SECTIONS 15909-15915 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 15909-15915

15909. The Legislature finds and declares all of the following:
(a) Pursuant to Section 14180, the Legislature directed the
department to apply for a successor federal waiver or demonstration
project, in part, to coincide with the end of the waiver described in
relevant part in subdivision (b) of Section 15900 to, among other
requirements, optimize opportunities to increase federal financial
participation and maximize financial resources to address
uncompensated care.
(b) Passage of federal health care reform, pursuant to 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), presents new options of federal support
for coverage of low-income individuals and significant expansion of
state coverage programs in 2014. Through the success of the Health
Care Coverage Initiatives established pursuant to Part 3.5
(commencing with Section 15900), and with implementation of a
successor federal Medicaid waiver or demonstration project,
California is well positioned to develop enrollment and coverage
expansion models that will lead the way to full implementation of
comprehensive health care reforms in 2014.

15909.1. For purposes of this part, the following definitions shall
apply:
(a) "Demonstration project" means a federal waiver or
demonstration project described in Section 14180 approved by the
federal Centers for Medicare and Medicaid Services that authorizes
the implementation of a successor to the Health Care Coverage
Initiative under Part 3.5 (commencing with Section 15900).
(b) "CEED project" means a local Coverage Expansion and Enrollment
Demonstration project authorized under this part.
(c) "Eligible entity" means a county, city and county, consortium
of counties serving a region consisting of more than one county, or
health authority. For purposes of this section and to the extent
allowed under the terms and conditions of the demonstration project,
a County Medical Services Program shall be considered a consortium of
counties serving a region consisting of more than one county.
(d) "Participating entity" means an eligible entity that operates
an approved CEED project.

15910. (a) Subject to federal approval of a demonstration project
effective on or after November 1, 2010, the department shall, by no
later than March 1, 2011, or alternatively, 180 days after federal
approval of the demonstration project, whichever occurs later,
authorize local CEED projects to provide scheduled health care
services, consistent with the terms and conditions of the
demonstration project, to uninsured adults 19 to 64, inclusive, years
of age, who are not otherwise eligible for Medicare or Medi-Cal,
with incomes up to 133 percent of the federal poverty level. To the
extent federal financial participation is made available under the
terms and conditions of the demonstration project and pursuant to
Section 15910.1, CEED project services may be made available to
individuals with incomes between 134 through 200 percent of the
federal poverty level.
(b) Eligible entities, consistent with the terms and conditions of
the demonstration project, may perform outreach and enrollment
activities to target populations, including, but not limited to, the
people who are homeless, individuals who frequently use hospital
inpatient or emergency department services for avoidable reasons, or
people with mental health or substance abuse treatment needs.
(c) CEED projects shall be designed and implemented with the
systems and program elements necessary to facilitate the transition
of those eligible individuals to Medi-Cal coverage, or alternatively,
to coverage through the California Health Benefit Exchange, by 2014,
pursuant to state and federal law, and the terms and conditions of
the demonstration project.
(d) The department shall authorize CEED projects that meet the
requirements set forth in this part and the terms and conditions of
the demonstration project.
(e) (1) By January 1, 2011, or alternatively, 60 days after
federal approval of the demonstration project, whichever occurs
later, the department shall notify all eligible entities of the
opportunity to elect to implement a CEED project, the applicable
requirements, and the process for submitting an application for
department approval of a CEED project.
(2) The director shall approve or deny an eligible entity's CEED
project application within 60 days of receipt of the application. If
the director denies an application, the denial shall be in writing
and shall specify the reasons therefor.
(3) Within 10 days of a denial by the director under this
subdivision, a participating entity may submit a written request for
reconsideration. The director shall respond in writing to a request
for reconsideration within 20 days, confirming or reversing the
denial, and specifying the reasons for the reconsidered decision.
(4) An approval of a CEED project may be effective retroactively,
and shall be effective on the date specified in the application, so
long as the effective date is consistent with the terms and
conditions of the demonstration project. If the eligible entity had
in operation a Health Care Coverage Initiative program under Part 3.5
(commencing with Section 15900) as of August 31, 2010, and the
eligible entity elects to continue funding the program, then the
existing Health Care Coverage Initiative program shall, to the extent
permitted by the terms and conditions of the demonstration project,
remain in effect until the CEED project is effective, but no later
than 180 days after the department provides notice to eligible
entities pursuant to this subdivision.
(f) Services provided pursuant to this part shall be available to
those eligible, uninsured individuals enrolled in the applicable CEED
project, subject to the limitations of this part and the terms and
conditions of the demonstration project. However, nothing in this
part is intended to create an entitlement program of any kind.
(g) Each CEED project shall establish an income eligibility
standard for individuals to enroll in the CEED project, which shall
be expressed as a percentage between 0 and 133 of the federal poverty
level. Notwithstanding the established eligibility standard, a CEED
project may impose a limit on enrollment in the CEED project, which
shall be subject to all of the following provisions:
(1) The special terms and conditions required by the federal
Centers for Medicare and Medicaid Services for the approval of the
demonstration project described in Section 14180 permit a limitation
on enrollment in a CEED project.
(2) Any enrollment limitation by a CEED project shall be
administered in accordance with the special terms and conditions
required by the federal Centers for Medicare and Medicaid Services.
(3) Any enrollment limitation by a CEED project is subject to
approval by the director.
(4) Prior to applying for approval from the director, the CEED
project shall submit to the director a resolution from the county
board of supervisors in which the CEED project is located approving
the proposed limitation on enrollment by the CEED project.
(h) CEED projects shall be established and implemented only to the
extent that federal financial participation is available and only to
the extent that available federal financial participation is not
jeopardized.
(i) For the purposes of operating a CEED project approved under
this part, and notwithstanding Section 14181, participating entities
shall be exempt from the provisions of Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code, shall not
be considered Medi-Cal managed care health plans subject to the
requirements applicable to the two-plan model and geographic managed
care plans, as contained in Article 2.7 (commencing with Section
14087.3), Article 2.81 (commencing with Section 14087.96) and Article
2.91 (commencing with Section 14089) of Chapter 7 of Part 1 and the
corresponding regulations, and shall not be considered prepaid health
plans as defined in Section 14251.

15910.1. (a) If federal financial participation is available for
CEED projects serving individuals with incomes between 134 and 200
percent of the federal poverty level, subject to federal funding
limits or requirements that differ from the requirements for
individuals described in subdivision (a) of Section 15910, the
department shall, in consultation with participating entities,
develop a process for allocating the available federal funding to
those approved CEED projects that have established an income
eligibility standard of at least 134 percent of the federal poverty
level, and that elect to serve the additional group of individuals
identified in this subdivision, if the participating entity
voluntarily agrees to provide the nonfederal share of the CEED
project expenditures for the additional group.
(b) To the extent permitted by the terms and conditions of the
demonstration project, the allocation of funding under this section
shall ensure that a Health Care Coverage Initiative program under
Part 3.5 (commencing with Section 15900) as of August 31, 2010, that
elects to continue as a participating entity under this article
receives, at a minimum, an allocation in an amount adequate to ensure
that their existing enrollees can continue to receive services under
their CEED project.
(c) Section 15910 and Section 15910.2 shall apply with respect to
CEED projects funded under this section, as appropriate.
(d) Payments to CEED projects approved under this section shall be
made in accordance with Section 15910.3 or through another mechanism
authorized under the terms and conditions for the demonstration
project.
(e) The nonfederal share of funding for CEED project expenditures
authorized under this section shall be provided in accordance with
Section 15911 or through another mechanism authorized by the terms
and conditions of the demonstration project.
(f) Any unused federal funds shall be distributed in accordance
with the terms and conditions of the demonstration project.

15910.2. (a) The department shall approve any CEED project that
meets both of the following requirements and any additional
requirements imposed by the terms and conditions of the demonstration
project:
(1) Is proposed by an eligible entity that voluntarily agrees to
commit, on an annual basis, to provide the nonfederal share of CEED
project expenditures for services to individuals who meet the income
eligibility standards specified for the CEED project.
(2) Includes the CEED project elements set forth in subdivision
(b).
(b) An approved CEED project shall include all of the following
elements, subject to the terms and conditions of the demonstration
project:
(1) Development of standardized eligibility and enrollment
procedures that interface with Medi-Cal processes according to the
milestones developed in consultation with the counties, county health
departments, public hospitals, and county human service departments.
CEED projects shall migrate to the standardized procedures in
accordance with the terms and conditions of the demonstration
project. If authorized under the terms and conditions of the
demonstration project, eligibility for CEED benefits may be provided
retroactively for any of the three months prior to the enrollment
date in which the individual would have been found eligible had he or
she applied during that month. If an individual is determined to be
retroactively eligible, CEED project coverage for the retroactive
period shall be limited to those services provided within the
approved CEED project network.
(2) (A) Assignment of eligible individuals to a medical home. For
purposes of this paragraph and subject to the terms and conditions of
the demonstration project, "medical home" means a single provider,
facility, or health care team that maintains an individual's medical
information, and coordinates health care services for enrolled
individuals. The medical home shall provide, at a minimum, all of the
following elements, which shall be considered in the contracting
process:
(i) A primary health care contact who facilitates the enrollee's
access to preventive, primary, specialty, mental health, or chronic
illness treatment, as appropriate.
(ii) An intake assessment of each new enrollee's general health
status.
(iii) Referrals to qualified professionals, community resources,
or other agencies as needed.
(iv) Care coordination for the beneficiary across the service
delivery system, as agreed to between the medical home and the CEED
project. This may include facilitating communication among enrollee's
health care providers, including appropriate outreach to mental
health providers.
(v) Care management, case management, and transitions among levels
of care, if needed and as agreed to between the medical home and the
CEED project.
(vi) Use of clinical guidelines and other evidence-based medicine
when applicable for treatment of the enrollee's health care issues
and timing of clinical preventive services.
(vii) Focus on continuous improvement in quality of care.
(viii) Timely access to qualified health care interpretation as
needed and as appropriate for enrollees with limited English
proficiency, as determined by applicable federal guidelines.
(ix) Health information, education, and support to beneficiaries
and, where appropriate, their families, if and when needed, in a
culturally competent manner.
(B) In implementing this section, and the terms and conditions of
the demonstration project, the department may alter the medical home
elements 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.
(3) A scheduled package of services required under the terms and
conditions of the demonstration project that shall be limited to
those services provided within an approved CEED project's provider
network and service delivery system.
(4) A provider network and service delivery system that seeks to
promote the viability of the existing safety net health care system
that serves the population to be covered by the CEED project. The
provider network and service delivery system shall meet the standards
established in the terms and conditions of the demonstration
project.
(5) Development of an outreach and enrollment plan that reaches
potential project enrollees and begins to prepare to transition
eligible individuals to Medi-Cal coverage in 2014, or alternatively,
to coverage through the California Health Benefit Exchange.
(6) A quality measurement and quality monitoring system.
(7) Data tracking systems to provide the department with required
data for quality monitoring, quality improvement, and evaluation.
(8) Demonstration of how the CEED project will provide consumer
assistance to individuals applying for, participating in, or
accessing, services in the CEED projects, including the availability
of materials that provide information on all of the following:
(A) The scope of covered services.
(B) The exceptions, reductions, and limitations that apply to
covered services.
(C) Any premium, copayment, or deductible requirements that may be
incurred by the enrollee.
(D) The participating providers in the CEED project network.
(E) The medical homes within the CEED project network from which
the enrollee may select.
(F) The CEED project's telephone number or numbers that may be
used by an enrollee to receive additional information about the
covered services or participating providers.
(9) Ability to meet program requirements, standards, and
performance measurements developed by the department, in consultation
with participating counties, for the CEED projects.

15910.3. (a) In consultation with participating entities, the
department shall determine actuarially sound per enrollee capitation
rates for CEED projects that are adequate and sufficient to ensure
access to services for enrollees and to at least cover the projected
cost of care. As part of the rate development process, each CEED
project shall submit a detailed proposal to the department outlining
proposed methodologies and rates that have been certified by
county-employed or county-retained actuaries using state and federal
Medicaid principles and the standards provided in this section.
(b) Rates determined under this section shall be based on
utilization and cost data specific to the enrolled population or
comparable data, including where available, project- and county-
specific data. In setting actuarially sound rates, the department
shall apply appropriate factors to ensure sufficient access to
primary and specialty care, and shall take into account the cost of
the services specified under the approved CEED project,
administrative costs, graduate medical education costs, the
utilization and intensity of services expected for CEED project
enrollees, and an appropriate case management fee.
(c) The department may include risk corridors to allow for
adjustments to rates if the actual cost or utilization of a CEED
project exceeds the projected cost.
(d) The department may develop additional payment mechanisms that
provide for incentive payments to CEED projects that meet designated
performance criteria for quality of and access to care.
(e) The rate shall be determined annually, and shall be effective
either the first day of each CEED project year, or another date
agreed upon by the participating entity and the department. Rates may
be adjusted outside the annual redetermination process if there is a
change in federal or state law or regulation that increases the cost
of fulfilling the obligations of a CEED project.
(f) Notwithstanding any other provision of law, payments to CEED
projects shall not be limited by an estimate of the reimbursement
that would be available for program services if those services were
provided to Medi-Cal beneficiaries under the Medi-Cal fee-for-service
program.
(g) CEED projects shall be paid actuarially sound rates as
determined under this section at the beginning of each quarter based
on enrollment. If payments are based on estimated enrollment data,
the payments shall be reconciled to actual enrollment on an annual
basis.

15911. (a) Funding for each CEED project shall be based on all of
the following:
(1) The amount of funding that the participating entity
voluntarily provides for the nonfederal share of CEED project
expenditures.
(2) Any limitations imposed by the terms and conditions of the
demonstration project.
(3) Whether additional funds are allocated to the CEED projects
under Section 15910.1 for services to individuals with incomes
between 134 and 200 percent of the federal poverty level.
(4) Whether funding under this part would result in the reduction
of other payments under the demonstration project.
(b) Nothing in this part shall be construed to require a political
subdivision of the state to participate in the program of CEED
projects as set forth in this part, and those local funds expended or
transferred for the nonfederal share of CEED project expenditures
under this part shall be considered voluntary contributions for
purposes of 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 the
federal American Recovery and Reinvestment Act of 2009 (Public Law
111-5), as amended by the federal Patient Protection and Affordable
Care Act.
(c) No state General Fund moneys shall be used to fund CEED
project services, nor to fund any related administrative costs
incurred by counties or any other political subdivision of the state.
(d) Subject to the terms and conditions of the demonstration
project, if a participating entity elects to fund the nonfederal
share of a CEED project, the nonfederal funding and payments to the
CEED project shall be provided through one of the following
mechanisms, at the options of the participating entity:
(1) On a quarterly basis, the participating entity shall transfer
to the department for deposit in the CEED Project Fund established
for the participating counties and pursuant to subparagraph (A), the
amount necessary to meet the nonfederal share of estimated payments
to the CEED project for the next quarter under subdivision (g)
Section 15910.3.
(A) The CEED Project Fund is hereby created in the State Treasury.
Notwithstanding Section 13340 of the Government Code, all moneys in
the fund shall be continuously appropriated to the department for the
purposes specified in this part. The fund shall contain all moneys
deposited into the fund in accordance with this paragraph.
(B) The department shall obtain the related federal financial
participation and pay the rates established under Section 15910.3,
provided that the intergovernmental transfer is transferred in
accordance with the deadlines imposed under the Medi-Cal Checkwrite
Schedule, no later than the next available warrant release date. This
payment shall be a nondiscretionary obligation of the department,
enforceable under a writ of mandate pursuant to Section 1085 of the
Code of Civil Procedure. Participating entities may request expedited
processing within seven business days of the transfer as made
available by the State Controllers Office, provided that the
participating entity prepay the department for the additional
administrative costs associated with the expedited processing.
(C) Total quarterly payment amounts shall be determined in
accordance with estimates of the number of enrollees in each rate
category, subject to annual reconciliation to final enrollment data.
(2) If a participating entity operates its CEED project through a
contract with another entity, the participating entity may pay the
operating entity based on the per enrollee rates established under
Section 15910.3 on a quarterly basis in accordance with estimates of
the number of enrollees in each rate category, subject to annual
reconciliation to final enrollment data.
(A) (i) On a quarterly basis, the participating entity shall
certify the expenditures made under this paragraph and submit the
report of certified public expenditures to the department.
(ii) The department shall report the certified public expenditures
of a participating entity under this paragraph on the next available
quarterly report as necessary to obtain federal financial
participation for the expenditures. The total amount of federal
financial participation associated with the participating entity's
expenditures under this paragraph shall be paid to the participating
entity.
(B) At the option of the participating entity, the CEED project
may be reimbursed on a cost basis in accordance with the methodology
applied to Health Care Coverage Initiative programs established under
Part 3.5 (commencing with Section 15900) including interim quarterly
payments.
(e) Notwithstanding Section 15910.3 and subdivision (d) of this
section, if the participating entity cannot reach an agreement with
the department as to the appropriate rate to be paid under Section
15910.3, at the option of the participating entity, the CEED project
shall be reimbursed on a cost basis in accordance with the
methodology applied to Health Care Coverage Initiative programs
established under Part 3.5 (commencing with Section 15900), including
interim quarterly payments. If the participating entity and the
department reach an agreement as to the appropriate rate, the rate
shall be applied no earlier than the first day of the CEED project
year in which the parties agree to the rate.
(f) If authorized under the terms and conditions of the
demonstration project, pending the department's development of rates
in accordance with Sections 15910.3, the department shall make
interim quarterly payments to approved CEED projects for expenditures
based on estimated costs submitted for rate setting.
(g) Participating entities that operate a CEED project directly or
through contract with another entity shall be entitled to any
federal financial participation available for administrative
expenditures incurred in the operation of the Medi-Cal program or the
demonstration project, including, but not limited to, outreach,
screening and enrollment, program development, data collection,
reporting and quality monitoring, and contract administration, but
only to the extent that the expenditures are allowable under federal
law and only to the extent the expenditures are not taken into
account in the determination of the per enrollee rates under Section
15910.3.
(h) On and after January 1, 2014, the state shall implement
comprehensive health care reform for the populations targeted by the
CEED in compliance with federal health care reform law, regulation,
and policy, including 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
subsequent amendments.
(i) Participation in the CEED projects under this article is
voluntary on the part of the county or counties for purposes of all
applicable federal laws. As part of its voluntary participation under
this article, the county or counties shall agree to reimburse the
state for the nonfederal share of state staffing or administrative
costs directly attributable to the cost of administering that county
or counties' CEED project. This section shall be implemented only to
the extent federal financial participation is not jeopardized.

15912. (a) Subject to the terms and conditions of the demonstration
project, the department shall ensure that the CEED projects
established under this part are evaluated to determine to what extent
the projects have met the standards and performance measures
described in paragraph (9) of subdivision (b) of Section 15910.2, and
the extent to which the CEED projects have complied with the
department's program to implement the transition of eligible CEED
project enrollees to Medi-Cal coverage, or alternatively, to coverage
through the California Health Benefit Exchange, in 2014.
(b) The department may seek federal or private funds or enter into
partnership with an independent, nonprofit group or foundation, an
academic institution, or a governmental entity providing grants for
health-related activities, to evaluate the programs funded under this
part.

15913. 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 part, and
the terms and conditions of the demonstration project secured
pursuant to subdivision (a) of Section 15910, by means of all-county
letters, plan letters, plan or provider bulletins, or similar
instructions. 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.

15914. The application process used by the department to authorize
entities to operate CEED projects and any agreements entered into by,
or modified by, the department for purposes of this part shall not
be subject to Part 2 (commencing with Section 10100) of Division 2 of
the Public Contract Code.

15915. In the event of a conflict between a provision of this part
and a term or condition of the successor federal waiver or
demonstration project pursuant to subdivision (a) of Section 15910,
the terms and conditions of the successor federal waiver or
demonstration project shall control.