Bill Text: CA SB117 | 2009-2010 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Adult day health care services: eligibility criteria:
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2009-10-11 - Chaptered by Secretary of State. Chapter 165, Statutes of 2009. [SB117 Detail]
Download: California-2009-SB117-Amended.html
Bill Title: Adult day health care services: eligibility criteria:
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Passed) 2009-10-11 - Chaptered by Secretary of State. Chapter 165, Statutes of 2009. [SB117 Detail]
Download: California-2009-SB117-Amended.html
BILL NUMBER: SB 117 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 1, 2009
AMENDED IN SENATE MARCH 9, 2009
INTRODUCED BY Senator Corbett
(Principal coauthor: Assembly Member Chesbro)
FEBRUARY 2, 2009
An act to amend Section 1570.7 of the Health and Safety Code, and
to amend Section 14571.2 of the Welfare and Institutions Code,
relating to adult day health care.
LEGISLATIVE COUNSEL'S DIGEST
SB 117, as amended, Corbett. Adult day health care services:
Medi-Cal reimbursement methodology and limit.
The California Adult Day Health Care Act provides for the
licensure and regulation of adult day health centers, with
administrative responsibility for the program shared among the State
Department of Public Health, the State Department of Health Care
Services, and the California Department of Aging pursuant to an
interagency agreement.
The act defines core staff for purposes of the act to include,
among others, a social worker, as defined.
This bill would replace the term social worker with social
services director.
Existing law establishes the Medi-Cal program, administered by the
State Department of Health Care Services, under which basic health
care services are provided to qualified low-income persons.
The Adult Day Health Medi-Cal Law establishes adult day health
care services as a Medi-Cal benefit for Medi-Cal beneficiaries who
meet certain criteria. Under existing law, participation in an adult
day health care program requires prior authorization by the State
Department of Health Care Services.
Existing law requires the department, effective August 1, 2010, to
establish a reimbursement methodology and a reimbursement limit for
adult day health care services on a prospective cost basis for
services that are provided to each participant, pursuant to his or
her individual plan of care, as specified. Existing law requires that
these provisions be implemented only to the extent that federal
financial participation is available.
This bill would, instead, provide that the requirement that the
department establish a reimbursement methodology and reimbursement
limit be effective August 1, 2013 2011 ,
and would make other conforming changes.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1570.7 of the Health and Safety Code is amended
to read:
1570.7. As used in this chapter and in any regulations
promulgated thereunder:
(a) "Adult day health care" means an organized day program of
therapeutic, social, and skilled nursing health activities and
services provided pursuant to this chapter to elderly persons or
adults with disabilities with functional impairments, either physical
or mental, for the purpose of restoring or maintaining optimal
capacity for self-care. Provided on a short-term basis, adult day
health care serves as a transition from a health facility or home
health program to personal independence. Provided on a long-term
basis, it serves as an alternative to institutionalization in a
long-term health care facility when 24-hour skilled nursing care is
not medically necessary or viewed as desirable by the recipient or
his or her family.
(b) "Adult day health center" or "adult day health care center"
means a licensed and certified facility that provides adult day
health care.
(c) "Core staff" includes the positions of program director,
registered nurse, social services director, activity director, and
program aide.
(d) "Department" or "state department" means the State Department
of Public Health.
(e) "Director" means the State Public Health Officer.
(f) "Elderly" or "older person" means a person 55 years of age or
older, but also includes other adults who are chronically ill or
impaired and who would benefit from adult day health care.
(g) "Extended hours" means those hours of operation prior to or
following the adult day health care program hours of service, as
designated by the adult day health care center in its plan of
operation, during which the adult day health care center may operate
an adult day program, or an Alzheimer's day care resource center, or
both.
(h) "Hours of service" means the program hours defined and posted
by the adult day health care center for the provision of adult day
health care services, pursuant to Section 14550 of the Welfare and
Institutions Code, which shall be no less than four hours, excluding
transportation.
(i) "Individual plan of care" means a plan designed to provide
recipients of adult day health care with appropriate treatment in
accordance with the assessed needs of each individual.
(j) "License" means a basic permit to operate an adult day health
care center. With respect to a health facility licensed pursuant to
Chapter 2 (commencing with Section 1250), "license" means a special
permit, as defined by Section 1251.5, empowering the health facility
to provide adult day health care services.
(k) "Long-term absence" or "long-term vacancy" means an absence or
vacancy lasting, or likely to last, more than one month. An adult
day health care center's policies and procedures shall be specific
regarding coverage in the situation for long-term absences or
vacancies.
(l) "Maintenance program" means procedures and exercises that are
provided to a participant, pursuant to Section 1580, in order to
generally maintain existing function. These procedures and exercises
are planned by a licensed or certified therapist and are provided by
a person who has been trained by a licensed or certified therapist
and who is directly supervised by a nurse or by a licensed or
certified therapist.
(m) "Program director" shall be a person with both of the
following:
(1) One of the following backgrounds:
(A) A person with a bachelor's degree and a minimum of two years
of experience in a management, supervisory, or administrative
position.
(B) A person with a master's degree and a minimum of one year of
experience in a management, supervisory, or administrative position.
(C) A registered nurse with a minimum of two years experience in a
management, supervisory, or administrative position.
(2) Appropriate skills, knowledge, and abilities related to the
health, and mental, cognitive, and social needs of the participant
group being served by the adult day health center.
(n) "Restorative therapy" means physical, occupational, and speech
therapy, and psychiatric and psychological services that are planned
and provided by a licensed or certified therapist. The therapy and
services may also be provided by an assistant or aide under the
appropriate supervision of a licensed therapist, as determined by the
licensed therapist. The therapy and services are provided to restore
function, when there is an expectation that the condition will
improve significantly in a reasonable period of time, as determined
by the multidisciplinary assessment team.
(o) "Short-term absence" or "short-term vacancy" means an absence
or vacancy lasting one month or less, and includes sick leave and
vacations. An adult day health care center shall ensure that
appropriate staff is designated to serve in these positions during
the short-term absence or vacancy and that the center's policies and
procedures are specific regarding coverage of short-term absences or
vacancies.
(p) "Social services director" shall be a person who meets one of
the following:
(1) The person holds a master's degree in social work from an
accredited school of social work.
(2) The person holds a master's degree in psychology, gerontology,
or counseling from an accredited school and has one year of
experience providing social services in one or more of the fields of
aging, health, or long-term care services.
(3) The person is licensed by the Board of Behavioral Sciences.
(4) The person holds a bachelor's degree in social work from an
accredited school with two years of experience providing social
services in one or more of the fields of aging, health, or long-term
care services.
SEC. 2. Section 14571.2 of the Welfare and Institutions Code is
amended to read:
14571.2. (a) Subject to the provisions of this section, the
department shall establish, effective August 1, 2013
2011 , a reimbursement methodology and a
reimbursement limit for adult day health care services on a
prospective cost basis for services that are provided to each
participant, pursuant to his or her individual plan of care. The
prospective reimbursement methodology shall be determined by the
department after consultation with the California Association for
Adult Day Services and other interested stakeholders.
(b) The following definitions shall apply for purposes of this
section:
(1) "Daily core services" means the services described in Section
14550.5.
(2) "Separately billable services" means services designated by
the department, after consultation with the California Association
for Adult Day Services, and shall include, but not be limited to, the
following:
(A) Physical therapy services.
(B) Occupational therapy services.
(C) Speech and language pathology services.
(D) Mental health services.
(E) Registered dietician services.
(F) Transportation services.
(c) The prospective reimbursement methodology for the daily core
services provided by each adult day health care center shall be
determined by the department based on the reasonable cost of
providing all of the adult day health care services included within
the core services and adjusted to the particular rate year. Services
and costs included in the calculation of the daily core services rate
shall include, but not be limited to, all of the following:
(1) Fixed or capital-related costs representing depreciation,
leases and rentals, interest, leasehold improvements, and other
amortization.
(2) Labor costs other than those for the separately billable
services, including direct and indirect labor and contracted staff
hours required by law or regulation.
(3) All other costs exclusive of fixed or capital-related costs,
leases or rentals, interest, leasehold improvements, and other
amortization.
(4) Add-ons, adjustments, and audit adjustments determined
annually in the calculation of the core rate to allow for changes
specified in subdivision (h), until those changes are reflected in
the cost report.
(5) Cost components required to comply with licensing and
certification laws and regulations.
(d) (1) The daily reimbursement rates for the separately billable
services shall be determined based upon the reasonable cost of
providing each service, how each of the individual billable services
is defined, and which professional is providing the service, subject
to the scope of his or her license. These reimbursement rates shall
not exceed the Medi-Cal rates for the same service on file at the
time the service is rendered.
(2) In establishing the total reimbursement limit, direct patient
care labor costs may be paid at a specified discrete percentile to
ensure maintenance of quality of care.
(e) The department shall determine a reimbursement limit
applicable to each adult day health center peer group established
pursuant to subdivision (m), taking into account total overall
average costs per day of attendance for providing the entire array of
adult day health care services, including the daily core services
and the separately billable services. The department shall determine
a reimbursement limit applicable to each adult day health care center
peer group established pursuant to subdivision (m) based on cost
containment principles applied to other acute care and long-term care
providers.
(f) By July 1, 2010, the department shall develop, after
consultation with the California Association for Adult Day Services,
all of the following:
(1) An adult day health care center cost report meeting the
requirements of subdivision (j) and a list of individual components
to be included in the core rate calculation.
(2) The methodology and documentation necessary to establish the
reimbursement rate for the separately billable services.
(3) The reimbursement rates for transportation services. Payments
for transportation services shall be subject to the limit on the
daily reimbursement and shall be reimbursed whether the center
provides transportation directly, by use of contracted
transportation, or both. The department shall review methodologies
for payment for transportation services. The review of payment
methodologies shall include a survey of other states' adult day
health care transportation systems, and transportation reports or
expert consultation relevant to nonemergency medical transportation
services in the community.
(g) (1) By January 1, 2011, the department shall facilitate the
training of providers in collaboration with the California
Association for Adult Day Services. The adult day health care centers
shall be trained in the all of the following elements:
(A) The use of the modified cost report, supplemental reports, and
the accounting and reporting manual.
(B) Plan of care documentation required to support the separately
billable rate components.
(C) Medical necessity and eligibility requirements and
documentation.
(2) By January 1, 2011, the department, after consultation with
the California Association for Adult Day Services, shall establish
facility peer groupings as specified in subdivision (m).
(h) By July 1, 2011, the department, after consultation with the
California Association for Adult Day Services, shall establish a
methodology for calculation of the reimbursement limit, rates for the
daily core services, and applicable percentiles limiting specific
cost categories within the core rate.
(i) (1) By March 30, 2013 2011 , a
preliminary estimate of the reimbursement limit, the reimbursement
rate for individual adult health care services, and separately
billable services shall be established and provided to the California
Association for Adult Day Services and other interested
stakeholders. The department shall allow an appropriate stakeholder
comment period following this action.
(2) The information supplied to all interested stakeholders in
paragraph (1) shall be compared to what would have been paid under
the rate methodology in effect for the 2012-13
2010-11 fiscal year.
(3) Based on the rate comparisons, a methodology to provide for a
multiyear phase in of the new prospective payment may be implemented.
(4) At the time of implementation, no adult day health care center'
s payment shall be decreased by more than 10 percent below the rate
paid in the rate year immediately preceding the first year that the
rate methodology prescribed in this section is implemented. In the
second and third rate years, no adult day health care center
reimbursement rate shall be decreased by more than 10 percent below
the adult day health care center's reimbursement rate on file at the
time of the application of the next year's reimbursement rate.
(j) (1) The department, with input from the California Association
for Adult Day Services and all interested stakeholders, shall
develop the cost reporting form and determine the costs that are to
be included and excluded from the annual cost reporting methodology.
(2) Cost reporting shall be consistent with Section 1861 of the
federal Social Security Act (42 U.S.C. Sec. 1395x) and Part 413 of
Title 42 of the Code of Federal Regulations.
(3) Cost reporting shall include itemization of the costs of all
adult day health care services such that information necessary to
determine costs associated with the core bundle of services and each
of the separately billable services can be collected.
(4) The cost report or supplemental report to the cost report, as
determined by the frequency the data will be required for calculation
of the core rate, shall collect staffing level and salary data for
all direct and indirect patient care staff, arranged through either
employment or contract.
(5) All adult day health care centers participating in the
Medi-Cal program shall maintain books and records according to
generally accepted accounting principles and the uniform accounting
systems adopted by the state, and shall submit annual cost reports
directly to the department.
(k) (1) The department may exclude any cost report or portion
thereof that it deems to be inaccurate, incomplete, or
unrepresentative, consistent with the policies established in
paragraph (2) of subdivision (j). For facilities that fail to file
cost reports with the department pursuant to this section, the
department shall reimburse those facilities at 10 percent below the
lowest reimbursement limit established in the facility's peer group
pursuant to subdivision (d).
(2) Cost report data shall be validated by using comparisons to
salary surveys and health industry administrative data maintained by
the Office of Statewide Health Planning and Development and other
state agencies. If cost report data is not statistically valid for a
given peer group, survey statistics shall be used as a proxy to
substitute for the cost report data.
(3) Cost report data for any adult day health care center that has
closed or is no longer a Medi-Cal participating facility shall be
excluded from the rate calculation.
(4) The specific process for maintaining cost data and submitting
cost reports shall be developed after consultation with the
California Association for Adult Day Services.
(l) Field audits shall be performed by the department in
accordance with all of the following laws and regulations:
(1) Section 1861 of the Social Security Act (42 U.S.C. Sec. 1395x)
and Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et
seq.).
(2) Sections 413.9, 433.32, and 483.10 of, Part 413 of, Title 42
of the Code of Federal Regulations.
(3) Centers for Medicare and Medicaid Services Publication 15-1
(federal Department of Health and Human Services Manual).
(4) Chapter 5 (commencing with Section 54001) of Division 3 of,
and Chapter 10 (commencing with Section 78001) of Division 5 of,
Title 22 of the California Code of Regulations.
(5) Sections 14170 and 14171.
(6) Relevant portions of the California Medicaid State Plan.
(m) (1) In accordance with field audit requirements, adult day
health care centers shall be placed in a minimum of three designated
peer groupings. Each adult day health care center in each of the
designated peer groupings shall be audited on an annual basis.
(2) If for any reason a field audit was not performed, the average
audit adjustment of the peer grouping shall be applied.
(3) The peer groupings shall include, at minimum, geographic
differences and size of facility. The need for additional groupings
shall be periodically reevaluated to ensure that the peer groupings
remain relevant on a statewide basis.
(4) The department shall analyze and evaluate the data obtained
through peer grouping analysis in order to determine if additional
peer groupings or data elements are necessary for refinement of the
peer groupings.
(5) After analyzing the data pursuant to paragraph (4), the
department may increase the number of peer groupings or change the
criteria to reflect pertinent factors affecting peer grouping costs.
(n) (1) An audit adjustment or adjustments, either specific to an
adult day health care center or by peer grouping, reflecting the
difference between reported and audited costs and participant days
for field audited centers, shall be applied to all adult day health
care centers for purposes of establishing the core services
reimbursement rate and the reimbursement limit for the following rate
year. Audit adjustments shall include all of the following:
(A) The results of settled appeals. The department shall consider
only the findings of audit appeal reports that are issued more than
180 days prior to the beginning of the new rate year.
(B) In the case of peer grouping audit adjustments, audited costs
shall be modified by a factor reflecting share-of-cost overpayments
and share-of-cost underpayments.
(C) The results of federal audits, when reported to the state,
shall be applied in determining audit adjustments.
(D) (i) An adjustment or adjustments to reported costs of adult
day health care centers shall be made to reflect changes in state or
federal laws and regulations that would affect those costs, including
increases in the minimum wage or increases in minimum staffing
requirements.
(ii) The costs described in clause (i) shall be reflected as an
add-on to the new rate or rates.
(iii) To the extent not prohibited by federal law or regulations,
add-ons to the rate or rates shall continue until those costs are
included in cost reports used to set the new rate or rates.
(2) Adjusted costs shall be divided into categories and treated as
follows:
(A) Fixed or capital-related costs shall include costs that
represent depreciation, leases and rentals, interest, leasehold
improvements, and other amortization. No update shall be applied.
(B) Property taxes, where identified, shall be updated at a rate
of 2 percent annually.
(C) Labor costs, which shall be defined as a ratio of salary,
wage, and benefits costs to the total costs of each adult day health
care center, shall be updated based upon the labor study conducted by
the department and using industry-specific wage data as reported by
the adult day health care centers. The separately billable services
shall be updated by applying the median market-based rate specific to
the specialty service category.
(D) All other costs shall include all other costs less fixed or
capital-related costs, property taxes, and labor costs. This cost
category shall be updated using the California Consumer Price Index.
(3) Prior to the implementation of this methodology, the
department shall take measures to ensure appropriate training of
state audit staff.
(o) The department shall provide updates on the rate methodology
to the appropriate fiscal and policy committees of the Legislature.
The appropriation for services paid under this rate methodology shall
be included in the annual Budget Act.
(p) Adult day health care centers may appeal findings that result
in an adjustment to the rate or rates pursuant to Section 14171 and
to Article 1.5 (commencing with Section 51016) of Chapter 3 of
Division 3 of Title 22 of the California Code of Regulations.
(q) (1) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code, the
department shall implement this section by means of a provider
bulletin or similar instruction without taking regulatory action. By
August 1, 2015 2014 , the department
shall adopt regulations in accordance with the requirements of
Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code.
(2) The department shall notify and consult with interested
stakeholders in implementing, interpreting, or making specific the
provisions described in this section.
(r) The department shall implement this section only to the extent
that federal financial participation is obtained.
(s) The department may file a state plan amendment to implement
the requirements of this section. Immediately upon filing any such
state plan amendment, the department shall provide the fiscal
committees of the Legislature with a copy of the state plan
amendment.
