Children's services.

The California Children's Services (CCS) program is a statewide program providing medically necessary services required by physically handicapped children whose parents are unable to pay for those services. The State Department of Health Care Services administers the CCS program. Counties, based on population size, are also charged with administering the program, either independently or jointly with the department. The services covered by the CCS program include expert diagnosis, medical treatment, surgical treatment, hospital care, physical therapy, occupational therapy, special treatment, materials, and the supply of appliances and their upkeep, maintenance, and transportation. Funding for the program comes from county, state, and federal sources. In order to be eligible for the CCS program, an applicant must be under 21 years of age, have or be suspected of having a condition covered by the program, and meet certain financial eligibility standards established by the department. Existing law prohibits services covered by the CCS program from being incorporated into a Medi-Cal managed care contract entered into after August 1, 1994, until January 1, 2017, except with respect to contracts entered into for county organized health systems or Regional Health Authority in specified counties. This bill would exempt contracts entered into under the Whole Child Model program, described below, from that prohibition and would extend to January 1, 2022, and until the evaluation required under the Whole Child Model program has been completed, the termination of the prohibition against CCS-covered services being incorporated in a Medi-Cal managed care contract entered into after August 1, 1994. The bill would authorize the department, no sooner than July 1, 2017, to establish a Whole Child Model program, under which managed care plans served by a county organized health system or Regional Health Authority in designated counties would provide CCS services to Medi-Cal eligible CCS children and youth. The bill would limit the number of managed care plans under a county organized health system or Regional Health Authority that are eligible to participate in the program. The bill would require the department to implement the program, as specified, and would require a managed care plan to obtain written approval from the department and establish a local stakeholder process, as prescribed. The bill would prohibit the department from approving the application of a managed care plan until the Director of Health Care Services has verified the readiness of the managed care plan to address the unique needs of CCS-eligible beneficiaries, including, among other things, that the managed care contractor demonstrates the availability of an appropriate provider network to serve the needs of children and youth with CCS conditions and complies with all CCS program guidelines. The bill would prohibit the department from implementing the program in any county until it has developed specific CCS monitoring and oversight standards for managed care plans. The bill would require the department to establish, through December 31, 2021, a statewide Whole Child Model program stakeholder advisory group comprised of specified stakeholders, including representatives from health plans and family resource centers, or modify an existing stakeholder advisory group and would require the department to consult with the Whole Child Model program stakeholder advisory group on the implementation of the program, as specified. The bill would impose various requirements on a Medi-Cal managed care plan serving children and youth with CCS-eligible conditions under the CCS program, including, but not limited to, coordinating services, as specified; providing appropriate access to care, services, and information, including continuity of care requirements; and providing for case management, care coordination, provider referral, and service authorization services. The bill would require a Medi-Cal managed care plan participating in the Whole Child Model program to ensure provision of case management, care coordination, provider referral, and service authorization services to children and youth, as prescribed, but would authorize the department to waive this requirement if the plan demonstrates that it cannot meet the requirement because it would result in substantially increased program costs, as specified. This bill would require a managed care plan to provide a timely process for accepting and acting upon complaints and grievances of CCS-eligible children and youth. The bill would require a specified stakeholder process to address proposed changes to CCS medical eligibility requirements. The bill would require the department to contract with an independent entity to conduct an evaluation to assess health plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the program, and would require the department to provide a report on the results of this evaluation to the Legislature no later than January 1, 2021. This bill would provide that its provisions are not intended to permit any reduction in benefits or eligibility levels under the existing CCS program. The bill would require the department, by July 1, 2020, to adopt regulations and, commencing July 1, 2018, would require the department to provide a status report to the Legislature until regulations have been adopted. The bill would authorize the Director of Health Care Services to enter into exclusive or nonexclusive contracts on a bid, nonbid, or negotiated basis and amend existing managed care contracts to provide or arrange for services provided under the bill. By imposing new duties on counties with respect to the transition and implementation of CCS program services, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.