BILL NUMBER: SB 586 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 28, 2015
INTRODUCED BY Senator Hernandez
( Coauthors: Assembly Members
Alejo, Bonta, and Chávez )
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 amended, 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 networks , 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 network and eligibility
standards, as well as the qualifications and exclusions required for
KIDS plan network contracts. The KIDS
plan network 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 these provisions,
and would prohibit implementation of the bill
these provisions 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 network
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, 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) Established 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 14094.24 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.
(1) "CCS tertiary hospital" means a hospital that is designated as
a tertiary hospital pursuant to the Standards for Tertiary Hospitals
set forth in the California Children's Services Manual of
Procedures.
(2) "Kids Integrated Delivery System (KIDS)" means an
entity selected a network approved 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 12 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 network 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 network and who receives Medi-Cal and CCS
services through the KIDS plan. network.
(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,
networks, 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: order to contract with the
department pursuant to this section, a KIDS network shall meet all of
the following criteria:
(1) Demonstrates Demonstrate
experience in effectively serving eligible children and providing
services in compliance with CCS program standards and requirements.
(2) Includes Include in the KIDS
plan network 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 network service area to ensure continuity
of care, timely access to quality services, and the least disruption
to existing patient-provider relationships.
(3) Develops Develop the KIDS
plan network 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 network service
area.
(4) Incorporates Incorporate
specific strategies to actively engage families as partners in
decisions affecting the health care and well-being of children
enrolled in the KIDS plan. network.
(5) Be anchored by a hospital that is designated as a CCS tertiary
hospital, or by a CCS provider in partnership with a CCS tertiary
hospital.
(c) A KIDS plan network 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
network pursuant to this subdivision.
(A) A KIDS plan network 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, network, in
collaboration and consultation with the designated county CCS agency
or agencies in the KIDS plan network
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)
(6) 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 networks
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. network.
Any shared savings that result from the implementation of these
arrangements shall be reinvested in services provided to children
enrolled in the KIDS plan. network.
(2) The department shall not enter into risk-sharing arrangements
with a KIDS plan network for specific
covered services unless the KIDS plan is responsible for the
management and authorization of those services.
(3) Payments to a KIDS plan network
that agrees to accept risk-sharing shall be actuarially sound.
(e) Eligibility for enrollment in a KIDS plan
network shall be determined in accordance with all of the
following:
(1) Children shall be deemed eligible for enrollment in a KIDS
plan network 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 network 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 network
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
network enrollees who continue to remain eligible for Medi-Cal
may remain in the KIDS plan network 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 network
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 the department
shall determine, in consultation with counties, KIDS plans,
networks, local KIDS family advisory councils,
and existing Medi-Cal managed care plans in the service area
and area, the timing and process for enrollment
in KIDS plans networks to ensure a
smooth transition for eligible children.
(D) If there is more than one KIDS plan
network 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 network
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
network in a manner that ensures the least
disruption in existing patient-provider relationships.
(E) Upon enrollment of an eligible child in a KIDS plan,
network, 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 networks 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 network 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
network 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 network
shall be provided services under the Medi-Cal fee-for-service
delivery system.
(5) The department shall instruct KIDS plans,
networks, 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 networks and to reenroll 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
network shall retain all rights to CCS program appeals and
fair hearings of denials of medical eligibility or of service
authorizations. authorizations, as well as
all due process and fair hearing rights under the Medi-Cal program.
(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
network 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, except for 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.