(a) Notwithstanding Section 14094.3, in furtherance of the waiver or demonstration project developed pursuant to Section 14180, the director shall establish, by January 1, 2012, organized health care delivery models for children eligible for California Children Services (CCS) under Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code. These models shall be chosen from the following:
(1) An enhanced primary care case management program.
(2) A provider-based accountable care organization.
(3) A specialty health care plan.
(4) A Medi-Cal managed care plan that includes payment and coverage for CCS-eligible conditions.
(b) Each model shall do all of the following:
(1) Establish clear standards and criteria for participation, exemption, enrollment, and disenrollment.
(2) Provide care coordination that links children and youth with special health care needs with appropriate services and resources in a coordinated manner to achieve optimum health.
(3) Establish networks that include CCS-approved providers and maintain the current system of regionalized pediatric specialty and subspecialty services to ensure that children and youth have timely access to appropriate and qualified providers.
(4) Coordinate out-of-network access if appropriate and qualified providers are not part of the network or in the region.
(5) Ensure that children enrolled in the model receive care for their CCS-eligible medical conditions from CCS-approved providers consistent with the CCS standards of care.
(6) Participate in a statewide quality improvement collaborative that includes stakeholders.
(7) (A) Establish and support medical homes, incorporating all of the following principles:
(i) Each child has a personal physician.
(ii) The medical home is a physician-directed medical practice.
(iii) The medical home utilizes a whole child orientation.
(iv) Care is coordinated or integrated across all of the elements of the health care system and the family and child’s community.
(v) Information, education, and support to consumers and families in the program is provided in a culturally competent manner.
(vi) Quality and safety practices and measures.
(vii) Provides enhanced access to care, including access to after-hours care.
(viii) Payment is structured appropriately to recognize the added value provided to children and their families.
(B) In implementing this section, and the terms and conditions of the demonstration project, the department may alter the medical home principles described in this paragraph as necessary to secure the increased federal financial participation associated with the provision of medical assistance in conjunction with a health home, as made available under the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and codified in Section 1945 of Title XIX of the federal Social Security Act. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to alter medical home principles under this section at least five days in advance of taking this action.
(8) Provide the department with data for quality monitoring and improvement measures, as determined necessary by the department. The department shall institute quality monitoring and improvement measures that are appropriate for children and youth with special health care needs.
(c) The services provided under these models shall not be limited to medically necessary services required to treat the CCS-eligible medical condition.
(d) Notwithstanding any other provision of law, and to the extent permitted by federal law, the department may require eligible individuals to enroll in these models.
(e) At the election of the Managed Risk Medical Insurance Board, and with the consent of the director, children enrolled in the Healthy Families Program pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code, who are eligible for CCS under Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, may enroll in the organized health care delivery models established under this section.
(f) For the purposes of implementing this section, the department shall seek proposals to establish and test these models of organized health care delivery systems, may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, and may amend existing managed care contracts to provide or arrange for services under this section. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this section shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code.
(g) (1) Entities contracting with the department under this section shall report expenditures for the services provided under the contract.
(2) If a contractor is paid according to a capitated or risk-based payment methodology, the rates shall be actuarially sound and take into account care coordination activities.
(h) (1) The department shall conduct an evaluation to assess the effectiveness of each model in improving the delivery of health care services for children who are eligible for CCS. The department shall consult with stakeholders in developing an evaluation for the models being tested.
(2) The evaluation process shall begin simultaneously with the development and implementation of the model delivery systems to compare the care provided to, and outcomes of, children enrolled in the models with those not enrolled in the models. The evaluation shall include, at a minimum, an assessment of all of the following:
(A) The types of services and expenditures for services.
(B) Improvement in the coordination of care for children.
(C) Improvement in the quality of care.
(D) Improvement in the value of care provided.
(E) The rate of growth of expenditures.
(F) Parent satisfaction.
(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, 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. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance.
(Added by Stats. 2010, Ch. 714, Sec. 23. (SB 208) Effective October 19, 2010.)
Last modified: October 25, 2018