CA Welf & Inst Code Section 14186.35

(a)

Not sooner than March 1, 2013, in-home supportive services (IHSS) shall be a Medi-Cal benefit available through managed care health plans in a county where this article is effective. Managed care health plans shall cover IHSS in accordance with the standards and requirements set forth in Article 7 (commencing with Section 12300) of Chapter 3. Specifically, managed care health plans shall do all of the following:

(1)

Ensure access to, provision of, and payment for IHSS for individuals who meet the eligibility criteria for IHSS.

(2)

Ensure recipients retain the right to be the employer, to select, engage, direct, supervise, schedule, and terminate IHSS providers in accordance with Section 12301.6.

(3)

Assume all financial liability for payment of IHSS services for recipients receiving said services pursuant to managed care.

(4)

Create a care coordination team, as needed, unless the consumer objects. If the consumer is an IHSS recipient, his or her participation and the participation of his or her provider shall be at the recipient’s option. The care coordination team shall include the consumer, his or her authorized representative, managed care health plan, county social services agency, Community Based Adult Services (CBAS) case manager for CBAS clients, Multipurpose Senior Services Program (MSSP) case manager for MSSP clients, and may include others as identified by the consumer.

(5)

Maintain the paramedical role and function of providers as authorized pursuant to Sections 12300 and 12301.

(6)

Ensure compliance with all requirements set forth in Section 14132.956 and any resulting state plan amendments.

(7)

Adhere to quality assurance provisions and individual data and other standards and requirements as specified by the State Department of Social Services including state and federal quality assurance requirements.

(8)

Share confidential beneficiary data with the contractors specified in this section to improve care coordination, promote shared understanding of the consumer’s needs, and ensure appropriate access to IHSS and other long-term services and supports.

(9)

(A)Enter into a memorandum of understanding with a county agency and the county’s public authority or nonprofit consortium pursuant to Section 12301.6 to continue to perform their respective functions and responsibilities pursuant to the existing ordinance or contract until the Director of Health Care Services provides notification pursuant to subdivision (a) of Section 12300.7 for that county.

(B)

Following the notification pursuant to subdivision (a) of Section 12300.7, enter into a memorandum of understanding with the county agencies to perform the following activities:

(i)

Assess, approve, and authorize each recipient’s initial and continuing need for services pursuant to Article 7 (commencing with Section 12300) of Chapter 3. County agency assessments shall be shared with the care coordination teams established under paragraph (4), when applicable, and the county agency thereafter may receive and consider additional input from the care coordination team.

(ii)

Plans may contract with counties for additional assessments for purposes of paragraph (6) of subdivision (b) of Section 14186. (iii)Enroll providers, conduct provider orientation, and retain enrollment documentation pursuant to Sections 12301.24 and 12305.81.

(iv)

Conduct criminal background checks on all potential providers and exclude providers consistent with the provisions set forth in Sections 12305.81, 12305.86, and 12305.87.

(v)

Provide assistance to IHSS recipients in finding eligible providers through the establishment of a provider registry as well as provide training for providers and recipients as set forth in Section 12301.6.

(vi)

Refer all providers to the California In-Home Supportive Services Authority or nonprofit consortium for the purposes of wages, benefits, and other terms and conditions of employment in accordance with subdivision (a) of Section 12300.7 and Title 23 (commencing with Section 110000) of the Government Code. (vii)Pursue overpayment recovery pursuant to Section 12305.83. (viii)Perform quality assurance activities including routine case reviews, home visits, and detecting and reporting suspected fraud pursuant to Section 12305.71.

(ix)

Share confidential data necessary to implement the provisions of this section.

(x)

Appoint an advisory committee of not more than 11 people, and no less than 50 percent of the membership of the advisory committee shall be individuals who are current or past users of personal assistance paid for through public or private funds or recipients of IHSS services.

(xi)

Continue to perform other functions necessary for the administration of the IHSS program pursuant to Article 7 (commencing with Section 12300) of Chapter 3 and regulations promulgated by the State Department of Social Services pursuant to that article.

(C)

A county may contract with an entity or may establish a public authority pursuant to Section 12301.6 for the performance of any or all of the activities set forth in a contract with a managed care health plan pursuant to this section.

(10)

Enter into a contract with the State Department of Social Services to perform the following activities:

(A)

Pay wages and benefits to IHSS providers in accordance with the wages and benefits negotiated pursuant to Title 23 (commencing with Section 110000) of the Government Code.

(B)

Perform obligations on behalf of the IHSS recipient as the employer of his or her provider, including unemployment compensation, disability benefits, applicable federal and state taxes, and federal old age survivor’s and disability insurance through the state’s payroll system for IHSS in accordance with Sections 12302.2 and 12317.

(C)

Provide technical assistance and support for all payroll-related activities involving the state’s payroll system for IHSS, including, but not limited to, the monthly restaurant allowance as set forth in Section 12303.7, the monthly cash payment in advance as set forth in Section 12304, and the direct deposit program as set forth in Section 12304.4.

(D)

Share recipient and provider data with managed care health plans for members who are receiving IHSS to support care coordination.

(E)

Provide an option for managed care health plans to participate in quality monitoring activities conducted by the State Department of Social Services pursuant to subdivision (f) of Section 12305.7 for recipients who are plan members.

(11)

In concert with the department, timely reimburse the state for payroll and other obligations of the beneficiary as the employer, including unemployment compensation, disability benefits, applicable federal and state taxes, and federal old age survivors and disability insurance benefits through the state’s payroll system.

(12)

In a county where services are provided in the homemaker mode, enter into a contract with the county to implement the provision of services pursuant to the homemaker mode as set forth in Section 12302.

(13)

Retain the IHSS individual provider mode as a choice available to beneficiaries in all participating managed care health plans in each county.

(14)

In a county where services are provided pursuant to a contract, and as needed, enter into a contract with a city, county, or city and county agency, a local health district, a voluntary nonprofit agency, or a proprietary agency as set forth in Section 12302 and in accordance with Section 12302.6.

(15)

Assume the financial risk associated with the cost of payroll and associated activities set forth in paragraph (10).

(b)

IHSS recipients receiving services through managed care health plans shall retain all of the following:

(1)

The responsibilities as the employer of the IHSS provider for the purposes of hiring, firing, and supervising their provider of choice as set forth in Section 12301.6.

(2)

The ability to appeal any action relating to his or her application for or receipt of services pursuant to Article 7 (commencing with Section 12300) of Chapter 3.

(3)

The right to employ a provider applicant who has been convicted of an offense specified in Section 12305.87 by submitting a waiver of the exclusion.

(4)

The ability to request a reassessment pursuant to Section 12301.1.

(c)

The department and the State Department of Social Services, along with the counties, managed care health plans, consumers, advocates, and other stakeholders, shall develop a referral process and informational materials for the appeals process that is applicable to home- and community-based services plan benefits authorized by a managed care health plan. The process established by this paragraph shall ensure ease of access for consumers.

(d)

For services provided through managed care health plans, the IHSS provider shall continue to adhere to the requirements set forth in subdivision (b) of Section 12301.24, subdivision (a) of Section 12301.25, subdivision (a) of Section 12305.81, and subdivision (a) of Section 12306.5.

(e)

In accordance with Section 14186.2, as the provision of IHSS transitions to managed care health plans in a phased-in approach, the State Department of Social Services shall do all of the following:

(1)

Retain program administration functions, in coordination with the department, including policy development, provider appeals and general exceptions, and quality assurance and program integrity for the IHSS program in accordance with Article 7 (commencing with Section 12300) of Chapter 3.

(2)

Perform the obligations on behalf of the recipient as employer relating to workers’ compensation as set forth in Section 12302.2 and Section 12302.21 for those entities that have entered into a contract with a managed care health plan pursuant to Section 12302.6.

(3)

Retain responsibilities related to the hearing process for IHSS recipient appeals as set forth in Chapter 7 (commencing with Section 10950) of Part 2.

(4)

Continue to have access to and provide confidential recipient data necessary for the administration of the program.

(f)

A managed care health plan shall not be deemed be the employer of an individual in-home supportive services provider referred to recipients under this section for purposes of liability due to the negligence or intentional torts of the individual provider.