2009 California Welfare and Institutions Code - Section 14180-14182 :: Article 5.4. Health Care Coordination, Improvement, And Long-term Cost Containment Waiver Or Demonstration Project

14180.  (a) The department shall submit an application to the
federal Centers for Medicare and Medicaid Services for a waiver or a
demonstration project to implement all of the following:
   (1) Strengthen California's health care safety net, which includes
disproportionate share hospitals, for low-income and vulnerable
Californians.
   (2) Maximize opportunities to reduce the number of uninsured
individuals.
   (3) Optimize opportunities to increase federal financial
participation and maximize financial resources to address
uncompensated care.
   (4) Promote long-term, efficient, and effective use of state and
local funds.
   (5) Improve health care quality and outcomes.
   (6) Promote home-and community-based care.
   (b) The waiver or demonstration project shall include proposals to
restructure the organization and delivery of services to be more
responsive to the health care needs of Medi-Cal enrollees for the
purpose of providing the most vulnerable Medi-Cal beneficiaries with
access to better coordinated and integrated care that will improve
their health outcomes, slow the long-term growth of the Medi-Cal
program, and continue support for the safety net care system and the
persons who rely on that system for needed care. These restructuring
proposals may include, but are not limited to, the following:
   (1) Better care coordination for seniors and persons with
disabilities, dual eligibles, children with special health care
needs, and persons with behavioral health conditions, which shall
include the establishment of organized delivery systems that
incorporate a medical home system and care and disease management, as
well as incentives that reward providers and beneficiaries for
achieving the desired clinical, utilization, and cost-specific
outcomes.
   (2) Improved coordination between Medicare and Medi-Cal coverage.
   (3) Improved coordination of care for children with significant
medical needs through improved integration of delivery systems and
use of medical homes and specialty centers, and providing incentives
for specialty and nonspecialty care.
   (4) Improved integration of physical and behavioral health care.
   (c) In developing the waiver or demonstration project application,
the department shall consult on a regular basis with interested
stakeholders and the Legislature.
   (d) The department shall determine the form of waiver most
appropriate to achieve the purposes listed in subdivision (a).
   (e) The department shall submit the waiver or demonstration
project application to the federal Centers for Medicare and Medicaid
Services by a date that allows sufficient time for the waiver or
demonstration project to be approved by no later than September 1,
2010, or the conclusion of any extension period granted in California'
s Medi-Cal Hospital/Uninsured Care Section 1115(a) Medicaid
Demonstration (No. 11-W-00193/9), whichever happens last.
   (f) In order to restructure the Medi-Cal program to improve the
delivery of care for specified populations and secure the maximum
amount of federal financial participation allowable, any waiver or
demonstration project application submitted pursuant to subdivision
(a) may specify and seek authority to enroll beneficiaries into
specified organized delivery systems. Subject to federal approval,
the specified organized delivery systems may include the utilization
of an enhanced primary care case management model, a medical home
model, or managed care model. The department is authorized to enroll
beneficiaries in an organized system of care subject to the
conditions in Section 14181. Subject to federal approval, any waiver
or demonstration project application submitted pursuant to
subdivision (a) shall include processes, and accompanying criteria,
by which the department will evaluate and grant exemption, on an
individual basis, from this section's requirements pertaining to the
mandatory enrollment of beneficiaries in specified organized delivery
systems.
   (g) (1) The department shall only implement the waiver or
demonstration project upon submittal of an implementation plan,
pursuant to Section 14181, to the appropriate policy and fiscal
committees of the Legislature at least 60 days prior to any
appropriation.
   (2) Pursuant to paragraph (1), mandatory enrollment in any
organized delivery system authorized pursuant to a waiver or
demonstration project authorized pursuant to this article shall only
occur when funds necessary to support that effort have been
appropriated.
   (3) It is the intent of the Legislature to neither impede nor
limit the department's existing statutory authority regarding the
operation of the Medi-Cal program and its health care delivery
systems by the enactment of this article.
   (h) The director shall have the discretion to utilize state plan
amendments, in whole or in part, to accomplish any or all purposes of
this article. In the event the director proceeds with state plan
amendments as specified, the department shall provide notification in
writing to the chairperson of the Joint Legislative Budget Committee
within 15 working days of that action and a brief description and
purpose of the amendment. This amendment shall be made available to
the Joint Legislative Budget Committee upon the request of the
chairperson.

14181.  (a) The California Health and Human Services Agency or
successor entity or designated department shall submit an
implementation plan to the appropriate policy and fiscal committees
of the Legislature for implementation of the federally approved
waiver or demonstration project. The implementation plan shall be
developed in consultation with a stakeholder advisory committee
established pursuant to subdivision (b). The implementation plan
shall specifically address the multiple and complex needs of seniors
and persons with disabilities, dual eligibles, children with special
health care needs, and persons with behavioral health conditions, and
the specific strategies the agency or successor entity or designated
department will use to ensure the provision of quality, accessible
health care services under the waiver or demonstration project,
including, at a minimum, the following elements:
   (1) Criteria, performance standards, and indicators shall be
adopted to ensure that plan services meet the multiple and complex
needs of beneficiaries and comply with the requirements of this
article. The performance standards shall incorporate, at a minimum,
existing statutory and regulatory requirements and protections
applicable to two-plan model and geographic managed care plans, as
well as those protections available under the Knox-Keene Health Care
Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340)
of Division 2 of the Health and Safety Code), but in addition shall
include specific requirements and standards based on the multiple and
complex care needs of seniors and persons with disabilities, dual
eligibles, children with special health care needs, and persons with
behavioral health conditions, including, but not limited to,
standards where applicable to the organized delivery system model in
all of the following areas:
   (A) Plan readiness.
   (B) Availability and accessibility of services, including physical
access and communication access.
   (C) Benefit management and scope of services.
   (D) Care coordination and care management.
   (E) Beneficiary complaints, grievances, and appeals.
   (F) Beneficiary participation.
   (G) Continuity of care.
   (H) Cultural and linguistic appropriateness.
   (I) Financial management.
   (J) Measurement and improvement of health outcomes.
   (K) Marketing, assignment, enrollment, and disenrollment.
   (L) Network capacity, including travel time and distance and
specialty care access.
   (M) Performance measurement and improvement.
   (N) Provider grievances and appeals.
   (O) Quality care.
   (P) Recordkeeping and reporting.
   (2) Strategies to be used to monitor performance of all
contractors and to ensure compliance with all components of the
waiver or demonstration project.
   (3) Provision of a comprehensive timeline of key milestones for
implementation of the waiver or demonstration project components.
   (4) Provision of a framework for evaluation of the waiver or
demonstration project, including the process, timelines, and criteria
for evaluating implementation, as well as the method for providing
periodic updates of outcomes and key implementation concerns.
   (b) Prior to preparing the implementation plan required by this
section, the agency or successor entity or designated department,
shall convene a stakeholder committee to advise on preparation of the
implementation plan. The stakeholder committee shall include, but
not be limited to, persons with disabilities, seniors, and
representatives of legal services agencies that serve clients in the
affected populations, health plans, specialty care providers,
physicians, hospitals, county government, labor, and others as deemed
appropriate by the agency or successor entity or designated
department. The stakeholder committee shall advise on the
implementation of the waiver or demonstration project until the
expiration of the waiver or demonstration project.

14182.  Notwithstanding the Administrative Procedure Act, Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code, the department may implement the provisions
of this article through all-county welfare director letters or
similar instruction, without taking regulatory action. Prior to
issuing any letter or similar instrument authorized pursuant to this
section, the department shall notify and consult with stakeholders,
including advocates, providers, and beneficiaries, in implementing,
interpreting, or making specific this article.