the benefits of mental health services, what self-determination means, and what services might be available. (III) Adhere to the CCS child's or youth's or the CCS child's or youth's family's determination about the appropriate involvement of his or her medical providers and caregivers, according to the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191). (IV) Are developed for the CCS child or youth across CCS specialty services, Medi-Cal primary care services, mental health and behavioral health benefits, regional center services, MTUs, and in-home supportive services (IHSS), including transitions among levels of care and between service locations. (V) Include individual care plans for CCS-eligible children and youth based on the results of the risk assessment process with a particular focus on CCS specialty care. (VI) Consider behavioral health needs of CCS-eligible children and youth and coordinate those services with the county mental health department as part of the CCS child's or youth's individual care plan, when appropriate, and facilitate a CCS child's or youth's ability to access appropriate community resources and other agencies, including referrals, as necessary and appropriate, for behavioral services, such as mental health services. (VII) Ensure that children and youth and their families have appropriate access to transportation and other support services necessary to receive treatment. (xvi) Incorporate all of the following into the CCS child's or youth's plan of care patterns and processes: (I) Access for families so that families know where to go for ongoing information, education, and support in order that they understand the goals, treatment plan, and course of care for their child or youth and their role in the process, what it means to have primary or specialty care for their child or youth, when it is time to call a specialist, primary, urgent care, or emergency room, what an interdisciplinary team is, and what the community resources are. (II) A primary or specialty care physician who is the primary clinician for the CCS-eligible child or youth and who provides core clinical management functions. (III) Care management and care coordination for the CCS-eligible child or youth across the health care system, including transitions among levels of care and interdisciplinary care teams. (IV) Provision of referrals to qualified professionals, community resources, or other agencies for services or items outside the scope of responsibility of the managed care health plan. (V) Use of clinical data to identify CCS-eligible children or youth at the care site with chronic illness or other significant health issues. (VI) Timely preventive, acute, and chronic illness treatment of CCS-eligible children or youth in the appropriate setting. (VII) Use of clinical guidelines or other evidence-based medicine when applicable for treatment of the CCS-eligible child's or youth's health care issues or timing of clinical preventive services. (xvii) Comply with all CCS program guidelines, including CCS program regulations, CCS numbered letters, and CCS program information notices. (xviii) Base treatment decisions for CCS-related conditions on CCS program guidelines or, if those guidelines do not exist, on treatment protocols or recommendations of the national pediatric specialty society with expertise in the condition. (xix) Establish a mechanism to provide information, education, and peer support to parents of CCS-eligible children and youth through parent-to-parent liaisons or relationships with local family resource centers or family empowerment centers. (xx) Establish a family advisory group for CCS families. Family representatives who serve on this advisory group shall receive ongoing information and training, travel reimbursement, child care, and other financial assistance as appropriate to enable participation in the advisory group. A representative of this local group shall serve on the department's statewide stakeholder advisory group established pursuant to subdivision (i). (xxi) Reimburse providers at rates sufficient to recruit and retain qualified providers with appropriate CCS expertise. Managed care plans shall pay physician and surgeon provider services at rates that are equal to or exceed the applicable CCS fee-for-service rates. (xxii) Utilize only appropriately credentialed CCS-paneled providers to treat CCS conditions. (xxiii) Utilize a provider dispute resolution process that meets the standards established under Section 1371.38 of the Health and Safety Code. (xxiv) Annually publicly report on the number of CCS-eligible children and youth served in their county by type of condition and services used and the number of youth who aged out of the CCS program by type of condition. (f) The department shall pay any managed care plan participating in the Whole Child Model program a separate, actuarially sound rate specifically for CCS children and youth. When contracting with managed care plans, the department may allow the use of risk corridors or other methods to appropriately mitigate a plan's risk for this population. (g) In implementing this section, the department may alter the medical home elements described in clause (xvi) of subparagraph (E) of paragraph (3) of subdivision (e) as necessary to secure the increased federal financial participation associated with the provision of medical assistance in conjunction with a health home, as made available under the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and codified in Section 1945 of Title XIX of the federal Social Security Act. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to alter medical home elements under this section at least five days in advance of taking this action. (h) The department shall not implement the Whole Child Model program in any county until it has developed and implemented specific CCS program monitoring and oversight standards for managed care plans that are subject to this section, including access monitoring, quality measures, and ongoing public data reporting. The department shall work with the stakeholder advisory group established pursuant to subdivision (i) to develop and implement robust monitoring processes to ensure that managed care plans are in compliance with all of the provisions of this section. The department shall monitor managed care plan compliance with the provisions of this section on at least an annual basis and post all monitoring data on its Internet Web site within 90 days. (i) The department shall establish a statewide Whole Child Model stakeholder advisory group, comprised of representatives of CCS providers, county CCS program administrators, health plans, family resource centers, family empowerment centers, CCS case managers, CCS MTUs, and a representative from each of the local family advisory groups established pursuant to clause (xx) of subparagraph (E) of paragraph (3) of subdivision (e). The department shall consult with the stakeholder advisory group on the implementation of the Whole Child Model and shall incorporate the recommendations of the stakeholder advisory group in developing the monitoring processes and outcome measures by which the Whole Child Model plans shall be monitored and evaluated. (j) The department shall contract with an independent entity that has experience in performing robust program evaluations to conduct an evaluation to assess health plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the Whole Child Model program, including access to primary and specialty care, and youth transitions from Whole Child Model program to adult Medi-Cal coverage, and shall provide a report on the results of this evaluation to the Legislature by no later than January 1, 2023. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code. The department shall consult with stakeholders, including, but not limited to, the Whole Child Model stakeholder advisory group, regarding the scope and structure of the review. This evaluation, at a minimum, shall compare the performance of the plans participating in the Whole Child Model program to the performance of the CCS program in counties where CCS is not incorporated into managed care and collect appropriate data to evaluate whether the inclusion of CCS services in a managed care delivery system improves access to care, quality of care, and the patient experience by analyzing all of the following by the child's or youth's race, ethnicity, and primary language spoken at home: (1) Access to specialty and primary care, and in particular, utilization of CCS-paneled providers. (2) The level of compliance with CCS clinical guidelines and the recommended guidelines of the American Academy of Pediatrics. (3) The type and location of CCS services and, with respect to health plans that have CCS services incorporated in their contracts, the extent to which CCS services are provided in-network compared to out of network. (4) Utilization rates of inpatient admissions, outpatient services, durable medical equipment, behavioral health services, home health, pharmacy, and other ancillary services. (5) Patient and family satisfaction. (6) Appeals, grievances, and complaints. (7) Authorization of CCS-eligible services. (8) Access to adult providers, support, and ancillary services for youth who have aged into adult Medi-Cal coverage from the Whole Child Model program. (9) For health plans with CCS incorporated into their contracts, network and provider participation, including participation of pediatricians, pediatric specialists, and pediatric subspecialists, by specialty and subspecialty. (k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking regulatory action, shall implement, interpret, or make specific this article, Article 2.97 (commencing with Section 14093), Article 2.98 (commencing with Section 14094), and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, CCS numbered letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2018, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing July 1, 2017, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted.   SEC. 3.   Article 2.985 (commencing with Section 14094.4) is added to Chapter 7 of Part 3 of Division 9 of the   Welfare and Institutions Code   , to read:   Article 2.985. Whole Child Model Program 14094.4. For the purposes of this article, the following definitions shall apply: (a) "CCS Provider" means a provider that is approved by the CCS program to treat a CCS-eligible condition pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code. (b) "County organized health system" or "COHS" means: (1) A county organized health system contracting with the department to provide Medi-Cal services to beneficiaries pursuant to Article 2.8 (commencing with Section 14087.5). (2) A regional health authority. (c) "Whole Child Model site" means a managed care plan under a county organized health system or Regional Health Authority that is selected to participate in the Whole Child Model program under a capitated payment model. (d) "Medi-Cal managed care plan" means a COHS. 14094.5. No sooner than July 1, 2017, the department may establish a Whole Child Model program for Medi-Cal and State Children' s Health Insurance Program (S-CHIP) eligible CCS children and youth enrolled in a managed care plan under a county organized health system or Regional Health Authority in up to __ counties. 14094.6. The goals for the Whole Child Model program for children and youth under 21 years of age who meet the eligibility requirements of Section 123805 of the Health and Safety Code and are enrolled in a managed care plan under a county organized health system or Regional Health Authority shall include all of the following: (a) Improving the coordination of primary and preventive services with specialty care services, medical therapy units, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), long-term services and supports (LTSS), and regional center services, and home- and community-based services using a child and youth and family-centered approach. (b) Maintaining or exceeding CCS program standards and specialty care access, including access to appropriate subspecialties. (c) Ensuring the continuity of child and youth access to expert, CCS dedicated case management and care coordination, provider referrals, and service authorizations through contracting with or the employment of county CCS staff to perform these functions. (d) Improving the transition of youth from CCS to adult Medi-Cal managed systems of care through better coordination of medical and nonmedical services and supports and improved access to appropriate adult providers for youth who age out of CCS. (e) Identifying, tracking, and evaluating the transition of children and youth from CCS to the Whole Child Model program to inform future CCS program improvements. 14094.7. (a) No sooner than July 1, 2017, the department shall establish an application process by which up to __ Medi-Cal managed care plans under a county organized health system, including the county organized health systems and Regional Health Authority that have incorporated CCS covered services into their contracts pursuant to Section 14094.3, may participate in the Whole Child Model program established under this section, pursuant to the criteria described in this section. The director shall consult with the Legislature, the federal Centers for Medicare and Medicaid Services, counties, CCS providers, and CCS families when determining the implementation date for this section. (b) In order to apply to become a Whole Child Model site, a managed care plan under a county organized health system or Regional Health Authority shall provide a written application of interest that provides the director with evidence of all of the following: (1) Written approval by the county board of supervisors to partner with the managed care plan for the integration of CCS medical and case management and service authorizations for CCS Medi-Cal beneficiaries into the managed care plan. (2) Written support from the local bargaining units representing affected CCS worker classifications. (3) Written support from CCS providers that serve a preponderance of the CCS children and youth in the county, home- and community-based services networks, and the regional center or centers that serve CCS children and youth in that county. (4) Written support from the family resource center or family empowerment center serving the affected county. (c) The department shall post its written approval of an application of interest on its Internet Web site at least 90 days before CCS services are incorporated into the managed care plan under the Whole Child Model program pursuant to this section. 14094.8. (a) The department shall not implement the Whole Child Model program in any county until it has developed and implemented specific CCS program monitoring and oversight standards for managed care plans that are subject to this article, including access monitoring, quality measures, and ongoing public data reporting. (b) The department shall work with the statewide stakeholder advisory group established pursuant to this article to develop and implement robust monitoring processes to ensure that managed care plans are in compliance with all of the provisions of this section. The department shall monitor managed care plan compliance with the provisions of this section on at least an annual basis and post all monitoring data on its Internet Web site within 90 days. (c) (1) In order to aid the transition of CCS services into Medi-Cal managed care plans participating in the Whole Child Model program, commencing January 1, 2017, and continuing through the completion of the transition of CCS enrollees into the Whole Child Model program, the department shall begin requesting and collecting from Medi-Cal managed care information about each health plan's provider network, including, but not limited to, the contracting primary care, specialty care providers, and hospital facilities contracting with the Medi-Cal managed care plan. (2) The department shall analyze the existing Medi-Cal managed care delivery system network and the CCS fee-for-service provider networks to determine the overlap of the provider networks in each county, and shall furnish this information to the Medi-Cal managed care plan. 14094.9. (a) A managed care plan shall not be approved to participate in the Whole Child Model program unless all of the following conditions have been satisfied: (1) The managed care plan has obtained written approval from the director of its application of interest. (2) The department has obtained all necessary federal approvals and waivers. (3) At least three months prior to implementation of the Whole Child Model program in the county or counties served by the plan, the Medi-Cal managed care plan has established a local stakeholder process with the meaningful engagement of a diverse group of families that represent a range of conditions, disabilities, and demographics, and local providers, including, but not limited to, the parent centers, such as family resource centers, family empowerment centers, and parent training and information centers, that support families in the affected county. (4) The director has verified the readiness of the managed care plan to address the unique needs of CCS-eligible beneficiaries, including, but not limited to, the requirements set forth in subdivision (b) of Section 14087.48, subdivisions (b) to (f), inclusive, of Section 14093.05, and all of the following: (A) Timely and appropriate communication with affected CCS-eligible children and youth and their parents or guardians. Communication shall be tested for readability by a health literacy and readability professional and targeted at a 6th grade reading level. Plan communications to families and providers shall also be shared with the plan's local family advisory group established pursuant to this article for feedback. (B) That the managed care contractor demonstrates the availability of an appropriate provider network to serve the needs of children and youth with CCS conditions, including primary care physicians, pediatric specialists and subspecialists, professional, allied, and medical supportive personnel, and an adequate number of accessible facilities. (C) That the Medi-Cal managed care plan has established and maintains an updated and accessible listing of providers and their specialties and subspecialties and makes it available to CCS-eligible children and youth and their parents or guardians, at a minimum by phone, written material, and Internet Web site. (D) That the Medi-Cal managed care plan has entered into an agreement with the county CCS program or the state, or both, for the provision of CCS care coordination and service authorization and how the plan will work with the CCS program to ensure continuity and consistency of CCS program expertise for that role, in accordance with this section. (b) A Medi-Cal managed care plan, prior to implementation of the Whole Child Model program, shall review historical CCS fee-for-service utilization data for CCS-eligible children and youth upon transition of CCS services to managed care plans so that the managed care plans are better able to assist CCS-eligible children and youth and prioritize assessment and care planning. 14094.10. (a) Each Medi-Cal managed care plan participating in the Whole Child Model program shall establish an assessment process that, at a minimum, does all of the following: (1) Assesses each CCS child's or youth's risk level and needs by performing a risk assessment process using means such as telephonic or in-person communication, review of utilization and claims processing data, or by other means as determined by the department. (2) Assesses, in accordance with the agreement with the county CCS program, the care needs of CCS-eligible children and youth and coordinates their CCS specialty services, Medi-Cal primary care services, mental health and behavioral health benefits, and regional center services across all settings, including coordination of necessary services within and, when necessary, outside of the managed care health plan's provider network. (3) Follows timeframes for reassessment of risk and, if necessary, circumstances or conditions that require redetermination of risk level, which shall be set by the department. (b) The risk assessment process shall be performed in accordance with all applicable federal and state laws. 14094.11. A Medi-Cal managed care plan participating in the Whole Child Model program shall meet all of the following requirements: (a) Work with the state or county CCS program, as appropriate, to ensure that, at a minimum, and in addition to other statutory and contractual requirements, care coordination and care management activities do all of the following: (1) Reflect a CCS child or youth family-centered, outcome-based approach to care planning. (2) Ensure families have access to ongoing information, education, and support so that they understand the care plan for their child or youth and their role in the individual care process, the benefits of mental health services, what self-determination means, and what services might be available. (3) Adhere to the CCS child's or youth's or the CCS child's or youth's family's determination about the appropriate involvement of his or her medical providers and caregivers, according to the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191). (4) Are developed for the CCS child or youth across CCS specialty services, Medi-Cal primary care services, mental health and behavioral health benefits, regional center services, MTUs, and in-home supportive services (IHSS), including transitions among levels of care and between service locations. (5) Include individual care plans for CCS-eligible children and youth based on the results of the risk assessment process with a particular focus on CCS specialty care. (6) Consider behavioral health needs of CCS-eligible children and youth and coordinate those services with the county mental health department as part of the CCS child's or youth's individual care plan, when appropriate, and facilitate a CCS child's or youth's ability to access appropriate community resources and other agencies, including referrals, as necessary and appropriate, for behavioral services, such as mental health services. (7) Ensure that children and youth and their families have appropriate access to transportation and other support services necessary to receive treatment. (b) Incorporate all of the following into the CCS child's or youth' s plan of care patterns and processes: (1) Access for families so that families know where to go for ongoing information, education, and support in order that they understand the goals, treatment plan, and course of care for their child or youth and their role in the process, what it means to have primary or specialty care for their child or youth, when it is time to call a specialist, primary, urgent care, or emergency room, what an interdisciplinary team is, and what the community resources are. (2) A primary or specialty care physician who is the primary clinician for the CCS-eligible child or youth and who provides core clinical management functions. (3) Care management and care coordination for the CCS-eligible child or youth across the health care system, including transitions among levels of care and interdisciplinary care teams. (4) Provision of referrals to qualified professionals, community resources, or other agencies for services or items outside the scope of responsibility of the managed care health plan. (5) Use of clinical data to identify CCS-eligible children or youth at the care site with chronic illness or other significant health issues. (6) Timely preventive, acute, and chronic illness treatment of CCS-eligible children or youth in the appropriate setting. 14094.12. A Medi-Cal managed care plan serving children and youth with CCS-eligible conditions under the CCS program shall do all of the following: (a) Coordinate with each regional center operating within the plan' s service area to assist CCS-eligible children and youth with developmental disabilities and their families in understanding and accessing services and act as a central point of contact for questions, access and care concerns, and problem resolution. (b) Coordinate with the local CCS Medical Therapy Unit (MTU) to ensure appropriate access to MTU services. The Medi-Cal managed care plan shall enter into a memorandum of understanding or similar agreement with the county regarding coordination of MTU services and services provided by the plan. (c) Ensure that families have access to ongoing information, education, and support so they understand the care plan, course of treatment, and expected outcomes for their child or youth, the assessment process, what it means, their role in the process, and what services their child or youth may be eligible for. (d) Facilitate communication among a CCS child's or youth's health care and personal care providers, including in-home supportive services and behavioral health providers, when appropriate, with the CCS-eligible child or youth, parent, or guardian. (e) Facilitate timely access to primary care, specialty care, medications, and other health services needed by the CCS child or youth, including referrals to address any physical or cognitive barriers to access. (f) Provide training for families about managed care processes and how to navigate a health plan, including their rights to appeal any service denials. The managed care plan shall partner with a family empowerment center or family resource center in its service area to provide this training. (g) Establish a mechanism to provide information, education, and peer support to parents of CCS-eligible children and youth through parent-to-parent liaisons or relationships with local family resource centers or family empowerment centers. (h) Provide that communication to, and services for, the CCS-eligible children or youth and their families are available in alternative formats that are culturally, linguistically, and physically appropriate through means, including, but not limited to, assistive listening systems, sign language interpreters, captioning, written communication, plain language, and written translations in at least the Medi-Cal threshold languages. (i) Provide that materials are available and provided to inform CCS children and youth and their families of procedures for obtaining CCS specialty services and Medi-Cal primary care and mental health benefits, including grievance and appeals procedures that are offered by the managed care plan or are available through the Medi-Cal program. (j) Identify and track children and youth with CCS-eligible conditions for the duration of the child's or youth's participation in the Whole Child Model program and for children and youth who age into adult Medi-Cal systems, for at least 10 years into adulthood. (k) Provide timely processes for accepting and acting upon complaints and grievances, including procedures for appealing decisions regarding coverage or benefits. The grievance process shall comply with Section 14450 of this code, and Sections 1368 and 1368.01 of the Health and Safety Code. (l) Annually publicly report on the number of CCS-eligible children and youth served in their county by type of condition and services used and the number of youth who aged out of the CCS program by type of condition, provided the required report does not contain individually identifiable information. If the required report would result in the publication of individually identifiable information, the plan shall not include that information in the required report. 14094.13. (a) Each Medi-Cal managed care plan shall establish and maintain a process by which families may maintain access to any CCS providers for treatment of the child's CCS condition, up to the length of the child's or youth's CCS qualifying condition or 12 months, whichever is longer, under the following conditions: (1) The CCS-eligible child or youth has an ongoing relationship with a provider who is a CCS-approved provider. (2) The provider will accept the health plan's rate for the service offered or the applicable Medi-Cal or CCS fee-for-service rate, whichever is higher, unless the physician and surgeon enter into an agreement on an alternative payment methodology mutually agreed to by the physician and surgeon and the Medi-Cal managed care plan. (3) The managed care plan determines that the provider meets applicable CCS standards and has no disqualifying quality of care issues, in accordance with guidance from the department, including all-plan letters and CCS numbered letters or other administrative communication. (4) The provider provides treatment information to the Medi-Cal managed care plan, to the extent authorized by the state and federal patient privacy provisions. (5) This section shall apply to out-of-network and out-of-county primary care and specialist providers. (b) A managed care plan, at its discretion, may extend the continuity of care period beyond the length of time specified in subdivision (a). (c) Each Medi-Cal managed care plan participating in the Whole Child Model program shall comply with continuity of care requirements in Section 1373.96 of the Health and Safety Code and Section 14185 of this code. 14094.14. (a) Each Medi-Cal managed care plan participating in the Whole Child Model program shall provide a mechanism for a CCS-eligible child's and youth's parent or caregiver to request a specialist or clinic as a primary care provider. (b) A CCS specialist or clinic may serve as a primary care provider if the specialist or clinic agrees to serve in a primary care provider role and is qualified to treat the required range of CCS-eligible conditions of the CCS child or youth. 14094.15. A Medi-Cal managed care plan shall meet all of the following requirements: (a) Comply with all CCS program guidelines, including CCS program regulations, CCS numbered letters, and CCS program information notices. (b) Base treatment decisions for CCS-related conditions on CCS program guidelines or, if those guidelines do not exist, on treatment protocols or recommendations of a national pediatric specialty society with expertise in the condition. (c) Use clinical guidelines or other evidence-based medicine when applicable for treatment of the CCS-eligible child's or youth's health care issues or timing of clinical preventive services. (d) Utilize only appropriately credentialed CCS-paneled providers to treat CCS conditions. (e) Utilize a provider dispute resolution process that meets the standards established under Section 1371.38 of the Health and Safety Code. 14094.16. (a) The department shall pay any managed care plan participating in the Whole Child Model program a separate, actuarially sound rate specifically for CCS children and youth. When contracting with managed care plans, the department may allow the use of risk corridors or other methods to appropriately mitigate a plan' s risk for this population. (b) A Medi-Cal managed care plan shall reimburse providers at rates sufficient to recruit and retain qualified providers with appropriate CCS expertise. (c) Medi-Cal managed care plans shall pay physician and surgeon provider services at rates that are equal to or exceed the applicable CCS fee-for-service rates, unless the physician and surgeon enters into an agreement on an alternative payment methodology mutually agreed to by the physician and surgeon and the Medi-Cal managed care plan 14094.17. (a) A Medi-Cal managed care plan participating in the Whole Child Model program shall create and maintain a clinical advisory committee composed of the managed care contractor's Chief Medical Officer, the county CCS medical director, and at least four CCS-paneled providers to review treatment authorizations and other clinical issues relating to CCS conditions. (b) (1) Each Medi-Cal managed care plan participating in the Whole Child Model program shall establish a family advisory group for CCS families. (2) Family representatives who serve on this advisory group shall receive ongoing information and training, travel reimbursement, child care, and other financial assistance as appropriate to enable participation in the advisory group. (3) A representative of this local group shall serve on the department's statewide stakeholder advisory group established pursuant to subdivision (c). (c) (1) The department shall establish a statewide Whole Child Model program stakeholder advisory group, comprised of representatives of CCS providers, county CCS program administrators, health plans, family resource centers, family empowerment centers, CCS case managers, CCS MTUs, and a representative from each of the local family advisory groups established pursuant to subdivision (b). (2) The department shall consult with the stakeholder advisory group on the implementation of the Whole Child Model program and shall incorporate the recommendations of the stakeholder advisory group in developing the monitoring processes and outcome measures by which the Whole Child Model plans shall be monitored and evaluated. 14094.18. (a) (1) The department shall contract with an independent entity that has experience in performing robust program evaluations to conduct an evaluation to assess Medi-Cal managed care plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the Whole Child Model program, including access to primary and specialty care, and youth transitions from Whole Child Model program to adult Medi-Cal coverage. (2) The department shall provide a report on the results of this evaluation required pursuant to this section to the Legislature by no later than January 1, 2023. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code. (b) The evaluation required by this section, at a minimum, shall compare the performance of the plans participating in the Whole Child Model program to the performance of the CCS program in counties where CCS is not incorporated into managed care and collect appropriate data to evaluate whether the inclusion of CCS services in a managed care delivery system improves access to care, quality of care, and the patient experience by analyzing all of the following by the child's or youth's race, ethnicity, and primary language spoken at home: (1) Access to specialty and primary care, and in particular, utilization of CCS-paneled providers. (2) The level of compliance with CCS clinical guidelines and the recommended guidelines of the American Academy of Pediatrics. (3) The type and location of CCS services and, with respect to health plans that have CCS services incorporated in their contracts, the extent to which CCS services are provided in-network compared to out of network. (4) Utilization rates of inpatient admissions, outpatient services, durable medical equipment, behavioral health services, home health, pharmacy, and other ancillary services. (5) Patient and family satisfaction. (6) Appeals, grievances, and complaints. (7) Authorization of CCS-eligible services. (8) Access to adult providers, support, and ancillary services for youth who have aged into adult Medi-Cal coverage from the Whole Child Model program. (9) For health plans with CCS incorporated into their contracts, network and provider participation, including participation of pediatricians, pediatric specialists, and pediatric subspecialists, by specialty and subspecialty. (c) The department shall consult with stakeholders, including, but not limited to, the Whole Child Model stakeholder advisory group, regarding the scope and structure of the review. 14094.19. This article is not intended, and shall not be interpreted, to permit any reduction in benefits or eligibility levels under the CCS program. 14094.20. (a) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking regulatory action, shall implement, interpret, or make specific this article, Article 2.97 (commencing with Section 14093), Article 2.98 (commencing with Section 14094), and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, CCS numbered letters, plan or provider bulletins, or similar instructions until the time regulations are adopted. By July 1, 2019, the department shall adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. Commencing July 1, 2017, the department shall provide a status report to the Legislature on a semiannual basis, in compliance with Section 9795 of the Government Code, until regulations have been adopted. (b) The director may enter into exclusive or nonexclusive contracts on a bid, nonbid, or negotiated basis and may amend existing managed care contracts to provide or arrange for services provided under this article. Contracts entered into or amended pursuant to this section shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, and shall be exempt from the review and approval of any division of the Department of General Services.