(a) If the department creates a Health Home Program pursuant to this article, the department shall determine whether a health home state plan amendment that targets adults is operationally viable.
(b) (1) In determining whether a health home state plan amendment that targets adults is operationally viable, the department shall consider whether a state plan amendment and any necessary Section 1115 waiver amendments could be designed in a manner that minimizes the impact on the General Fund, whether the department has the capacity to administer the health home state plan amendment through the state, a contracting entity, a county, or regional approach, and whether a sufficient provider network exists for providing health home services to populations the department intends to target, including the populations described in subdivision (c).
(2) If the department determines that a health home state plan amendment that targets adults is operationally viable pursuant to paragraph (1), then the department shall design a state plan amendment and any necessary Section 1115 waiver amendments to target and provide health home services to beneficiaries who meet the criteria specified in subdivision (c).
(3) (A) If the department determines a health home state plan amendment that targets adults is not operationally viable, then the department shall inform the appropriate policy and fiscal committees of the Legislature, within 120 days of that determination, of the reasons the program is not operationally viable as described in paragraph (1), and about current efforts underway by the department that help to address health care issues experienced by homeless Medi-Cal beneficiaries.
(B) The requirement for informing the appropriate policy and fiscal committees of the Legislature under subparagraph (A) is inoperative four years after the date the report is due, pursuant to Section 10231.5 of the Government Code.
(c) A state plan amendment and any necessary Section 1115 waiver amendments submitted pursuant to this section shall target adult beneficiaries who meet both of the following criteria:
(1) Have current diagnoses of chronic, physical health, mental health, or substance use disorders prevalent among frequent hospital users.
(2) Have a level of severity in conditions established by the department, based on one or more of the following factors:
(A) Frequent inpatient hospital admissions, including hospitalization for medical, psychiatric, or substance use related conditions.
(B) Excessive use of crisis or emergency services.
(C) Chronic homelessness.
(d) (1) For the purposes of providing health home services to the population identified in subdivision (c), the department shall select health home providers or providers who plan to subcontract with health home team members with all of the following:
(A) Demonstrated experience working with frequent hospital or emergency department users.
(B) Demonstrated experience working with people who are chronically homeless.
(C) The capacity and administrative infrastructure to participate in the Health Home Program, including the ability to meet requirements of federal guidelines.
(D) A viable plan, with roles identified among providers of the health home, to do all of the following:
(i) Reach out to and engage frequent hospital or emergency department users and chronically homeless eligible individuals.
(ii) Link eligible individuals who are homeless or experiencing housing instability to permanent housing, such as supportive housing.
(iii) Ensure coordination and linkages to services needed to access and maintain health stability, including medical, mental health, and substance use care, as well as social services and supports to address social determinants of health.
(2) The department may design additional provider criteria to those identified in paragraph (1) after consultation with stakeholder groups who have expertise in engagement and services for the population identified in subdivision (c).
(3) The department may authorize health home providers eligible under this subdivision to serve Medi-Cal enrollees through a fee-for-service or managed care delivery system that may include supplemental payments, and may allow for county-operated and other public and private providers to participate in this program.
(4) If the department designs a state plan amendment designed to serve the population identified in subdivision (c), the department shall design strategies to outreach to, engage, and provide health home services to the population identified in subdivision (c), based on consultation with stakeholders who have expertise in engaging, providing services to, and designing programs addressing the needs of, the population.
(5) If the department creates a health home program that targets adults described in subdivision (c), the department may also submit state plan amendments and any necessary waiver amendments targeting other adult populations.
(Added by Stats. 2013, Ch. 642, Sec. 2. (AB 361) Effective January 1, 2014.)