(a) The eligible entity shall meet both of the following requirements and any additional requirements imposed by the Special Terms and Conditions of the demonstration project in order for the department to authorize the LIHP proposed by the eligible entity:
(1) The eligible entity shall voluntarily agree to commit, on an annual basis, to provide the nonfederal share of LIHP expenditures for health care services to eligible individuals for the LIHP.
(2) The LIHP proposed by the eligible entity shall include the LIHP elements set forth in subdivision (b).
(b) The LIHP elements shall include all of the following, subject to the Special Terms and Conditions of the demonstration project:
(1) Development of standardized eligibility and enrollment procedures that interface with Medi-Cal processes by December 31, 2013, according to the milestones developed in consultation with the counties, county health departments, public hospitals, and county human service departments. LIHPs shall migrate to the standardized procedures in accordance with the Special Terms and Conditions of the demonstration project and subdivision (c) of Section 15910.
(2) Eligibility for LIHP 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, LIHP coverage for the retroactive period shall be limited to those services provided within the approved LIHP network or out-of-network emergency services as authorized under the Special Terms and Conditions of the demonstration project.
(3) The LIHP shall perform annual eligibility redeterminations for persons participating in the LIHP to assess if they remain eligible for the LIHP or are eligible for Medi-Cal or the Healthy Families Program.
(4) (A) Assignment of eligible individuals to a medical home. For purposes of this paragraph and subject to the Special 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 enrollees across the service delivery system, as agreed to between the medical home and the LIHP. 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 LIHP.
(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 Special 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.
(5) A minimum set of core benefits or services required under the Special Terms and Conditions of the demonstration project that shall be limited to those services provided within an approved LIHP provider network and service delivery system as required under the Special Terms and Conditions of the demonstration project.
(6) 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 LIHP. The provider network and service delivery system shall meet the standards established in the Special Terms and Conditions of the demonstration project.
(7) 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.
(8) A quality measurement and quality monitoring system.
(9) Data tracking systems to provide the department with required data for quality monitoring, quality improvement, and evaluation.
(10) Demonstration of how the LIHP will provide consumer assistance to individuals applying for, participating in, or accessing, services in the LIHP, 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 LIHP network.
(E) The medical homes within the LIHP network from which the enrollee may select.
(F) The LIHP telephone number or numbers that may be used by an enrollee to receive additional information about the covered services or participating providers.
(11) Ability to meet program requirements, standards, and performance measurements developed by the department, in consultation with participating entities for the LIHP.
(Amended by Stats. 2011, Ch. 86, Sec. 28. (AB 1066) Effective July 15, 2011.)