2007 California Welfare and Institutions Code Part 3.5. Health Care Coverage Initiative

CA Codes (wic:15900-15908)

15900.  The Legislature finds and declares the following:
   (a) Approximately 21 percent of nonelderly Californians lack
health insurance coverage. Many are low-income individuals who are
not eligible for existing public health coverage programs.
   (b) One hundred eighty million dollars (0,000,000) in federal
funds will be available for three years to reimburse for public
expenditures made under a Health Care Coverage Initiative for
uninsured individuals. These funds are to be provided pursuant to the
Special Terms and Conditions of California's Section 1115 Medicaid
demonstration project waiver number 11-W-00193/9 relating to hospital
financing and health coverage expansion.
   (c) California's health care safety net system plays an essential
role in delivering critical health services to low-income
individuals.
   (d) Local governments have the unique ability to design health
service delivery models that meet the needs of their diverse
populations and build on local infrastructures.



15901.  (a) There is hereby established the Health Care Coverage
Initiative to expand health care coverage to low-income uninsured
individuals in California.
   (b) The Health Care Coverage Initiative shall operate pursuant to
the Special Terms and Conditions of California's Section 1115
Medicaid demonstration project waiver number 11-W-00193/9 relating to
hospital financing and health coverage expansion that became
effective September 1, 2005. The initiative shall be implemented only
to the extent that federal financial participation is available.



15902.  (a) Persons eligible to be served by the Health Care
Coverage Initiative are low-income uninsured individuals who are not
currently eligible for the Medi-Cal program, Healthy Families
Program, or Access for Infants and Mothers program.
   (b) Funding for the Health Care Coverage Initiative shall be used
to expand health care coverage for eligible uninsured individuals.
   (c) Any expansion of health care coverage for uninsured
individuals shall not diminish access to health care available for
other uninsured individuals, including access through
disproportionate share hospitals, county clinics, or community
clinics.
   (d) Services provided under the Health Care Coverage Initiative
shall be available to those eligible uninsured individuals enrolled
in a Health Care Coverage program, and nothing in this part shall be
construed to create an entitlement program of any kind.
   (e) No state General Fund moneys shall be used to fund the Health
Care Coverage Initiative, nor to fund any related administrative
costs provided to counties.



15903.  The Health Care Coverage Initiative shall be designed and
implemented to achieve all of the following outcomes:
   (a) Expand the number of Californians who have health care
coverage.
   (b) Strengthen and build upon the local health care safety net
system, including disproportionate share hospitals, county clinics,
and community clinics.
   (c) Improve access to high quality health care and health outcomes
for individuals.
   (d) Create efficiencies in the delivery of health services that
could lead to savings in health care costs.
   (e) Provide grounds for long-term sustainability of the programs
funded under the initiative.
   (f) Implement programs in an expeditious manner in order to meet
federal requirements regarding the timing of expenditures.



15904.  (a) The State Department of Health Care Services shall issue
a request for applications for funding the Health Care Coverage
Initiative.
   (b) The department shall allocate federal funds available to be
claimed under the Health Care Coverage programs.
   (c) The department shall select the Health Care Coverage programs
that best meet the requirements and desired outcomes set forth in
this part.
   (d) The following elements shall be used in evaluating the
proposals to make selections and to determine the allocation of the
available funds:
   (1) Enrollment processes, with an identification system to
demonstrate enrollment of the uninsured into the program.
   (2) Use of a medical record system, which may include electronic
medical records.
   (3) Designation of a medical home and assignment of eligible
individuals to a primary care provider. For purposes of this
paragraph, "medical home" means a single provider or facility that
maintains all of an individual's medical information. The primary
care provider shall be a provider from which the enrollee can access
primary and preventive care.
   (4) Provision of a benefit package of services, including
preventive and primary care services, and care management services
designed to treat individuals with chronic health care conditions,
mental illness, or who have high costs associated with their medical
conditions, to improve their health and decrease future costs.
Benefits may include case management services.
   (5) Quality monitoring processes to assess the health care
outcomes of individuals enrolled in the Health Care Coverage program.

   (6) Promotion of the use of preventive services and early
intervention.
   (7) The provision of care to Medi-Cal beneficiaries by the
applicant and the degree to which the applicant coordinates its care
with services provided to Medi-Cal beneficiaries.
   (8) Screening and enrollment processes for individuals who may
qualify for enrollment into Medi-Cal, the Healthy Families Program,
and the Access for Infants and Mothers Program prior to enrollment
into the Health Care Coverage program.
   (9) The ability to demonstrate how the Health Care Coverage
program will promote the viability of the existing safety net health
care system.
   (10) Documentation to support the applicant's ability to implement
the Health Care Coverage program by September 1, 2007, and to use
its allocation for each project year.
   (11) Demonstration of how the program will provide consumer
assistance to individuals applying to, participating in, or accessing
services in the program.
   (e) Entities eligible to apply for the initiative funds are a
county, city and county, consortium of counties serving a region
consisting of more than one county, or health authority. No entity
shall submit more than one proposal.
   (f) The department shall rank the program applications based on
the criteria in this section. The amount of federal funding available
to be claimed shall be allocated based upon the ranking of the
applications. The department shall allocate the available federal
funding to the highest ranking applications until all of the funding
is allocated. The department shall select at least five programs, and
no single program shall receive an allocation greater than 30
percent of the total federal allotment. The department is not
required to fund the entire amount requested in a program
application.
   (g) The department shall seek to balance the allocations
throughout geographic areas of the state.
   (h) Each county, city and county, consortium of counties, or
health authority that is selected to receive funding shall provide
the necessary local funds for the nonfederal share of the certified
public expenditures, or intergovernmental transfers to the extent
allowable under the demonstration project, required to claim the
federal funds made available from the federal allotment. The
certified public expenditures, or intergovernmental transfers to the
extent allowable under the demonstration project, shall meet the
requirements of the Special Terms and Conditions of California's
Section 1115 Medicaid demonstration project waiver number
11-W-00193/9 relating to hospital financing and health coverage
expansion that became effective September 1, 2005.
   (i) The federal allocation shall be available to the selected
programs for the three-year period covering the Health Care Coverage
program pursuant to the Special Terms and Conditions of California's
Section 1115 Medicaid demonstration project waiver number
11-W-00193/9 relating to hospital financing and health coverage
expansion, unless the selected programs do not incur expenditures
sufficient to claim the allocation of federal funds in the particular
program year. Selected programs shall expend the funds according to
an expenditure schedule determined by the department.
   (j) The department may reallocate the available federal funds
among selected programs or other program applicants that were
previously not selected for funding, if necessary to meet federal
requirements regarding the timing of expenditures, notwithstanding
subdivision (f). If a selected program fails to substantially comply
with the requirements of this article, the department may reallocate
the available federal funds from that selected program to other
selected programs or other program applications that previously were
not selected for funding. If a selected program is unable to meet its
spending targets, determined at the end of the second quarter of
each program year, the department may reallocate funds to other
selected programs or other program applications that previously were
not selected for funding, to ensure that all available federal funds
are claimed. Selected programs receiving reallocated funds must have
the ability to make the certified public expenditures necessary to
claim the reallocated federal funds.
   (k) Federal funds provided for the initiative shall supplement,
and not supplant, any county, city and county, health authority,
state, or federal funds that would otherwise be spent on health care
services in the county, city and county, consortium of counties, or a
health authority region. Federal funds allocated under the
initiative shall reimburse the selected county, city and county,
consortium of counties, or health authority for the benefits and
services provided under subdivision (d) of Section 15904.
Administrative costs associated with the development and management
of the initiative shall not be paid from the Health Care Coverage
program allocation, and any allocations for administrative funds
shall be in addition to the allocations made for the initiative.




15905.  Applications submitted to the department shall include, but
not be limited to, each of the following:
   (a) A description of the proposed Health Care Coverage program,
including, but not limited to, all of the following:
   (1) Eligibility criteria.
   (2) Screening and enrollment processes that include an
identification system to demonstrate enrollment into the Health Care
Coverage program.
   (3) Screening processes to identify individuals who may qualify
for enrollment into Medi-Cal, the Healthy Families Program, or the
Access for Infants and Mothers Program.
   (b) A description of the quality monitoring system to be
implemented with the Health Care Coverage program.
   (c) A description of the population to be served.
   (d) A list of health care providers who have agreed to participate
in the Health Care Coverage program.
   (e) A description of the organized health care delivery systems to
be used for the Health Care Coverage program, including, but not
limited to, designation of a medical home and processes used to
assign eligible individuals to a primary care provider.
   (f) A list of the health benefits to be provided, including the
preventive and primary care services and how they will be promoted.
   (g) A description of the care management services to be provided,
and the providers of those services.
   (h) A calculation of the average cost per individual served.
   (i) The number of individuals to be served.
   (j) The mechanism under which the proposed Health Care Coverage
Initiative will make expenditures to, or on behalf of, providers and
other entities, including, but not limited to, documentation to
support the ability to implement the Health Care Coverage program by
September 1, 2007, and to claim the full amount of the allocation for
each program year.
   (k) A description of the source of the local nonfederal share of
funds.
   (l) A description of how the proposed Health Care Coverage program
will strengthen the local health care safety net system.
   (m) A consent form signed by the applicant to provide requested
data elements as required per the Special Terms and Conditions of
California's Section 1115 Medicaid demonstration project waiver
number 11-W-00193/9 relating to hospital financing and health
coverage expansion.
   (n) Use of a reliable medical record system, that may include, but
need not be limited to, existing electronic medical records.
   (o) A complete description of health care services currently
provided to Medi-Cal beneficiaries and a description as to how the
proposed Health Care Coverage program will coordinate its Health Care
Coverage program with services provided to Medi-Cal beneficiaries.




15906.  (a) The department shall seek partnership with an
independent, nonprofit group or foundation, an academic institution,
or a governmental entity providing grants for health-related
activities, to evaluate the programs funded under the initiative.
   (b) The evaluation shall, at a minimum, include an assessment of
the extent to which the programs have met the outcomes listed in
Section 15903.
   (c) The department and the selected programs shall provide the
data for the evaluation.
   (d) The evaluation shall be submitted concurrently to the
appropriate policy and fiscal committees of the Legislature and to
the Secretary of Health and Human Services.



15907.  (a) The department shall monitor the programs funded under
the initiative for compliance with applicable federal requirements
and the requirements under this part, and pursuant to the Special
Terms and Conditions of California's Section 1115 Medicaid
demonstration project waiver number 11-W-00193/9 relating to hospital
financing and health coverage expansion.
   (b) To the extent necessary to implement this part, the department
shall submit, by September 1, 2006, to the federal Centers for
Medicare and Medicaid Services, proposed waiver amendments on the
structure of, and eligibility and benefits under, the Health Care
Coverage Initiative.
   (c) The department shall monitor the allocations to selected
programs at least quarterly for spending levels.
   (d) No funds made available from the Health Care Support Fund for
the Health Care Coverage Initiative shall be used by the department
for administration.
   (e)  The request for applications, including any part of the
process described herein for selecting entities to operate the Health
Care Coverage programs, and any agreements entered into with a
county, city and county, consortium of counties, or health authority
pursuant to this part shall not be subject to Part 2 (commencing with
Section 10100) of Division 2 of the Public Contract Code.
   (f) The department may adopt regulations to implement this part.
These regulations may initially be adopted as emergency regulations
in accordance with the rulemaking provisions of the Administrative
Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1
of Division 3 of Title 2 of the Government Code). For purposes of
this part, the adoption of regulations shall be deemed an emergency
and necessary for the immediate preservation of the public peace,
health, and safety or general welfare. Any emergency regulations
adopted pursuant to this section shall not remain in effect
subsequent to the date that this part is repealed pursuant to Section
15908.
   (g) As an alternative to subdivision (f), and notwithstanding the
rulemaking provisions of Chapter 3.5 (commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code, or any
other provision of law, the department may implement and administer
this part by means of provider bulletins, county letters, manuals, or
other similar instructions, without taking regulatory action. The
department shall notify the fiscal and appropriate policy committees
of the Legislature of its intent to issue a provider bulletin, county
letter, manual, or other similar instruction, at least five days
prior to issuance. In addition, the department shall provide a copy
of any provider bulletin, county letter, manual, or other similar
instruction issued under this paragraph to the fiscal and appropriate
policy committees of the Legislature.
   (h) The department shall consult with interested parties and
appropriate stakeholders regarding the implementation and ongoing
administration of this part.


15908.  This part shall become inoperative on the date that the
director executes a declaration, which shall be retained by the
director and provided to the fiscal and appropriate policy committees
of the Legislature, stating that the federal demonstration project
provided for in this part has been terminated by the federal Centers
for Medicare and Medicaid Services, and shall, six months after the
date the declaration is executed, be repealed.