WELFARE AND INSTITUTIONS CODE
SECTION 14139.05-14139.62
14139.05. The Legislature finds and declares that:
(a) Long-term care services in California include an uncoordinated
array of categorical programs offering medical, social, and other
support services that are funded and administered by a variety of
federal, state, and local agencies and are replete with gaps,
duplication, and little or no emphasis on the specific concerns of
individual consumers.
(b) Although the need for a coordinated continuum of long-term
care services has long been apparent, numerous obstacles prevent its
development, including inflexible and inconsistent funding sources,
economic incentives that encourage the placement of consumers in the
highest levels of care, lack of coordination between aging, health,
and social service agencies at both state and local levels, and
inflexible state and federal regulations.
(c) The office of the Legislative Analyst and others have pointed
out that California's systems of service delivery in a number of
areas are dysfunctional, due to the fragmentation of responsibility
and funding for interrelated services. Principles proposed by the
Legislative Analyst to guide the restructuring of these systems
include recognizing program linkages, coordinating service delivery
mechanisms, removing barriers to innovation, and instilling financial
incentives to promote prevention and coordination.
(d) It is both more efficient and more humane to restructure
long-term care services so that duplicative and confusing eligibility
criteria, assessments, intake forms, and service limitations will
not inhibit consumer satisfaction, impede improvements in consumer
health status, and result in the ineffective use of resources.
(e) There is a growing interest in community-directed systems of
funding and organizing the broad array of health, support, and
community living services needed by persons of all ages with
disabilities.
(f) It is in the interest of those in need of long-term care
services, and the state as a whole, to develop a long-term care
system that provides dignity and maximum independence for the
consumer, creates home and community based alternatives to
unnecessary out-of-home placement, and is cost effective.
14139.1. (a) It is the intent of the Legislature to establish the
Long-Term Care Integration Pilot Program that will integrate the
financing and administration of long-term care services in up to five
pilot project sites in the state. Contingent upon a state approved
administrative action plan, at least one site shall be in a rural or
underserved part of the state.
(b) It is further the intent of the Legislature to support, in
each pilot project site, the development of a model integrated
service delivery system that meets the needs of all beneficiaries,
both those who live in their own homes and those who are in
out-of-home placements, in a humane, appropriate, and cost-effective
manner.
14139.11. The goals of this pilot program shall be to:
(a) Provide a continuum of social and health services that foster
independence and self-reliance, maintain individual dignity, and
allow consumers of long-term care services to remain an integral part
of their family and community life.
(b) If out-of-home placement is necessary, to ensure that it is at
the appropriate level of care, and to prevent unnecessary
utilization of acute care hospitals.
(c) If family caregivers are involved in the long-term care of an
individual, to support caregiving arrangements that maximize the
family's ongoing relationship with, and care for, that individual.
(d) Deliver long-term care services in the least restrictive
environment appropriate for the consumer.
(e) Encourage as much self direction as possible by consumers,
given their capability and interest, and involve them and their
family members as partners in the development and implementation of
the pilot project.
(f) Identify performance outcomes that will be used to evaluate
the appropriateness and quality of the services provided, as well as
the efficacy and cost effectiveness of each pilot project, including,
but not limited to, the use of acute and out-of-home care, consumer
satisfaction, the health status of consumers, and the degree of
independent living maintained among those served.
(g) Test a variety of models intended to serve different
geographic areas, with differing populations and service
availability.
(h) Achieve greater efficiencies through consolidated screening
and reporting requirements.
(i) Allow each pilot project site to use existing funding sources
in a manner that it determines will meet local need and that is
cost-effective.
(j) Allow the pilot project sites to determine other services that
may be necessary to meet the needs of eligible beneficiaries.
(k) Identify ways to expand funding options for the pilot program
to include medicare and other funding sources.
14139.12. It is the intent of the Legislature that the costs of
this pilot program to the General Fund will not exceed the direct and
indirect costs that existing programs would expect to incur had the
integrated services not been provided through this pilot program. If
the Department of Finance determines, and informs the director in
writing, that the implementation of this pilot program will result in
any additional costs to the state relative to the provision of
long-term care services to eligible beneficiaries, the department may
terminate the operation of all or any part of this pilot program.
The state shall not be held liable for any additional costs incurred
by a pilot project site. Any such determination made by the
Department of Finance shall be available to any party upon request.
14139.13. (a) Any contract entered into pursuant to this article
may be renewed if the long-term care services agency continues to
meet the requirements of this article and the contract. Failure to
meet these requirements shall be cause for nonrenewal of the
contract. The department may condition renewal on timely completion
of a mutually agreed upon plan of corrections of any deficiencies.
(b) The department may terminate or decline to renew a contract in
whole or in part when the director determines that the action is
necessary to protect the health of the beneficiaries or the funds
appropriated to the Medi-Cal program. The administrative hearing
requirements of Section 14123 do not apply to the nonrenewal or
termination of a contract under this article.
(c) In order to achieve maximum cost savings the Legislature
hereby determines that an expedited contract process for contracts
under this article is necessary. Therefore, contracts under this
article shall be exempt from Chapter 2 (commencing with Section
10290) of Part 2 of Division 2 of the Public Contract Code.
(d) The Director of the Department of Managed Health Care shall,
at the director's request, immediately grant an exemption from
Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code for purposes of carrying out any contract
entered into pursuant to this article.
14139.2. The department shall serve as the lead agency for the
administration of this chapter. The department's responsibilities
shall include, but are not limited to:
(a) Development of criteria for the selection of pilot project
sites.
(b) Selection of the pilot project sites to participate in the
pilot program.
(c) Providing, or arranging for, technical assistance to
participating sites.
(d) Development of specific performance outcome measures by which
the program can be evaluated.
(e) Development of standards for complying with reporting
requirements specified in state law for the programs integrated
within the pilot program implemented pursuant to this article. The
standards developed pursuant to this subdivision shall apply in lieu
of any existing reporting obligations for the programs. The existing
individual reporting requirements for programs integrated within the
pilot program shall be deemed to have been met through the reports
required by this section. Existing requirements for reports to the
Office of Statewide Health Planning and Development shall not be
eliminated.
(f) Seeking all federal waivers necessary for full implementation
of the pilot program.
(g) Setting a payment rate consistent with Section 14139.5.
(h) Approval or disapproval of administrative action plans.
14139.21. The department may accept funding from federal agencies,
foundations or other nongovernmental sources and may contract with
qualified consultants to assist with the provision of technical
assistance, the development of data collection, reporting, and
analysis systems, or any other purposes that further the goals of
this demonstration program. The department shall not accept funds
from any entity that stands to gain financially from implementation
of the pilot program. In contracting with consultants to assist with
the pilot program, the department shall specify timelines and
delivery dates so as to ensure the continued implementation of the
pilot program.
14139.22. (a) The department shall convene a working group that
shall include the Director of Health Services, the Director of Social
Services, and the Director of Aging, or the program staff from each
of those departments who have direct responsibility for the programs
listed in subdivision (b) of Section 14139.32, and may include the
Director of Mental Health and the Director of Rehabilitation, or
program staff from those departments with direct responsibilities for
programs that may be included as a service in any pilot project
site, and representatives from each pilot project site upon its
selection.
(b) The department shall consult with the working group during the
designing of the pilot program, in the selection of the pilot
project sites, and in the monitoring of the program under this
article, and shall utilize the working group as a resource for
problem-solving and a means of maintaining interdepartmental and
intersite communication.
(c) The working group shall strive to ensure that the pilot
program under this article makes maximum use of home-based and
community-based services, and throughout the continuum of care for
each beneficiary, encourages the use of the least restrictive
environment in which the beneficiary can receive appropriate care.
14139.23. Upon the implementation of the pilot program,
responsibility for administering the programs integrated within the
pilot program shall be transferred to the department, and shall be
specified in an interagency agreement between participating
departments. Prior requirements for any program integrated within
this pilot program shall be deemed to have been met through
compliance with the requirements established by this article, by the
department for the pilot program by each county's approved plan, and
by the approved applicable federal waivers.
14139.24. The department shall seek all federal waivers necessary
to allow for federal financial participation in the pilot program
implemented pursuant to this article. This article shall not be
implemented unless and until the director has executed a declaration
that the approval of all necessary federal waivers has been obtained
by the department.
14139.25. Notwithstanding any other provision of this article,
costs to the General Fund shall not exceed the amount that would have
been expended in the absence of the pilot program.
14139.3. (a) Pilot project sites may be comprised of a single
county, a multicounty unit, or a subcounty unit.
(b) Each selected site shall do all of the following:
(1) Establish a consolidated long-term care services fund that
shall accommodate state and federal fiscal and auditing requirements,
shall be used solely for the purposes described in this article, and
shall not be used for any county pooled investment fund.
(2) Identify a local entity, that may be either a governmental
entity or a not-for-profit private agency, to administer the fund.
The local entity may be one that already exists, or may be
established for the express purpose of administering the fund. This
agency shall be designated as the long-term care services agency and
shall contract with the department to carry out this article.
(3) Develop and provide to the department an administrative action
plan that shall include, but is not limited to:
(A) A complete description of the covered scope of services and
programs to be integrated.
(B) A complete description of the proposed long-term care delivery
system and how it will improve system efficiency and enhance service
quality.
(C) Demonstration of a willingness and commitment by the long-term
care services agency to work with local community groups, providers,
and consumers to obtain their input.
(D) Proposed measurable performance outcomes that the pilot
program is designed to achieve.
(E) A description of the expected impact on current program
services to Medi-Cal eligible beneficiaries and consumers of
non-Medi-Cal services included in the integrated system.
(F) Assurance of minimal disruption to current recipients of
long-term care services during the phase-in of the pilot project.
(G) Reasonable assurance that services provided will be responsive
to the religious, cultural, and language needs of beneficiaries.
(H) Assurances that providers who serve the needs of special
populations such as religious and cultural groups or residents of
multilevel facilities as defined in paragraph (9) of subdivision (d)
of Section 15432 of the Government Code and community care retirement
communities as defined in subdivision (u) of Section 1771 of the
Health and Safety Code, will be able to continue to serve those
persons when willing to contract under the same terms and conditions
as similar providers.
(I) Specific alternative concepts, requirements, staffing
patterns, or methods for providing services under the pilot project.
(J) A process to assure that Medi-Cal dollars are appropriately
expended in accordance with federal requirements.
(K) A description of how the pilot project site will maintain
adequate fiscal control and ensure quality of care for beneficiaries.
(L) A description of how the pilot project site will coordinate,
relate to, or integrate with Medi-Cal managed care plans, local
managed care plans, and other organizations which provide services
not part of the pilot project.
(M) A proposed timeline for planning and startup of the pilot
project.
(N) An estimate of costs and savings.
(O) Demonstration of the financial viability of the plan.
(c) The administrative action plan shall reflect a planning
process that includes long-term care consumers, their families, and
organizations that represent them, organizations that provide
long-term care services, and representatives of employees who deliver
direct long-term care services. The planning process may include,
but is not limited to, the members of the local advisory committee
required pursuant to Section 14139.31.
(d) The administrative action plan shall receive the approval of
the county board of supervisors before it is submitted to the
department for final state approval. The board of supervisors shall
present evidence of the commitment to the administrative action plan
of all publicly funded agencies that currently serve consumers who
will be eligible under the pilot project, and all publicly and
nonpublicly funded agencies that will be responsible for providing
services under the pilot project. This evidence may include
resolutions adopted by agency governing bodies, memoranda of
understanding, or other agreements pertinent to the implementation of
the plan.
14139.31. In order to be selected, a pilot project site shall
demonstrate that it has an active advisory committee that includes
consumers of long-term care services, representatives of local
organizations of persons with disabilities, seniors, representatives
of local senior organizations, representatives of employees who
deliver direct long-term care services, and representatives of
organizations that provide long-term care services. At least one-half
of the members of the advisory committee must be consumers of
services provided under this chapter or their representatives.
14139.32. (a) The administrative action plan shall identify the
funds to be transferred into the consolidated long-term care services
fund.
(b) The funds shall include Medi-Cal long-term institutional care,
the Medi-Cal Personal Care Services Program, and the In-Home
Supportive Services Program and may include funds from the following
programs and services:
(1) Multipurpose Seniors Services Program.
(2) Alzheimer's Day Care Resources Centers Program.
(3) Linkages Program.
(4) Respite Program.
(5) Adult Day Health Care Program.
(6) Medi-Cal home health agency services.
(7) Medi-Cal home-based and community-based waiver programs.
(8) Medi-Cal hospice services.
(9) Medi-Cal acute care hospital services.
(10) Other Medi-Cal services, including, but not limited to,
primary, ancillary, and acute care.
(c) Optional program funds enumerated in subdivision (b) of
Section 14139.32 shall be included in the long-term care services
fund in any case where a program was funded prior to its integration
into the pilot project.
(d) In determining which project sites to select for participation
in the pilot program, the department shall give preference to those
sites that include funds from the largest number of programs existing
within the project site at the time the site applies for selection,
provided the administrative action plan meets all other selection
criteria. With the exception of up to one rural county, preference
shall be given to project sites that include primary, ancillary, and
acute care in the consolidated fund, provided their administrative
action plan meets all other selection criteria.
14139.33. The administrative action plan shall delineate the
services to be provided to all eligible beneficiaries. At a minimum,
services to be provided shall include all of the following:
(a) Care or case management, including assessment, development of
a service plan in conjunction with the consumer and other appropriate
parties, authorization and arrangement for purchase of services or
linkages with other appropriate entities, service coordination
activities, and followup to determine whether the services received
were appropriate and consistent with the service plan. Service
coordination activities shall ensure that the records of each
beneficiary are maintained in a consistent and complete manner and
are accessible to the beneficiary or his or her family, and providers
involved in his or her care. This shall be the case whether a
beneficiary resides in his or her own home or in a licensed facility.
(b) Education of beneficiaries, their families, and others in
their informal support network, including independent living skills
training to maximize the independence of the beneficiary.
(c) In-home services.
(d) Adult day services.
(e) Institutional long-term care.
(f) Hospice services.
(g) Linkages to acute care services and primary care services, if
they are not included in the integrated plan.
14139.34. The administrative action plan may also include any of
the following services:
(a) Transportation.
(b) Home modification.
(c) Medical services, including, but not limited to, primary,
ancillary, and acute care.
(d) Housing and residential services.
(e) Other services determined by the pilot project to be necessary
to meet the needs of eligible beneficiaries.
14139.35. The department may exempt a pilot project site from the
requirements of subdivisions (d) and (f) of Section 14139.33 if both
the following conditions are met:
(a) State funds were not being used in the geographic area covered
by the pilot projects to provide those services at the time of
application to the pilot program.
(b) The pilot project site can demonstrate to the department how
it plans to develop these services, and within what timeframe, during
the pilot program.
14139.36. (a) If primary, ancillary, and acute care are not
included among the services offered by a pilot project site, the
administrative action plan shall include all of the following:
(1) A mechanism for tracking the usage of these services by
beneficiaries of the plan.
(2) Provisions for the future inclusion of those services in the
integrated plan, including the process and timeline by which they
will be integrated.
(b) The department shall, in consultation with the pilot project
sites, apply to the federal health care financing administration for
a waiver that allows the pilot projects to include medicare funds in
the long-term care services fund. Upon receipt of the waiver, within
a time period to be designated by the department specific to each
site, each pilot project site shall assume responsibility for
primary, ancillary, and acute care services.
14139.37. The administrative action plan shall delineate
specifically how the pooled funds will be used to deliver services to
all eligible recipients in the geographic area covered by the pilot
project site.
14139.38. Participating counties shall continue their financial
maintenance of effort for each of the programs integrated within the
pilot program under this article. The amount of a county's
maintenance of effort shall be the same as if the program were not
integrated within the pilot program pursuant to this article, and
funds equal to this amount shall be deposited in the local
consolidated long-term care services fund.
14139.4. (a) The long-term care services agency shall be
responsible and at risk for implementing the administrative action
plan. The long-term care services agency shall do all of the
following:
(1) Respond, or provide for response to, consumer needs on a
24-hour, seven-day-a-week basis.
(2) Conduct comprehensive assessments.
(3) Determine eligibility for long-term care services based on the
assessment information.
(4) Provide for contractual arrangements for the provision of, and
payment for, sufficient services to meet the long-term care needs of
the eligible beneficiary in his or her home, community, residential
facility, nursing facility, or other location based on the mix of
programs or services included in the administrative action plan.
(5) Provide linkages to acute care hospitals.
(6) Maintain control over utilization of services that are
authorized.
(7) Monitor the quality of care provided to consumers.
(8) Maintain a consumer grievance process.
(9) Manage the overall cost-effectiveness of the pilot project for
its duration.
(b) Services may be provided through contracts with
community-based providers. In instances where a specific service does
not exist in the community, the long-term care services agency may
facilitate the development of local programs that provide these
services or may provide the services directly, if doing so can be
demonstrated to be cost effective.
14139.41. (a) For purposes of this chapter, "eligible beneficiaries"
shall be defined as persons meeting all the following criteria:
(1) Are Medi-Cal eligible.
(2) Are functionally or cognitively impaired. For purposes of this
paragraph "cognitively impaired" means having an impairment caused
by organic brain disorder or disease.
(3) Are adults.
(4) Need assistance with two or more activities of daily living or
are unable to remain living independently without the long-term care
services provided through the pilot program operated pursuant to
this article.
(b) To the extent eligible beneficiaries also receive services
from a regional center that serves a pilot project site, the pilot
project shall delineate in its administrative action plan how
services will be coordinated by the two agencies.
14139.42. (a) Each pilot project site shall serve all eligible
beneficiaries who live in the geographic area served by the long-term
care services agency. In order to eliminate duplicative
administrative costs and to achieve a more efficient delivery system,
pilot project sites shall also serve non-Medi-Cal eligible
individuals who, but for the implementation of the pilot project,
would have received services from programs whose funds are included
in the consolidated long-term care services fund.
(b) Funding sources allocated for persons who are not eligible for
Medi-Cal benefits may be integrated into the consolidated long-term
care services fund. To the extent those funds are spent on services
for persons who are not eligible for Medi-Cal benefits, they shall be
segregated from capitated funds for Medi-Cal beneficiaries. No funds
derived from the capitated Medi-Cal rate may be used for persons who
are not eligible for Medi-Cal.
14139.43. This article shall not preclude a long-term care services
agency from entering into additional agreements, separate from the
pilot project, to serve additional individuals or populations.
14139.44. Pilot project sites shall ensure provider reimbursement
rates that are adequate to maintain compliance with applicable
federal and state requirements.
14139.5. The department shall set a capitated rate of payment that
is actuarially sound and that is based on the number of beneficiaries
who are eligible for Medi-Cal benefits to be enrolled in the pilot
project, the mix of provided services and programs being integrated,
and past Medi-Cal expenditures for services. The rate shall reflect,
and the contract shall delineate, the rate at which the local
long-term care services agency shall assume the total risk and the
mechanisms that shall be used, which may include, but are not limited
to, risk corridors, reinsurance, or alternative methods of risk
assumption.
14139.51. If the department determines that a program or programs
cannot reasonably be capitated, funds may be transferred separately
from the capitation payment. The amount of those noncapitated funds
shall be based on amounts that would have been expended by the state
for those programs in the absence of the pilot program implemented
under this article.
It is the intent of the Legislature that, if any local pilot
project experiences net savings, those savings shall be used for
project expansion and improvement, or to build the required tangible
net equity, or if there is no need for expansion or improvement or to
build tangible net equity, may be shared by the long-term care
services agency and the state.
14139.53. (a) The department shall develop criteria to ensure that
pilot project sites maintain fiscal solvency, including, but not
limited to, the following:
(1) The capability to achieve and maintain sufficient fiscal
tangible net equity within a timeframe to be specified by the
department for each pilot project site.
(2) The capability to maintain prompt and timely provider
payments.
(3) A management information system that is approved by the
department and is capable of meeting the requirements of the pilot
program.
(b) Any pilot project established under this article shall
immediately notify the department in writing of any fact or facts
that are likely to result in the pilot project or the long-term care
services agency being unable to meet its financial obligations. The
written notice shall describe the fact or facts, the anticipated
financial consequences, and the actions that will be taken to address
the anticipated consequences, and shall be made available upon
request unless otherwise prohibited by law.
14139.6. (a) It is the intent of the Legislature that local
entities that are potential participants in this pilot program shall
be assured of sufficient time to plan their pilot projects, and that
the selected pilot project sites shall be assured of sufficient time
to phase in the implementation of their programs. To that end, it is
the intent of the Legislature that the department, in consultation
with potential pilot project sites and the pilot program working
group, shall develop a realistic timeline with guidelines for the
planning and implementation of pilot projects.
(b) Nothing in this chapter shall prohibit the department, in
consultation with the pilot program working group, from establishing
a two-stage selection process in which local pilot project sites may
be selected on a preliminary basis. Final selection of local pilot
project sites shall be based on the completion of an administrative
action plan that the department determines satisfactorily meets the
selection criteria.
14139.61. The department may adopt emergency regulations as
necessary to implement this article in accordance with 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
initial adoption of emergency regulations shall be deemed to be an
emergency and considered by the Office of Administrative Law as
necessary for the immediate preservation of the public peace, health
and safety, or general welfare. Emergency regulations adopted
pursuant to this section shall remain in effect for no more than 180
days.
14139.62. Contingent on the availability of funding, the department
shall evaluate the effectiveness of each pilot project on a schedule
that coincides with federal waiver reporting requirements, and shall
make this information available upon request. The department's
evaluation shall include, but not be limited to, the following:
(a) Whether or not the pilot project has reduced the fragmentation
and improved the coordination of the long-term care delivery system
in the pilot project area.
(b) Whether or not the long-term care delivery system is more
efficient and makes better use of available resources.
(c) Whether or not the goals identified in Section 14139.11 have
been met.
WELFARE AND INSTITUTIONS CODE
SECTION 14139.05-14139.62
14139.05. The Legislature finds and declares that:
(a) Long-term care services in California include an uncoordinated
array of categorical programs offering medical, social, and other
support services that are funded and administered by a variety of
federal, state, and local agencies and are replete with gaps,
duplication, and little or no emphasis on the specific concerns of
individual consumers.
(b) Although the need for a coordinated continuum of long-term
care services has long been apparent, numerous obstacles prevent its
development, including inflexible and inconsistent funding sources,
economic incentives that encourage the placement of consumers in the
highest levels of care, lack of coordination between aging, health,
and social service agencies at both state and local levels, and
inflexible state and federal regulations.
(c) The office of the Legislative Analyst and others have pointed
out that California's systems of service delivery in a number of
areas are dysfunctional, due to the fragmentation of responsibility
and funding for interrelated services. Principles proposed by the
Legislative Analyst to guide the restructuring of these systems
include recognizing program linkages, coordinating service delivery
mechanisms, removing barriers to innovation, and instilling financial
incentives to promote prevention and coordination.
(d) It is both more efficient and more humane to restructure
long-term care services so that duplicative and confusing eligibility
criteria, assessments, intake forms, and service limitations will
not inhibit consumer satisfaction, impede improvements in consumer
health status, and result in the ineffective use of resources.
(e) There is a growing interest in community-directed systems of
funding and organizing the broad array of health, support, and
community living services needed by persons of all ages with
disabilities.
(f) It is in the interest of those in need of long-term care
services, and the state as a whole, to develop a long-term care
system that provides dignity and maximum independence for the
consumer, creates home and community based alternatives to
unnecessary out-of-home placement, and is cost effective.
14139.1. (a) It is the intent of the Legislature to establish the
Long-Term Care Integration Pilot Program that will integrate the
financing and administration of long-term care services in up to five
pilot project sites in the state. Contingent upon a state approved
administrative action plan, at least one site shall be in a rural or
underserved part of the state.
(b) It is further the intent of the Legislature to support, in
each pilot project site, the development of a model integrated
service delivery system that meets the needs of all beneficiaries,
both those who live in their own homes and those who are in
out-of-home placements, in a humane, appropriate, and cost-effective
manner.
14139.11. The goals of this pilot program shall be to:
(a) Provide a continuum of social and health services that foster
independence and self-reliance, maintain individual dignity, and
allow consumers of long-term care services to remain an integral part
of their family and community life.
(b) If out-of-home placement is necessary, to ensure that it is at
the appropriate level of care, and to prevent unnecessary
utilization of acute care hospitals.
(c) If family caregivers are involved in the long-term care of an
individual, to support caregiving arrangements that maximize the
family's ongoing relationship with, and care for, that individual.
(d) Deliver long-term care services in the least restrictive
environment appropriate for the consumer.
(e) Encourage as much self direction as possible by consumers,
given their capability and interest, and involve them and their
family members as partners in the development and implementation of
the pilot project.
(f) Identify performance outcomes that will be used to evaluate
the appropriateness and quality of the services provided, as well as
the efficacy and cost effectiveness of each pilot project, including,
but not limited to, the use of acute and out-of-home care, consumer
satisfaction, the health status of consumers, and the degree of
independent living maintained among those served.
(g) Test a variety of models intended to serve different
geographic areas, with differing populations and service
availability.
(h) Achieve greater efficiencies through consolidated screening
and reporting requirements.
(i) Allow each pilot project site to use existing funding sources
in a manner that it determines will meet local need and that is
cost-effective.
(j) Allow the pilot project sites to determine other services that
may be necessary to meet the needs of eligible beneficiaries.
(k) Identify ways to expand funding options for the pilot program
to include medicare and other funding sources.
14139.12. It is the intent of the Legislature that the costs of
this pilot program to the General Fund will not exceed the direct and
indirect costs that existing programs would expect to incur had the
integrated services not been provided through this pilot program. If
the Department of Finance determines, and informs the director in
writing, that the implementation of this pilot program will result in
any additional costs to the state relative to the provision of
long-term care services to eligible beneficiaries, the department may
terminate the operation of all or any part of this pilot program.
The state shall not be held liable for any additional costs incurred
by a pilot project site. Any such determination made by the
Department of Finance shall be available to any party upon request.
14139.13. (a) Any contract entered into pursuant to this article
may be renewed if the long-term care services agency continues to
meet the requirements of this article and the contract. Failure to
meet these requirements shall be cause for nonrenewal of the
contract. The department may condition renewal on timely completion
of a mutually agreed upon plan of corrections of any deficiencies.
(b) The department may terminate or decline to renew a contract in
whole or in part when the director determines that the action is
necessary to protect the health of the beneficiaries or the funds
appropriated to the Medi-Cal program. The administrative hearing
requirements of Section 14123 do not apply to the nonrenewal or
termination of a contract under this article.
(c) In order to achieve maximum cost savings the Legislature
hereby determines that an expedited contract process for contracts
under this article is necessary. Therefore, contracts under this
article shall be exempt from Chapter 2 (commencing with Section
10290) of Part 2 of Division 2 of the Public Contract Code.
(d) The Director of the Department of Managed Health Care shall,
at the director's request, immediately grant an exemption from
Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code for purposes of carrying out any contract
entered into pursuant to this article.
14139.2. The department shall serve as the lead agency for the
administration of this chapter. The department's responsibilities
shall include, but are not limited to:
(a) Development of criteria for the selection of pilot project
sites.
(b) Selection of the pilot project sites to participate in the
pilot program.
(c) Providing, or arranging for, technical assistance to
participating sites.
(d) Development of specific performance outcome measures by which
the program can be evaluated.
(e) Development of standards for complying with reporting
requirements specified in state law for the programs integrated
within the pilot program implemented pursuant to this article. The
standards developed pursuant to this subdivision shall apply in lieu
of any existing reporting obligations for the programs. The existing
individual reporting requirements for programs integrated within the
pilot program shall be deemed to have been met through the reports
required by this section. Existing requirements for reports to the
Office of Statewide Health Planning and Development shall not be
eliminated.
(f) Seeking all federal waivers necessary for full implementation
of the pilot program.
(g) Setting a payment rate consistent with Section 14139.5.
(h) Approval or disapproval of administrative action plans.
14139.21. The department may accept funding from federal agencies,
foundations or other nongovernmental sources and may contract with
qualified consultants to assist with the provision of technical
assistance, the development of data collection, reporting, and
analysis systems, or any other purposes that further the goals of
this demonstration program. The department shall not accept funds
from any entity that stands to gain financially from implementation
of the pilot program. In contracting with consultants to assist with
the pilot program, the department shall specify timelines and
delivery dates so as to ensure the continued implementation of the
pilot program.
14139.22. (a) The department shall convene a working group that
shall include the Director of Health Services, the Director of Social
Services, and the Director of Aging, or the program staff from each
of those departments who have direct responsibility for the programs
listed in subdivision (b) of Section 14139.32, and may include the
Director of Mental Health and the Director of Rehabilitation, or
program staff from those departments with direct responsibilities for
programs that may be included as a service in any pilot project
site, and representatives from each pilot project site upon its
selection.
(b) The department shall consult with the working group during the
designing of the pilot program, in the selection of the pilot
project sites, and in the monitoring of the program under this
article, and shall utilize the working group as a resource for
problem-solving and a means of maintaining interdepartmental and
intersite communication.
(c) The working group shall strive to ensure that the pilot
program under this article makes maximum use of home-based and
community-based services, and throughout the continuum of care for
each beneficiary, encourages the use of the least restrictive
environment in which the beneficiary can receive appropriate care.
14139.23. Upon the implementation of the pilot program,
responsibility for administering the programs integrated within the
pilot program shall be transferred to the department, and shall be
specified in an interagency agreement between participating
departments. Prior requirements for any program integrated within
this pilot program shall be deemed to have been met through
compliance with the requirements established by this article, by the
department for the pilot program by each county's approved plan, and
by the approved applicable federal waivers.
14139.24. The department shall seek all federal waivers necessary
to allow for federal financial participation in the pilot program
implemented pursuant to this article. This article shall not be
implemented unless and until the director has executed a declaration
that the approval of all necessary federal waivers has been obtained
by the department.
14139.25. Notwithstanding any other provision of this article,
costs to the General Fund shall not exceed the amount that would have
been expended in the absence of the pilot program.
14139.3. (a) Pilot project sites may be comprised of a single
county, a multicounty unit, or a subcounty unit.
(b) Each selected site shall do all of the following:
(1) Establish a consolidated long-term care services fund that
shall accommodate state and federal fiscal and auditing requirements,
shall be used solely for the purposes described in this article, and
shall not be used for any county pooled investment fund.
(2) Identify a local entity, that may be either a governmental
entity or a not-for-profit private agency, to administer the fund.
The local entity may be one that already exists, or may be
established for the express purpose of administering the fund. This
agency shall be designated as the long-term care services agency and
shall contract with the department to carry out this article.
(3) Develop and provide to the department an administrative action
plan that shall include, but is not limited to:
(A) A complete description of the covered scope of services and
programs to be integrated.
(B) A complete description of the proposed long-term care delivery
system and how it will improve system efficiency and enhance service
quality.
(C) Demonstration of a willingness and commitment by the long-term
care services agency to work with local community groups, providers,
and consumers to obtain their input.
(D) Proposed measurable performance outcomes that the pilot
program is designed to achieve.
(E) A description of the expected impact on current program
services to Medi-Cal eligible beneficiaries and consumers of
non-Medi-Cal services included in the integrated system.
(F) Assurance of minimal disruption to current recipients of
long-term care services during the phase-in of the pilot project.
(G) Reasonable assurance that services provided will be responsive
to the religious, cultural, and language needs of beneficiaries.
(H) Assurances that providers who serve the needs of special
populations such as religious and cultural groups or residents of
multilevel facilities as defined in paragraph (9) of subdivision (d)
of Section 15432 of the Government Code and community care retirement
communities as defined in subdivision (u) of Section 1771 of the
Health and Safety Code, will be able to continue to serve those
persons when willing to contract under the same terms and conditions
as similar providers.
(I) Specific alternative concepts, requirements, staffing
patterns, or methods for providing services under the pilot project.
(J) A process to assure that Medi-Cal dollars are appropriately
expended in accordance with federal requirements.
(K) A description of how the pilot project site will maintain
adequate fiscal control and ensure quality of care for beneficiaries.
(L) A description of how the pilot project site will coordinate,
relate to, or integrate with Medi-Cal managed care plans, local
managed care plans, and other organizations which provide services
not part of the pilot project.
(M) A proposed timeline for planning and startup of the pilot
project.
(N) An estimate of costs and savings.
(O) Demonstration of the financial viability of the plan.
(c) The administrative action plan shall reflect a planning
process that includes long-term care consumers, their families, and
organizations that represent them, organizations that provide
long-term care services, and representatives of employees who deliver
direct long-term care services. The planning process may include,
but is not limited to, the members of the local advisory committee
required pursuant to Section 14139.31.
(d) The administrative action plan shall receive the approval of
the county board of supervisors before it is submitted to the
department for final state approval. The board of supervisors shall
present evidence of the commitment to the administrative action plan
of all publicly funded agencies that currently serve consumers who
will be eligible under the pilot project, and all publicly and
nonpublicly funded agencies that will be responsible for providing
services under the pilot project. This evidence may include
resolutions adopted by agency governing bodies, memoranda of
understanding, or other agreements pertinent to the implementation of
the plan.
14139.31. In order to be selected, a pilot project site shall
demonstrate that it has an active advisory committee that includes
consumers of long-term care services, representatives of local
organizations of persons with disabilities, seniors, representatives
of local senior organizations, representatives of employees who
deliver direct long-term care services, and representatives of
organizations that provide long-term care services. At least one-half
of the members of the advisory committee must be consumers of
services provided under this chapter or their representatives.
14139.32. (a) The administrative action plan shall identify the
funds to be transferred into the consolidated long-term care services
fund.
(b) The funds shall include Medi-Cal long-term institutional care,
the Medi-Cal Personal Care Services Program, and the In-Home
Supportive Services Program and may include funds from the following
programs and services:
(1) Multipurpose Seniors Services Program.
(2) Alzheimer's Day Care Resources Centers Program.
(3) Linkages Program.
(4) Respite Program.
(5) Adult Day Health Care Program.
(6) Medi-Cal home health agency services.
(7) Medi-Cal home-based and community-based waiver programs.
(8) Medi-Cal hospice services.
(9) Medi-Cal acute care hospital services.
(10) Other Medi-Cal services, including, but not limited to,
primary, ancillary, and acute care.
(c) Optional program funds enumerated in subdivision (b) of
Section 14139.32 shall be included in the long-term care services
fund in any case where a program was funded prior to its integration
into the pilot project.
(d) In determining which project sites to select for participation
in the pilot program, the department shall give preference to those
sites that include funds from the largest number of programs existing
within the project site at the time the site applies for selection,
provided the administrative action plan meets all other selection
criteria. With the exception of up to one rural county, preference
shall be given to project sites that include primary, ancillary, and
acute care in the consolidated fund, provided their administrative
action plan meets all other selection criteria.
14139.33. The administrative action plan shall delineate the
services to be provided to all eligible beneficiaries. At a minimum,
services to be provided shall include all of the following:
(a) Care or case management, including assessment, development of
a service plan in conjunction with the consumer and other appropriate
parties, authorization and arrangement for purchase of services or
linkages with other appropriate entities, service coordination
activities, and followup to determine whether the services received
were appropriate and consistent with the service plan. Service
coordination activities shall ensure that the records of each
beneficiary are maintained in a consistent and complete manner and
are accessible to the beneficiary or his or her family, and providers
involved in his or her care. This shall be the case whether a
beneficiary resides in his or her own home or in a licensed facility.
(b) Education of beneficiaries, their families, and others in
their informal support network, including independent living skills
training to maximize the independence of the beneficiary.
(c) In-home services.
(d) Adult day services.
(e) Institutional long-term care.
(f) Hospice services.
(g) Linkages to acute care services and primary care services, if
they are not included in the integrated plan.
14139.34. The administrative action plan may also include any of
the following services:
(a) Transportation.
(b) Home modification.
(c) Medical services, including, but not limited to, primary,
ancillary, and acute care.
(d) Housing and residential services.
(e) Other services determined by the pilot project to be necessary
to meet the needs of eligible beneficiaries.
14139.35. The department may exempt a pilot project site from the
requirements of subdivisions (d) and (f) of Section 14139.33 if both
the following conditions are met:
(a) State funds were not being used in the geographic area covered
by the pilot projects to provide those services at the time of
application to the pilot program.
(b) The pilot project site can demonstrate to the department how
it plans to develop these services, and within what timeframe, during
the pilot program.
14139.36. (a) If primary, ancillary, and acute care are not
included among the services offered by a pilot project site, the
administrative action plan shall include all of the following:
(1) A mechanism for tracking the usage of these services by
beneficiaries of the plan.
(2) Provisions for the future inclusion of those services in the
integrated plan, including the process and timeline by which they
will be integrated.
(b) The department shall, in consultation with the pilot project
sites, apply to the federal health care financing administration for
a waiver that allows the pilot projects to include medicare funds in
the long-term care services fund. Upon receipt of the waiver, within
a time period to be designated by the department specific to each
site, each pilot project site shall assume responsibility for
primary, ancillary, and acute care services.
14139.37. The administrative action plan shall delineate
specifically how the pooled funds will be used to deliver services to
all eligible recipients in the geographic area covered by the pilot
project site.
14139.38. Participating counties shall continue their financial
maintenance of effort for each of the programs integrated within the
pilot program under this article. The amount of a county's
maintenance of effort shall be the same as if the program were not
integrated within the pilot program pursuant to this article, and
funds equal to this amount shall be deposited in the local
consolidated long-term care services fund.
14139.4. (a) The long-term care services agency shall be
responsible and at risk for implementing the administrative action
plan. The long-term care services agency shall do all of the
following:
(1) Respond, or provide for response to, consumer needs on a
24-hour, seven-day-a-week basis.
(2) Conduct comprehensive assessments.
(3) Determine eligibility for long-term care services based on the
assessment information.
(4) Provide for contractual arrangements for the provision of, and
payment for, sufficient services to meet the long-term care needs of
the eligible beneficiary in his or her home, community, residential
facility, nursing facility, or other location based on the mix of
programs or services included in the administrative action plan.
(5) Provide linkages to acute care hospitals.
(6) Maintain control over utilization of services that are
authorized.
(7) Monitor the quality of care provided to consumers.
(8) Maintain a consumer grievance process.
(9) Manage the overall cost-effectiveness of the pilot project for
its duration.
(b) Services may be provided through contracts with
community-based providers. In instances where a specific service does
not exist in the community, the long-term care services agency may
facilitate the development of local programs that provide these
services or may provide the services directly, if doing so can be
demonstrated to be cost effective.
14139.41. (a) For purposes of this chapter, "eligible beneficiaries"
shall be defined as persons meeting all the following criteria:
(1) Are Medi-Cal eligible.
(2) Are functionally or cognitively impaired. For purposes of this
paragraph "cognitively impaired" means having an impairment caused
by organic brain disorder or disease.
(3) Are adults.
(4) Need assistance with two or more activities of daily living or
are unable to remain living independently without the long-term care
services provided through the pilot program operated pursuant to
this article.
(b) To the extent eligible beneficiaries also receive services
from a regional center that serves a pilot project site, the pilot
project shall delineate in its administrative action plan how
services will be coordinated by the two agencies.
14139.42. (a) Each pilot project site shall serve all eligible
beneficiaries who live in the geographic area served by the long-term
care services agency. In order to eliminate duplicative
administrative costs and to achieve a more efficient delivery system,
pilot project sites shall also serve non-Medi-Cal eligible
individuals who, but for the implementation of the pilot project,
would have received services from programs whose funds are included
in the consolidated long-term care services fund.
(b) Funding sources allocated for persons who are not eligible for
Medi-Cal benefits may be integrated into the consolidated long-term
care services fund. To the extent those funds are spent on services
for persons who are not eligible for Medi-Cal benefits, they shall be
segregated from capitated funds for Medi-Cal beneficiaries. No funds
derived from the capitated Medi-Cal rate may be used for persons who
are not eligible for Medi-Cal.
14139.43. This article shall not preclude a long-term care services
agency from entering into additional agreements, separate from the
pilot project, to serve additional individuals or populations.
14139.44. Pilot project sites shall ensure provider reimbursement
rates that are adequate to maintain compliance with applicable
federal and state requirements.
14139.5. The department shall set a capitated rate of payment that
is actuarially sound and that is based on the number of beneficiaries
who are eligible for Medi-Cal benefits to be enrolled in the pilot
project, the mix of provided services and programs being integrated,
and past Medi-Cal expenditures for services. The rate shall reflect,
and the contract shall delineate, the rate at which the local
long-term care services agency shall assume the total risk and the
mechanisms that shall be used, which may include, but are not limited
to, risk corridors, reinsurance, or alternative methods of risk
assumption.
14139.51. If the department determines that a program or programs
cannot reasonably be capitated, funds may be transferred separately
from the capitation payment. The amount of those noncapitated funds
shall be based on amounts that would have been expended by the state
for those programs in the absence of the pilot program implemented
under this article.
It is the intent of the Legislature that, if any local pilot
project experiences net savings, those savings shall be used for
project expansion and improvement, or to build the required tangible
net equity, or if there is no need for expansion or improvement or to
build tangible net equity, may be shared by the long-term care
services agency and the state.
14139.53. (a) The department shall develop criteria to ensure that
pilot project sites maintain fiscal solvency, including, but not
limited to, the following:
(1) The capability to achieve and maintain sufficient fiscal
tangible net equity within a timeframe to be specified by the
department for each pilot project site.
(2) The capability to maintain prompt and timely provider
payments.
(3) A management information system that is approved by the
department and is capable of meeting the requirements of the pilot
program.
(b) Any pilot project established under this article shall
immediately notify the department in writing of any fact or facts
that are likely to result in the pilot project or the long-term care
services agency being unable to meet its financial obligations. The
written notice shall describe the fact or facts, the anticipated
financial consequences, and the actions that will be taken to address
the anticipated consequences, and shall be made available upon
request unless otherwise prohibited by law.
14139.6. (a) It is the intent of the Legislature that local
entities that are potential participants in this pilot program shall
be assured of sufficient time to plan their pilot projects, and that
the selected pilot project sites shall be assured of sufficient time
to phase in the implementation of their programs. To that end, it is
the intent of the Legislature that the department, in consultation
with potential pilot project sites and the pilot program working
group, shall develop a realistic timeline with guidelines for the
planning and implementation of pilot projects.
(b) Nothing in this chapter shall prohibit the department, in
consultation with the pilot program working group, from establishing
a two-stage selection process in which local pilot project sites may
be selected on a preliminary basis. Final selection of local pilot
project sites shall be based on the completion of an administrative
action plan that the department determines satisfactorily meets the
selection criteria.
14139.61. The department may adopt emergency regulations as
necessary to implement this article in accordance with 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
initial adoption of emergency regulations shall be deemed to be an
emergency and considered by the Office of Administrative Law as
necessary for the immediate preservation of the public peace, health
and safety, or general welfare. Emergency regulations adopted
pursuant to this section shall remain in effect for no more than 180
days.
14139.62. Contingent on the availability of funding, the department
shall evaluate the effectiveness of each pilot project on a schedule
that coincides with federal waiver reporting requirements, and shall
make this information available upon request. The department's
evaluation shall include, but not be limited to, the following:
(a) Whether or not the pilot project has reduced the fragmentation
and improved the coordination of the long-term care delivery system
in the pilot project area.
(b) Whether or not the long-term care delivery system is more
efficient and makes better use of available resources.
(c) Whether or not the goals identified in Section 14139.11 have
been met.
WELFARE AND INSTITUTIONS CODE
SECTION 14139.05-14139.62
14139.05. The Legislature finds and declares that:
(a) Long-term care services in California include an uncoordinated
array of categorical programs offering medical, social, and other
support services that are funded and administered by a variety of
federal, state, and local agencies and are replete with gaps,
duplication, and little or no emphasis on the specific concerns of
individual consumers.
(b) Although the need for a coordinated continuum of long-term
care services has long been apparent, numerous obstacles prevent its
development, including inflexible and inconsistent funding sources,
economic incentives that encourage the placement of consumers in the
highest levels of care, lack of coordination between aging, health,
and social service agencies at both state and local levels, and
inflexible state and federal regulations.
(c) The office of the Legislative Analyst and others have pointed
out that California's systems of service delivery in a number of
areas are dysfunctional, due to the fragmentation of responsibility
and funding for interrelated services. Principles proposed by the
Legislative Analyst to guide the restructuring of these systems
include recognizing program linkages, coordinating service delivery
mechanisms, removing barriers to innovation, and instilling financial
incentives to promote prevention and coordination.
(d) It is both more efficient and more humane to restructure
long-term care services so that duplicative and confusing eligibility
criteria, assessments, intake forms, and service limitations will
not inhibit consumer satisfaction, impede improvements in consumer
health status, and result in the ineffective use of resources.
(e) There is a growing interest in community-directed systems of
funding and organizing the broad array of health, support, and
community living services needed by persons of all ages with
disabilities.
(f) It is in the interest of those in need of long-term care
services, and the state as a whole, to develop a long-term care
system that provides dignity and maximum independence for the
consumer, creates home and community based alternatives to
unnecessary out-of-home placement, and is cost effective.
14139.1. (a) It is the intent of the Legislature to establish the
Long-Term Care Integration Pilot Program that will integrate the
financing and administration of long-term care services in up to five
pilot project sites in the state. Contingent upon a state approved
administrative action plan, at least one site shall be in a rural or
underserved part of the state.
(b) It is further the intent of the Legislature to support, in
each pilot project site, the development of a model integrated
service delivery system that meets the needs of all beneficiaries,
both those who live in their own homes and those who are in
out-of-home placements, in a humane, appropriate, and cost-effective
manner.
14139.11. The goals of this pilot program shall be to:
(a) Provide a continuum of social and health services that foster
independence and self-reliance, maintain individual dignity, and
allow consumers of long-term care services to remain an integral part
of their family and community life.
(b) If out-of-home placement is necessary, to ensure that it is at
the appropriate level of care, and to prevent unnecessary
utilization of acute care hospitals.
(c) If family caregivers are involved in the long-term care of an
individual, to support caregiving arrangements that maximize the
family's ongoing relationship with, and care for, that individual.
(d) Deliver long-term care services in the least restrictive
environment appropriate for the consumer.
(e) Encourage as much self direction as possible by consumers,
given their capability and interest, and involve them and their
family members as partners in the development and implementation of
the pilot project.
(f) Identify performance outcomes that will be used to evaluate
the appropriateness and quality of the services provided, as well as
the efficacy and cost effectiveness of each pilot project, including,
but not limited to, the use of acute and out-of-home care, consumer
satisfaction, the health status of consumers, and the degree of
independent living maintained among those served.
(g) Test a variety of models intended to serve different
geographic areas, with differing populations and service
availability.
(h) Achieve greater efficiencies through consolidated screening
and reporting requirements.
(i) Allow each pilot project site to use existing funding sources
in a manner that it determines will meet local need and that is
cost-effective.
(j) Allow the pilot project sites to determine other services that
may be necessary to meet the needs of eligible beneficiaries.
(k) Identify ways to expand funding options for the pilot program
to include medicare and other funding sources.
14139.12. It is the intent of the Legislature that the costs of
this pilot program to the General Fund will not exceed the direct and
indirect costs that existing programs would expect to incur had the
integrated services not been provided through this pilot program. If
the Department of Finance determines, and informs the director in
writing, that the implementation of this pilot program will result in
any additional costs to the state relative to the provision of
long-term care services to eligible beneficiaries, the department may
terminate the operation of all or any part of this pilot program.
The state shall not be held liable for any additional costs incurred
by a pilot project site. Any such determination made by the
Department of Finance shall be available to any party upon request.
14139.13. (a) Any contract entered into pursuant to this article
may be renewed if the long-term care services agency continues to
meet the requirements of this article and the contract. Failure to
meet these requirements shall be cause for nonrenewal of the
contract. The department may condition renewal on timely completion
of a mutually agreed upon plan of corrections of any deficiencies.
(b) The department may terminate or decline to renew a contract in
whole or in part when the director determines that the action is
necessary to protect the health of the beneficiaries or the funds
appropriated to the Medi-Cal program. The administrative hearing
requirements of Section 14123 do not apply to the nonrenewal or
termination of a contract under this article.
(c) In order to achieve maximum cost savings the Legislature
hereby determines that an expedited contract process for contracts
under this article is necessary. Therefore, contracts under this
article shall be exempt from Chapter 2 (commencing with Section
10290) of Part 2 of Division 2 of the Public Contract Code.
(d) The Director of the Department of Managed Health Care shall,
at the director's request, immediately grant an exemption from
Chapter 2.2 (commencing with Section 1340) of Division 2 of the
Health and Safety Code for purposes of carrying out any contract
entered into pursuant to this article.
14139.2. The department shall serve as the lead agency for the
administration of this chapter. The department's responsibilities
shall include, but are not limited to:
(a) Development of criteria for the selection of pilot project
sites.
(b) Selection of the pilot project sites to participate in the
pilot program.
(c) Providing, or arranging for, technical assistance to
participating sites.
(d) Development of specific performance outcome measures by which
the program can be evaluated.
(e) Development of standards for complying with reporting
requirements specified in state law for the programs integrated
within the pilot program implemented pursuant to this article. The
standards developed pursuant to this subdivision shall apply in lieu
of any existing reporting obligations for the programs. The existing
individual reporting requirements for programs integrated within the
pilot program shall be deemed to have been met through the reports
required by this section. Existing requirements for reports to the
Office of Statewide Health Planning and Development shall not be
eliminated.
(f) Seeking all federal waivers necessary for full implementation
of the pilot program.
(g) Setting a payment rate consistent with Section 14139.5.
(h) Approval or disapproval of administrative action plans.
14139.21. The department may accept funding from federal agencies,
foundations or other nongovernmental sources and may contract with
qualified consultants to assist with the provision of technical
assistance, the development of data collection, reporting, and
analysis systems, or any other purposes that further the goals of
this demonstration program. The department shall not accept funds
from any entity that stands to gain financially from implementation
of the pilot program. In contracting with consultants to assist with
the pilot program, the department shall specify timelines and
delivery dates so as to ensure the continued implementation of the
pilot program.
14139.22. (a) The department shall convene a working group that
shall include the Director of Health Services, the Director of Social
Services, and the Director of Aging, or the program staff from each
of those departments who have direct responsibility for the programs
listed in subdivision (b) of Section 14139.32, and may include the
Director of Mental Health and the Director of Rehabilitation, or
program staff from those departments with direct responsibilities for
programs that may be included as a service in any pilot project
site, and representatives from each pilot project site upon its
selection.
(b) The department shall consult with the working group during the
designing of the pilot program, in the selection of the pilot
project sites, and in the monitoring of the program under this
article, and shall utilize the working group as a resource for
problem-solving and a means of maintaining interdepartmental and
intersite communication.
(c) The working group shall strive to ensure that the pilot
program under this article makes maximum use of home-based and
community-based services, and throughout the continuum of care for
each beneficiary, encourages the use of the least restrictive
environment in which the beneficiary can receive appropriate care.
14139.23. Upon the implementation of the pilot program,
responsibility for administering the programs integrated within the
pilot program shall be transferred to the department, and shall be
specified in an interagency agreement between participating
departments. Prior requirements for any program integrated within
this pilot program shall be deemed to have been met through
compliance with the requirements established by this article, by the
department for the pilot program by each county's approved plan, and
by the approved applicable federal waivers.
14139.24. The department shall seek all federal waivers necessary
to allow for federal financial participation in the pilot program
implemented pursuant to this article. This article shall not be
implemented unless and until the director has executed a declaration
that the approval of all necessary federal waivers has been obtained
by the department.
14139.25. Notwithstanding any other provision of this article,
costs to the General Fund shall not exceed the amount that would have
been expended in the absence of the pilot program.
14139.3. (a) Pilot project sites may be comprised of a single
county, a multicounty unit, or a subcounty unit.
(b) Each selected site shall do all of the following:
(1) Establish a consolidated long-term care services fund that
shall accommodate state and federal fiscal and auditing requirements,
shall be used solely for the purposes described in this article, and
shall not be used for any county pooled investment fund.
(2) Identify a local entity, that may be either a governmental
entity or a not-for-profit private agency, to administer the fund.
The local entity may be one that already exists, or may be
established for the express purpose of administering the fund. This
agency shall be designated as the long-term care services agency and
shall contract with the department to carry out this article.
(3) Develop and provide to the department an administrative action
plan that shall include, but is not limited to:
(A) A complete description of the covered scope of services and
programs to be integrated.
(B) A complete description of the proposed long-term care delivery
system and how it will improve system efficiency and enhance service
quality.
(C) Demonstration of a willingness and commitment by the long-term
care services agency to work with local community groups, providers,
and consumers to obtain their input.
(D) Proposed measurable performance outcomes that the pilot
program is designed to achieve.
(E) A description of the expected impact on current program
services to Medi-Cal eligible beneficiaries and consumers of
non-Medi-Cal services included in the integrated system.
(F) Assurance of minimal disruption to current recipients of
long-term care services during the phase-in of the pilot project.
(G) Reasonable assurance that services provided will be responsive
to the religious, cultural, and language needs of beneficiaries.
(H) Assurances that providers who serve the needs of special
populations such as religious and cultural groups or residents of
multilevel facilities as defined in paragraph (9) of subdivision (d)
of Section 15432 of the Government Code and community care retirement
communities as defined in subdivision (u) of Section 1771 of the
Health and Safety Code, will be able to continue to serve those
persons when willing to contract under the same terms and conditions
as similar providers.
(I) Specific alternative concepts, requirements, staffing
patterns, or methods for providing services under the pilot project.
(J) A process to assure that Medi-Cal dollars are appropriately
expended in accordance with federal requirements.
(K) A description of how the pilot project site will maintain
adequate fiscal control and ensure quality of care for beneficiaries.
(L) A description of how the pilot project site will coordinate,
relate to, or integrate with Medi-Cal managed care plans, local
managed care plans, and other organizations which provide services
not part of the pilot project.
(M) A proposed timeline for planning and startup of the pilot
project.
(N) An estimate of costs and savings.
(O) Demonstration of the financial viability of the plan.
(c) The administrative action plan shall reflect a planning
process that includes long-term care consumers, their families, and
organizations that represent them, organizations that provide
long-term care services, and representatives of employees who deliver
direct long-term care services. The planning process may include,
but is not limited to, the members of the local advisory committee
required pursuant to Section 14139.31.
(d) The administrative action plan shall receive the approval of
the county board of supervisors before it is submitted to the
department for final state approval. The board of supervisors shall
present evidence of the commitment to the administrative action plan
of all publicly funded agencies that currently serve consumers who
will be eligible under the pilot project, and all publicly and
nonpublicly funded agencies that will be responsible for providing
services under the pilot project. This evidence may include
resolutions adopted by agency governing bodies, memoranda of
understanding, or other agreements pertinent to the implementation of
the plan.
14139.31. In order to be selected, a pilot project site shall
demonstrate that it has an active advisory committee that includes
consumers of long-term care services, representatives of local
organizations of persons with disabilities, seniors, representatives
of local senior organizations, representatives of employees who
deliver direct long-term care services, and representatives of
organizations that provide long-term care services. At least one-half
of the members of the advisory committee must be consumers of
services provided under this chapter or their representatives.
14139.32. (a) The administrative action plan shall identify the
funds to be transferred into the consolidated long-term care services
fund.
(b) The funds shall include Medi-Cal long-term institutional care,
the Medi-Cal Personal Care Services Program, and the In-Home
Supportive Services Program and may include funds from the following
programs and services:
(1) Multipurpose Seniors Services Program.
(2) Alzheimer's Day Care Resources Centers Program.
(3) Linkages Program.
(4) Respite Program.
(5) Adult Day Health Care Program.
(6) Medi-Cal home health agency services.
(7) Medi-Cal home-based and community-based waiver programs.
(8) Medi-Cal hospice services.
(9) Medi-Cal acute care hospital services.
(10) Other Medi-Cal services, including, but not limited to,
primary, ancillary, and acute care.
(c) Optional program funds enumerated in subdivision (b) of
Section 14139.32 shall be included in the long-term care services
fund in any case where a program was funded prior to its integration
into the pilot project.
(d) In determining which project sites to select for participation
in the pilot program, the department shall give preference to those
sites that include funds from the largest number of programs existing
within the project site at the time the site applies for selection,
provided the administrative action plan meets all other selection
criteria. With the exception of up to one rural county, preference
shall be given to project sites that include primary, ancillary, and
acute care in the consolidated fund, provided their administrative
action plan meets all other selection criteria.
14139.33. The administrative action plan shall delineate the
services to be provided to all eligible beneficiaries. At a minimum,
services to be provided shall include all of the following:
(a) Care or case management, including assessment, development of
a service plan in conjunction with the consumer and other appropriate
parties, authorization and arrangement for purchase of services or
linkages with other appropriate entities, service coordination
activities, and followup to determine whether the services received
were appropriate and consistent with the service plan. Service
coordination activities shall ensure that the records of each
beneficiary are maintained in a consistent and complete manner and
are accessible to the beneficiary or his or her family, and providers
involved in his or her care. This shall be the case whether a
beneficiary resides in his or her own home or in a licensed facility.
(b) Education of beneficiaries, their families, and others in
their informal support network, including independent living skills
training to maximize the independence of the beneficiary.
(c) In-home services.
(d) Adult day services.
(e) Institutional long-term care.
(f) Hospice services.
(g) Linkages to acute care services and primary care services, if
they are not included in the integrated plan.
14139.34. The administrative action plan may also include any of
the following services:
(a) Transportation.
(b) Home modification.
(c) Medical services, including, but not limited to, primary,
ancillary, and acute care.
(d) Housing and residential services.
(e) Other services determined by the pilot project to be necessary
to meet the needs of eligible beneficiaries.
14139.35. The department may exempt a pilot project site from the
requirements of subdivisions (d) and (f) of Section 14139.33 if both
the following conditions are met:
(a) State funds were not being used in the geographic area covered
by the pilot projects to provide those services at the time of
application to the pilot program.
(b) The pilot project site can demonstrate to the department how
it plans to develop these services, and within what timeframe, during
the pilot program.
14139.36. (a) If primary, ancillary, and acute care are not
included among the services offered by a pilot project site, the
administrative action plan shall include all of the following:
(1) A mechanism for tracking the usage of these services by
beneficiaries of the plan.
(2) Provisions for the future inclusion of those services in the
integrated plan, including the process and timeline by which they
will be integrated.
(b) The department shall, in consultation with the pilot project
sites, apply to the federal health care financing administration for
a waiver that allows the pilot projects to include medicare funds in
the long-term care services fund. Upon receipt of the waiver, within
a time period to be designated by the department specific to each
site, each pilot project site shall assume responsibility for
primary, ancillary, and acute care services.
14139.37. The administrative action plan shall delineate
specifically how the pooled funds will be used to deliver services to
all eligible recipients in the geographic area covered by the pilot
project site.
14139.38. Participating counties shall continue their financial
maintenance of effort for each of the programs integrated within the
pilot program under this article. The amount of a county's
maintenance of effort shall be the same as if the program were not
integrated within the pilot program pursuant to this article, and
funds equal to this amount shall be deposited in the local
consolidated long-term care services fund.
14139.4. (a) The long-term care services agency shall be
responsible and at risk for implementing the administrative action
plan. The long-term care services agency shall do all of the
following:
(1) Respond, or provide for response to, consumer needs on a
24-hour, seven-day-a-week basis.
(2) Conduct comprehensive assessments.
(3) Determine eligibility for long-term care services based on the
assessment information.
(4) Provide for contractual arrangements for the provision of, and
payment for, sufficient services to meet the long-term care needs of
the eligible beneficiary in his or her home, community, residential
facility, nursing facility, or other location based on the mix of
programs or services included in the administrative action plan.
(5) Provide linkages to acute care hospitals.
(6) Maintain control over utilization of services that are
authorized.
(7) Monitor the quality of care provided to consumers.
(8) Maintain a consumer grievance process.
(9) Manage the overall cost-effectiveness of the pilot project for
its duration.
(b) Services may be provided through contracts with
community-based providers. In instances where a specific service does
not exist in the community, the long-term care services agency may
facilitate the development of local programs that provide these
services or may provide the services directly, if doing so can be
demonstrated to be cost effective.
14139.41. (a) For purposes of this chapter, "eligible beneficiaries"
shall be defined as persons meeting all the following criteria:
(1) Are Medi-Cal eligible.
(2) Are functionally or cognitively impaired. For purposes of this
paragraph "cognitively impaired" means having an impairment caused
by organic brain disorder or disease.
(3) Are adults.
(4) Need assistance with two or more activities of daily living or
are unable to remain living independently without the long-term care
services provided through the pilot program operated pursuant to
this article.
(b) To the extent eligible beneficiaries also receive services
from a regional center that serves a pilot project site, the pilot
project shall delineate in its administrative action plan how
services will be coordinated by the two agencies.
14139.42. (a) Each pilot project site shall serve all eligible
beneficiaries who live in the geographic area served by the long-term
care services agency. In order to eliminate duplicative
administrative costs and to achieve a more efficient delivery system,
pilot project sites shall also serve non-Medi-Cal eligible
individuals who, but for the implementation of the pilot project,
would have received services from programs whose funds are included
in the consolidated long-term care services fund.
(b) Funding sources allocated for persons who are not eligible for
Medi-Cal benefits may be integrated into the consolidated long-term
care services fund. To the extent those funds are spent on services
for persons who are not eligible for Medi-Cal benefits, they shall be
segregated from capitated funds for Medi-Cal beneficiaries. No funds
derived from the capitated Medi-Cal rate may be used for persons who
are not eligible for Medi-Cal.
14139.43. This article shall not preclude a long-term care services
agency from entering into additional agreements, separate from the
pilot project, to serve additional individuals or populations.
14139.44. Pilot project sites shall ensure provider reimbursement
rates that are adequate to maintain compliance with applicable
federal and state requirements.
14139.5. The department shall set a capitated rate of payment that
is actuarially sound and that is based on the number of beneficiaries
who are eligible for Medi-Cal benefits to be enrolled in the pilot
project, the mix of provided services and programs being integrated,
and past Medi-Cal expenditures for services. The rate shall reflect,
and the contract shall delineate, the rate at which the local
long-term care services agency shall assume the total risk and the
mechanisms that shall be used, which may include, but are not limited
to, risk corridors, reinsurance, or alternative methods of risk
assumption.
14139.51. If the department determines that a program or programs
cannot reasonably be capitated, funds may be transferred separately
from the capitation payment. The amount of those noncapitated funds
shall be based on amounts that would have been expended by the state
for those programs in the absence of the pilot program implemented
under this article.
It is the intent of the Legislature that, if any local pilot
project experiences net savings, those savings shall be used for
project expansion and improvement, or to build the required tangible
net equity, or if there is no need for expansion or improvement or to
build tangible net equity, may be shared by the long-term care
services agency and the state.
14139.53. (a) The department shall develop criteria to ensure that
pilot project sites maintain fiscal solvency, including, but not
limited to, the following:
(1) The capability to achieve and maintain sufficient fiscal
tangible net equity within a timeframe to be specified by the
department for each pilot project site.
(2) The capability to maintain prompt and timely provider
payments.
(3) A management information system that is approved by the
department and is capable of meeting the requirements of the pilot
program.
(b) Any pilot project established under this article shall
immediately notify the department in writing of any fact or facts
that are likely to result in the pilot project or the long-term care
services agency being unable to meet its financial obligations. The
written notice shall describe the fact or facts, the anticipated
financial consequences, and the actions that will be taken to address
the anticipated consequences, and shall be made available upon
request unless otherwise prohibited by law.
14139.6. (a) It is the intent of the Legislature that local
entities that are potential participants in this pilot program shall
be assured of sufficient time to plan their pilot projects, and that
the selected pilot project sites shall be assured of sufficient time
to phase in the implementation of their programs. To that end, it is
the intent of the Legislature that the department, in consultation
with potential pilot project sites and the pilot program working
group, shall develop a realistic timeline with guidelines for the
planning and implementation of pilot projects.
(b) Nothing in this chapter shall prohibit the department, in
consultation with the pilot program working group, from establishing
a two-stage selection process in which local pilot project sites may
be selected on a preliminary basis. Final selection of local pilot
project sites shall be based on the completion of an administrative
action plan that the department determines satisfactorily meets the
selection criteria.
14139.61. The department may adopt emergency regulations as
necessary to implement this article in accordance with 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
initial adoption of emergency regulations shall be deemed to be an
emergency and considered by the Office of Administrative Law as
necessary for the immediate preservation of the public peace, health
and safety, or general welfare. Emergency regulations adopted
pursuant to this section shall remain in effect for no more than 180
days.
14139.62. Contingent on the availability of funding, the department
shall evaluate the effectiveness of each pilot project on a schedule
that coincides with federal waiver reporting requirements, and shall
make this information available upon request. The department's
evaluation shall include, but not be limited to, the following:
(a) Whether or not the pilot project has reduced the fragmentation
and improved the coordination of the long-term care delivery system
in the pilot project area.
(b) Whether or not the long-term care delivery system is more
efficient and makes better use of available resources.
(c) Whether or not the goals identified in Section 14139.11 have
been met.
