Public social services: Medi-Cal.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans. Existing federal law provides for the federal Medicare Program, which is a public health insurance program for persons 65 years of age and older and specified persons with disabilities who are under 65 years of age. Existing law provides for the county-administered In-Home Supportive Services (IHSS) program, under which, either through employment by the recipient, by or through contract by the county, by the creation of a public authority, or pursuant to a contract with a nonprofit consortium, qualified aged, blind, and disabled persons receive services enabling them to remain in their own homes. Existing law, to the extent that federal financial participation is available, and pursuant to a demonstration project or waiver of federal law, requires the department to establish pilot projects in up to 4 counties, to develop effective health care models to provide services to persons who are dually eligible under both the Medi-Cal and Medicare programs. Existing law requires the department to, not sooner than March 1, 2011, identify health care models that may be included in a pilot project, develop a timeline and process for selecting, financing, monitoring, and evaluating the pilot projects, and provide this timeline and process to certain committees of the Legislature. This bill would revise terminology used in these provisions and would require the department to establish demonstration sites, as defined, in up to 8 counties not sooner than March 1, 2013. This bill would require the department to enter into a memorandum of understanding (MOU) , with specified terms and conditions, with the federal Centers for Medicare and Medicaid Services (CMS) in developing the process for selecting, financing, monitoring, and evaluating the health care models for the demonstration project, and would require the department to require a demonstration site, as defined, to comply with specified requirements to the extent that the terms and conditions of the MOU do not address the specific selection, financing, monitoring, and evaluation criteria. This bill would require the department, with exceptions, to enroll dual eligible beneficiaries into a demonstration site unless the dual eligible beneficiary makes an affirmative choice to opt out of enrollment or is already enrolled in specific entities, as specified. Existing law requires the department to seek a demonstration project or federal waiver of Medicaid law to implement specified objectives, which may include better care coordination for seniors, persons with disabilities, and children with special health care needs. Existing law authorizes the department to require certain seniors and persons with disabilities to be assigned as mandatory enrollees into managed care health plans, and requires the department to meet prescribed conditions if the department exercises this authority. This bill would add prescribed conditions to those requirements, including, among other things, requiring the department to provide to a beneficiary a written notice with prescribed information when a request for exemption from plan enrollment is denied. This bill would require the department, in addition to the dual eligibles demonstration project, to assign Medi-Cal beneficiaries who have dual eligibility in Medi-Cal and the Medicare Program as mandatory enrollees into new and existing Medi-Cal managed care health plans, as defined, for their Medi-Cal benefits in counties participating in the demonstration project unless the beneficiary is exempt, as specified. This bill would authorize the department to contract with additional managed care health plans to provide Medi-Cal services in specified counties. This bill would require the department to ensure and improve the care coordination and integration of health care services for Medi-Cal beneficiaries residing in counties participating in the demonstration project who are dual eligible beneficiaries and receive Medi-Cal benefits and services through the demonstration project or through mandatory enrollment in managed care health plans, and for Medi-Cal beneficiaries who receive long-term services and supports, as defined, and would require the department to perform various duties before the department contracts with managed care health plans or Medi-Cal providers to furnish Medi-Cal benefits and services, as specified. This bill would provide that it is the intent of the Legislature that long-term services and supports be provided through managed care health plans in counties participating in the demonstration project. This bill would require that Medi-Cal long-term services and supports, including in-home supportive services, community-based adult services, Multipurpose Senior Services Program (MSSP) services, and skilled nursing facility and subacute care services, as specified, be covered services under managed care health plan contracts and would, with some exceptions, provide that these services only be available through managed care health plan contracts to beneficiaries residing in counties participating in the demonstration project. This bill would provide that home- and community-based services plan benefits, as defined, may be covered services under managed care health plan contracts for beneficiaries in counties participating in the demonstration project. Existing law requires the State Department of Health Care Services to pay capitation rates to health plans participating in the Medi-Cal managed care program using actuarial methods and authorizes the department to establish health-plan- and county-specific rates, as specified. This bill would apply those provisions to specified managed care organizations and to the capitation rates the department pays on and after the effective date of this bill under any managed care health plan contract, as specified. This bill would, to the extent consistent with federal law, authorize the department to defer payments to Medi-Cal managed care health plans and providers, as applicable, contracting with the department, as specified, which are payable to the plans during the final month of the 2012–13 state fiscal year, if certain conditions are satisfied. This bill would provide that specified sections shall become inoperative under certain circumstances. This bill would appropriate $1,000 from the General Fund to the State Department of Health Care Services for administration. This bill would become operative only if AB 1496 or SB 1036 of the 2011–12 Regular Session is enacted and takes effect. This bill would declare that it is to take effect immediately as a bill providing for appropriations related to the Budget Bill.