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CALIFORNIA LEGISLATURE— 2025–2026 REGULAR SESSION

94

Introduced by Assembly Member Addis

February 20, 2026

An act to amend Sections 14094.7, 14094.17, and 14094.18 of the Welfare and Institutions Code, relating to Medi-Cal.

Vote: majority   Appropriation: no   Fiscal committee: yes   Local program: no

LEGISLATIVE COUNSEL’S DIGEST

Existing law establishes the California Children’s Services (CCS) program, which is administered by the State Department of Health Care Services and counties, to provide medically necessary services, based on financial eligibility, for persons under 21 years of age who have certain medical conditions, including, among others, cystic fibrosis or hemophilia.

Existing law provides for the Medi-Cal program, which is administered by the department, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.

Existing law authorizes the department to establish a Whole Child Model program, under which managed care plans served by a county organized health system or Regional Health Authority in designated counties provide CCS treatment services to Medi-Cal eligible CCS children and youth. In implementing the program, existing law requires the department to, among other things, establish a statewide Whole Child Model program stakeholder advisory group and to consult with that advisory group on the implementation of the Whole Child Model program, as specified. Existing law terminates the advisory group on December 31, 2026.

This bill would rename the statewide Whole Child Model program stakeholder advisory group to the California Children’s Services (CCS) advisory group. The bill would require the advisory group to additionally be composed of have specified membership, including no more than 6 representatives of CCS clients not enrolled in a managed care plan, plan or enrolled in a managed care plan, but not on a family advisory committee, former CCS clients, and caregivers of former CCS clients, among others. The bill would also require the department to consult with the advisory group on the implementation of the CCS Classic program and to consider the recommendations of the advisory group in developing monitoring processes and outcome measures for the CCS program. Beginning no later than December 31, 2027, the The bill would require the department to biennially deliver a summary report to the Legislature that briefly describes publish two summary reports on its internet website by specified dates that describe the department’s progress and actions on specified matters relating to the CCS program. The bill would delete the December 31, 2026, sunset date, and would instead make the provisions relating to the stakeholder advisory group and the related reporting requirement inoperative on January 1, 2037.

This bill would make conforming changes to reflect the renaming of the advisory group.

The people of the State of California do enact as follows:

SECTION 1.

Section 14094.7 of the Welfare and Institutions Code is amended to read:

14094.7.

(a) No sooner than July 1, 2017, the department may implement the Whole Child Model program established under this section, pursuant to the criteria described in this article. The director shall provide notice to the Legislature, the federal Centers for Medicare and Medicaid Services, counties, CCS providers, and CCS families when each managed care plan, including a transition plan with the county CCS program, has been reviewed and certified as ready to enroll children based on the criteria described in this article.

(b) The department shall do all of the following:

(1) Develop specific CCS program monitoring and oversight standards for managed care plans that are subject to this article, including access monitoring, quality measures, and ongoing public data reporting. No later than January 1, 2025, the department shall, at minimum, do all of the following:

(A) Annually provide an analysis on its internet website regarding trends on CCS enrollment for Whole Child Model counties and non-Whole Child Model counties, in a way that enables a comparison of trends between the two categories of CCS counties.

(B) Develop utilization and quality measures, to be reported on an annual basis in a form and manner specified by the department, that relate specifically to CCS specialty care and report such measures for both Whole Child Model counties and non-Whole Child Model counties. When developing measures, the department shall consider both of the following:

(i) Recommendations of the CCS Redesign Performance Measure Quality Subcommittee established by the department as part of the CCS advisory group pursuant to subdivision (c) of Section 14097.17. 14094.17.

(ii) Available data regarding the percentage of children with CCS eligible conditions who receive an annual special care center visit.

(C) Require, as part of its monitoring and oversight responsibilities, any Whole Child Model plan, as applicable, that is subject to one or more findings in its most recent annual medical audit pertaining to access or quality of care in the CCS program to implement quality improvement strategies that are specifically targeted to the CCS population, as determined by the department.

(2) Establish a stakeholder process pursuant to Section 14094.17.

(3) Consult with the CCS advisory group established pursuant to Section 14094.17 to develop and implement robust monitoring processes to ensure that managed care plans are in compliance with all of the provisions of this section. The department shall monitor managed care plan compliance with the provisions of this section on at least an annual basis and post CCS-specific monitoring dashboards on its internet website on at least an annual basis.

(c) (1) In order to aid the transition of CCS services into Medi-Cal managed care plans participating in the Whole Child Model program, commencing January 1, 2017, and continuing through the completion of the transition of CCS enrollees into the Whole Child Model program, the department shall begin requesting and collecting from Medi-Cal managed care plans information about each health plan’s provider network, including, but not limited to, the contracting primary care, specialty care providers, and hospital facilities contracting with the Medi-Cal managed care plan.

(2) The department shall analyze the existing Medi-Cal managed care delivery system network and the CCS fee-for-service provider networks to determine the overlap of the provider networks in each county and shall furnish this information to the Medi-Cal managed care plan.

(d) A managed care plan shall not be approved to participate in the Whole Child Model program unless all of the following conditions have been satisfied:

(1) The managed care plan has obtained written approval from the director.

(2) The department has obtained any necessary federal approvals.

(3) The Medi-Cal managed care plan has established a local stakeholder process with the meaningful engagement of a diverse group of families that represent a range of conditions, disabilities, and demographics, and local providers, including, but not limited to, the parent centers, such as family resource centers, family empowerment centers, and parent training and information centers, that support families in the affected county.

(4) The director has verified the readiness of the managed care plan to address the unique needs of CCS-eligible beneficiaries, including, but not limited to, the requirements set forth in subdivision (b) of Section 14087.48, subdivisions (b) to (f), inclusive, of Section 14093.05, and all of the following:

(A) That the managed care contractor has demonstrated the availability of an appropriate provider network to serve the needs of children and youth with CCS conditions, including primary care physicians, pediatric specialists and subspecialists, professional, allied, and medical supportive personnel, licensed acute care hospitals, and special care centers.

(B) That the Medi-Cal managed care plan has established and maintains an updated and accessible listing of providers and their specialties and subspecialties and makes it available to CCS-eligible children and youth and their parents or guardians, at a minimum by telephone, written material, and internet website.

(C) That the Medi-Cal managed care plan has entered into an agreement with the county CCS program or the state, or both, for the transition of CCS care coordination and service authorization and how the plan will work with the CCS program to ensure continuity and consistency of CCS program expertise for that role, in accordance with this section.

(e) A Medi-Cal managed care plan, prior to implementation of the Whole Child Model program, shall review historical CCS fee-for-service utilization data for CCS-eligible children and youth upon transition of CCS services to managed care plans so that the managed care plans are better able to assist CCS-eligible children and youth and prioritize assessment and care planning.

SEC. 2.

Section 14094.17 of the Welfare and Institutions Code is amended to read:

14094.17.

(a) A Medi-Cal managed care plan participating in the Whole Child Model program shall create and maintain a clinical advisory committee, composed of the managed care contractor’s chief medical officer or the equivalent, the county CCS medical director, and at least four CCS-paneled providers, to advise on clinical issues relating to CCS conditions, including treatment authorization guidelines, and serve as clinical advisers on other clinical issues relating to CCS conditions.

(b) (1) A Medi-Cal managed care plan participating in the Whole Child Model program shall establish a family advisory group for CCS families.

(2) Family representatives who serve on this advisory group may receive a reasonable per diem payment to enable in-person participation in the advisory group. A plan may conduct family advisory group meetings by teleconference or through other similar electronic means to facilitate family participation in this advisory group.

(3) A representative of this local group shall be invited to serve on the department’s CCS advisory group established pursuant to subdivision (c).

(c) (1) The department shall establish a statewide Whole Child Model program stakeholder advisory group, or modify an existing Whole Child Model program stakeholder advisory group, group composed of, but not limited to, representatives of all of the following:

(A) CCS providers.

(B) County CCS program administrators and medical directors.

(C) Health plans.

(D) Family resource centers.

(E) Regional centers.

(F) Recognized exclusive representatives of CCS county providers.

(G) CCS case managers.

(H) CCS medical therapy units.

(I) Members of family advisory groups established pursuant to subdivision (b).

(J) CCS clients not enrolled in a managed care plan, plan or enrolled in a managed care plan, but not on a family advisory committee, including current and former foster youth, or their caregivers.

(K) Former CCS clients.

(L) Caregivers of former CCS clients.

(M) Patient advocates.

(3) The statewide Whole Child Model program stakeholder advisory group, as established pursuant to paragraph (1), is hereby renamed the California Children’s Services (CCS) advisory group.

(4) Members shall be appointed to the CCS advisory group by the department through a simple application process available on the department’s internet website. statement of interest application.

(5) Participation in the CCS advisory group established pursuant to this subdivision shall be voluntary.

(6) The department shall consult with the CCS advisory group established pursuant to this subdivision on the implementation of the Whole Child Model program and the CCS Classic program and shall consider the recommendations of the CCS advisory group in developing monitoring processes and outcome measures for the CCS program.

(7) The department shall biennially deliver a summary report to the appropriate budget and policy committees of the Legislature beginning no later than December 31, 2027. The report shall briefly publish two summary reports and post them on its internet website, with due dates of December 31, 2028, and December 31, 2030. The reports shall describe the department’s progress towards the measures listed under subdivision (b) of Section 14094.18 and on the department’s actions towards the top CCS program priorities that have been identified in consultation with, and informed by feedback from, the CCS advisory group members.

(8) This subdivision shall become inoperative on January 1, 2037.

SEC. 3.

Section 14094.18 of the Welfare and Institutions Code is amended to read:

14094.18.

(a) (1) The department shall contract with an independent entity that has experience in performing robust program evaluations to conduct an evaluation to assess Medi-Cal managed care plan performance and the outcomes and the experience of CCS-eligible children and youth participating in the Whole Child Model program, including access to primary and specialty care, and youth transitions from Whole Child Model program to adult Medi-Cal coverage.

(2) The department shall provide a report on the results of this evaluation required pursuant to this section to the Legislature by January 1, 2021, or three years from the date when all counties described in Section 14094.5 are fully operational under the Whole Child Model program pursuant to this article, whichever is later. A report submitted to the Legislature pursuant to this subdivision shall be submitted in compliance with Section 9795 of the Government Code.

(b) The evaluation required by this section, at a minimum, shall evaluate the performance of the plans participating in the Whole Child Model program as compared to the performance of the CCS program prior to the implementation of the Whole Child Model program in those same counties. The evaluation shall evaluate whether the inclusion of CCS services in a managed care delivery system improves access to care, quality of care, and the patient experience by analyzing all of the following, and when possible, disaggregating the results, based on the child’s or youth’s race, ethnicity, and primary language spoken at home:

(1) Access to specialty and primary care, and in particular, utilization of CCS-paneled providers.

(2) The type and location of CCS services and the extent to which CCS services are provided in-network compared to out of network.

(3) Utilization rates of inpatient admissions, outpatient services, durable medical equipment, behavioral health services, home health, pharmacy, and other ancillary services.

(4) Patient and family satisfaction.

(5) Appeals and grievances, including the number of petitions to the plan to extend the continuity of care period for durable medical equipment and CCS providers, the results of those appeals, whether any subsequent appeals were made to the department, and the results of those appeals to the department.

(6) Authorization of CCS-eligible services.

(7) Network and provider participation, including participation of pediatricians, pediatric specialists, and pediatric subspecialists, by specialty and subspecialty.

(8) The ability of a child or youth who ages out of CCS and remains in the same Medi-Cal managed care plan to retain the child’s or youth’s existing providers, to the extent possible or known.

(c) The evaluation required by this section shall also evaluate managed care plans participating in the Whole Child Model program as compared to the CCS program in counties where CCS services are not incorporated into managed care, and collect appropriate data to evaluate all of the following:

(1) The rate of new CCS enrollment in each county.

(2) The percentage of CCS-eligible children and youth with a diagnosis requiring a referral to a CCS special care center who have been seen by a CCS special care center.

(3) The percentage of CCS children and youth discharged from a hospital who had at least one followup contact or visit within 28 days after discharge.

(4) Appeals and grievances.

(d) The department shall consult with stakeholders, including, but not limited to, the CCS advisory group, regarding the scope and structure of the review.