AGING AND LONG-TERM CARE
SB 397 (Escutia) – Elder Death Review Team
Requires notification to be made as soon as possible, but no later than 24 hours, after the death of the resident in a skilled nursing facility.
Requires the notification to be made on a form, created by the Elder Death Review Team, and include the resident’s name, gender, date of birth, date and location of the resident’s death, whether there was a do not resuscitate order or advanced directive in place for the patient, and whether the elder was receiving hospice care.
Requires the State Department of Health Services and Department of Social Services to monitor compliance with this bill.
Status: Provisions Removed from Version Heard in Committee
SB 571 (Perata) – Adult Day Health Care Services: Certification
Requires an applicant for certification of an Adult Day Health Care (ADHC) center to attend an orientation provided by the California Department of Aging (CDA) and to submit documentation of the need for the facility and other information, including a program plan, policies and procedures, a marketing plan, and a budget.
Allows CDA, prior to approving or denying the application, to conduct a face-to-face interview with the applicant.
Requires CDA to examine the applicant’s ability to comply with licensing and certification requirements governing ADHC centers, ability to provide services in its program plan, and other factors, as specified.
Allows CDA to give priority to an application for certification based on demonstrated need, the applicant is in a rural county, or other factors as specified.
Status: Died in the Senate Appropriations Committee
SB 1248 (Alquist) – Long-Term Health Care Facilities: Resident Rights
Extends the rights of nursing home and intermediate care facility residents guaranteed by the Medicare and Medi-Cal (Medicaid) programs to all other nursing home and intermediate care facility residents.
Exempts a noncertified facility from the obligation to provide notice of Medicaid or Medicare benefits, covered services, or eligibility procedures.
Status: Chapter 530, Statutes of 2006
SB 1312 (Alquist) – Health Care Facilities
Deletes from existing law an exemption from periodic inspections for acute psychiatric hospitals, skilled nursing facilities, intermediate care facilities, congregate living facilities, correctional treatment centers and nursing facilities that are deemed to meet standards for certification to participate in Medicare, Medicaid, or both programs, as specified.
Requires inspections and investigations of long-term health care facilities that are certified by the Medicare or Medicaid programs to determine compliance with federal standards and California statutes and regulations.
Requires the Department of Health Services (DHS) to identify all state law standards for the staffing and operation of long-term health care facilities in order to ensure maximum effectiveness of inspections. Permits initial license and renewal fees for long-term health care facilities to be increased, as specified, in order to recover any additional costs incurred by DHS as a result of this requirement.
Makes other technical and clarifying changes, including clarifying changes to recent law regarding the creation in the State Treasury of the DHS, Licensing and Certification Program Fund.
Authorizes DHS to assess an administrative penalty on specified hospitals in an amount not to exceed $25,000 per violation if a licensee receives a notice of deficiency constituting an immediate jeopardy to the health or safety of a patient and is required to submit a plan of correction.
Defines immediate jeopardy as a situation in which the licensee’s noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury, harm, impairment, or death to the patient.
Requires above to apply only to incidents occurring on or after January 1, 2007, and requires it only to be operative until regulations adopted pursuant to below are in effect in accordance with the Administrative Procedures Act.
Authorizes the DHS Director to assess an administrative penalty in an amount not to exceed $50,000 per violation against a hospital licensee for a violation of licensing law or rules or regulations promulgated there under.
Requires DHS to promulgate regulations establishing the criteria to assess an administrative penalty against a hospital, as specified. Requires the criteria to include, but need not be limited to, the following:
· The patient’s physical and mental condition.
· The probability and severity of the risk that the violation presents to the patient.
· The actual financial harm to patients, if any.
· The nature, scope, and severity of the violation.
· The facility’s history of compliance with related state and federal statutes and regulations.
· Factors beyond the facility’s control that restrict the facility’s ability to comply with licensing laws or rules and regulations promulgated there under.
· The demonstrated willfulness of the violation.
· The extent to which the facility detected the violation and took steps to immediately correct the violation and prevent the violation from recurring.
Requires the regulations to apply only to incidents occurring on or after the effective date of the regulations.
Authorizes a hospital licensee to request a hearing, as specified, if the licensee disputes a determination by DHS regarding the reasonableness of the proposed deadline for correction or the amount of the penalty within 10 working days. Requires penalties to be paid when all appeals have been exhausted and DHS’ position has been upheld.
Requires moneys collected by DHS as a result of administrative penalties imposed under above to be deposited into the Licensing and Certification Fund, as specified. Requires these moneys to be tracked and available for expenditure, upon appropriation by the Legislature, to support internal departmental quality improvement activities.
Status: Chapter 895, Statutes of 2006
SB 1755 (Chesbro) – Medi-Cal: Adult Day Health Care Services
Establishes new eligibility criteria for Adult Day Health Care Center (ADHC) services, thereby limiting participation in ADHC, for purposes of Medi-Cal reimbursement, to Medi-Cal recipients who meet all of the following criteria:
· The person is 18 years of age or older with one or more chronic, or postacute medical, cognitive, or mental health conditions, and a physician, nurse practitioner or other health care provider requested ADHC for that person.
· The person has functional impairments in two or more activities of daily living, instrumental activities of daily living, or a combination of both, and requires assistance or supervision in performing these activities.
· The person requires ongoing or intermittent protective supervision, skilled observation, assessment, or intervention by a skilled health or mental health professional to improve, stabilize, maintain or minimize deterioration of the medical, cognitive, or mental health condition.
· The person requires ADHC services, as defined, that are individualized and planned, including, when necessary, the coordination of formal and informal services outside of ADHC, to support the individual and his or her family or caregiver in the living arrangement of his or her choice and to avoid or delay the use of institutional services, including, but not limited to hospital emergency department services, inpatient acute care hospital services, inpatient mental health services, or placement in a nursing facility or an intermediate care facility for the developmentally disabled (ICF-DD). Specifies that notwithstanding the criteria outlined above, any person who is a resident of an ICF-DD Habilitative shall be eligible for ADHC if specified alternative conditions are met.
Establishes specific requirements for Medi-Cal treatment authorization requests for ADHC centers, including requiring authorization to be granted only if specified medical necessity criteria are met.
Requires the Department of Health Services to establish, by August 1, 2010, a reimbursement methodology for ADHC in Medi-Cal, based on reasonable costs, and a reimbursement limit for ADHC services, on a prospective cost basis for services that are provided to each participant, pursuant to his or her individual plan of care. Establishes daily core services and separately billable services.
Requires ADHC centers to offer and provide directly on premises, in accordance with each participant’s plan of care, and subject to prior authorization by the Medi-Cal program, specified core services, as defined, to each participant during each day of the participant’s attendance at the center.
Authorizes, but does not require, ADHC centers to provide one or more of the core services above, at an enhanced level, if specific conditions occur, as defined, generally unexpected conditions, events, symptoms or groups of symptoms requiring additional intervention or assistance by ADHC personnel, whether the intervention is on an individual or group basis.
Status: Chapter 691, Statutes of 2006
AB 10 (Daucher) – Appropriate Facility Placement Standards
Requires the State Department of Health Services (DHS) to select three voluntary pilot programs that utilize a documentation tool, if available, to be allowed to charge a fee for long-term care navigation services. Requires that the fee would be voluntary and would be charged to non-Medi-Cal seniors and persons with disabilities 18 years of age or older who are at risk for nursing home placement and who would like long-term care navigation services.
Declares that, upon appropriation by the Legislature, the fee revenue would serve as matching federal targeted case management dollars to provide funding for Medi-Cal eligible seniors and persons with disabilities at risk of nursing home placement to receive the same long-term care navigation services as persons who utilize the private pay method.
Requires DHS, 24 months after commencement of the pilot programs, to evaluate the pilot programs, and submit this evaluation to the appropriate legislative committees.
Requires DHS to seek a federal waiver, to be drafted by a third party approved by DHS. Provides that it would be implemented only if the federal waiver is approved and DHS determines that implementation of the pilot programs is cost-neutral.
Status: Died in the Senate Appropriations Committee
AB 132 (Nunez, et al.) – Medi-Cal: Prescription Drug Benefit
Requires the Department of Health Services (DHS), beginning on and retroactive to January 12, 2006, and concluding 15 calendar days later, to provide drug benefits to dual eligibles, to the extent that funds are appropriated for this purpose, when one or more of the following conditions are met:
· The pharmacy submits a claim to the beneficiary’s Medicare Drug Plan (Plan) and the claim is denied payment for reasons other than processing errors or omissions made by the pharmacy, lack of medical necessity, or health and safety reasons.
· The pharmacy is unable to submit a claim solely due to incomplete or inaccurate enrollment information from the plan, the federal Centers for Medicare and Medicaid Services (CMS), or entities under contract with CMS to provide enrollment information.
· The plan provides information that the deductible or copayment amount is higher than the $1 to $5 copayment amounts that are established by Medicare for full-benefit duals. In this case DHS shall pay the Medi-Cal rate less the plan reimbursement amount and the Medicare copayment amount.
Requires that, to obtain reimbursement from DHS, a pharmacy be an enrolled provider in the Medi-Cal program and certify on its claims under penalty of perjury that one of the conditions specified above exists.
Permits the director of DHS to impose a pre- or post-service prepayment or postpayment review or audit to determine whether a pharmacy has accurately and in good faith established the existence of any conditions certified by the pharmacy as outlined above in support of a submitted claim to DHS.
Requires DHS to seek reimbursement from the federal government of all funds spent to comply with these related provisions.
States that to the extent that DHS reimburses a pharmacy for claims authorized under these provisions, the director shall have the right to recover or recoup the full cost expended by the state for that reimbursement from the dual eligible beneficiary’s plan.
Limits reimbursement for claims to those drug benefits provided to a dual eligible beginning on January 12, 2006 and concluding 15 calendar days later.
Permits the Governor to extend coverage for these drug benefits from the close of the initial 15-day period for up to an additional 15-calendar day period upon notice to the Joint Legislative Budget Committee.
Appropriates $150 million from the General Fund for the purposes of this bill, with $22.5 million to backfill an amount expended under an account for which the Governor’s original executive action for this subject drew funds.
Status: Chapter 2, Statutes of 2006
AB 813 (Nunez) – Medi-Cal: Emergency Drug Benefits
Requires the Department of Health Services (DHS), beginning on May 17, 2006, and ending January 31, 2007, to provide emergency drug benefits to dual eligibles when one or more of the following conditions are met:
· The pharmacy submits a claim for the provision of drug benefits to the beneficiary’s plan and the claim is denied payment due to error by the Medicare program, and the pharmacy has made a good faith effort to resolve the error with the plan and Medicare.
· The pharmacy is unable to submit a claim solely due to incomplete or inaccurate plan enrollment information from the beneficiary’s Medicare drug plan, the federal Center for Medicare and Medicaid Services (CMS), or entities under contract with CMS to provide enrollment information, and the pharmacy has attempted to resolve these problems with the Medicare facilitated enrollment contractor and the plan, where appropriate.
· The Medicare drug plan provides information that the deductible or copayment amount is higher than the $1 to $5 copayment amounts that are established by Medicare for dual eligibles. Requires DHS, in this case, to pay only the difference between the copayment amount established by Medicare for dual eligible beneficiaries and the actual copayment amount charged.
· The benefit requires that a request for prior authorization or exception be made to the beneficiary’s plan and was sought by the pharmacist, but the pharmacy does not receive a response within 24 hours for an emergency drug or within 72 hours for a nonemergency drug. Requires that a pharmacy show proof of the submission of the request that was made to either the plan or the beneficiary’s prescribing physician when submitting a claim to DHS. Effective September 1, 2006, coverage under this provision will only occur if authorization has been sought by the beneficiary’s physician.
Requires DHS, in providing these benefits, to implement prepayment utilization controls, including prior authorization, and permits DHS to implement postpayment reviews or audits to determine whether a pharmacy has accurately and in good faith established the existence of any condition certified by the pharmacy pursuant to above in support of a submitted claim.