California’s workers’ compensation (WC) program provides medical care and wage replacement benefits to workers suffering on-the-job injuries and illnesses. It is a mandatory “nofault” system in which benefits are paid by the employer without the need to determine whether employer or employee negligence caused the injury. Payments under the WC program for medical care related to treatment of a work-related injury or illness are primary to payments by other health insurance programs. Employers provide workers’ compensation coverage by purchasing WC insurance from commercial insurance companies or from the California State Compensation Fund (a public nonprofit carrier) or by setting up...

This chapter provides an overview of the home health services provided to California’s injured workers that we developed from available data and interviews with selected individuals from stakeholder groups with significant interest in the fee schedule and related issues. Based on the findings from the interviews, it concludes with a summary of the issues that DWC will need to address in implementing a fee schedule for home health care services.

We used data provided by the Workers’ Compensation Insurance Rating Bureau (WCIRB) and One Call Care Management Company to obtain an understanding of the relative importance of the different types...

We start our review of how various programs pay for home health care services with the Medicare program. This is because Labor Code Section 5307.1 requires that with certain exceptions (e.g., pharmaceutical services) the maximum allowable fees under the OMFS be in accordance with the fee-related structure and rules of the relevant Medicare payment system. Under the fee schedules adopted by the AD under this provision, the maximum allowable fees are limited to no more than 120 percent of estimated aggregate Medicare fees for the same class of services. As amended by SB 863, Labor Code Section 5307.8 requires the...

SB 863 requires that DWC base the OMFS for home care services not otherwise covered by Medicare or other OMFS fee schedules on the regulations adopted for the IHSS program administered by California Department of Social Services. Given this mandate, a thorough understanding of the IHSS program is a necessary prerequisite to any analysis of fee schedule issues.

The IHSS program provides the supportive services necessary to enable elderly and disabled individuals to remain safely within their homes.¹ To be eligible for services, individuals must qualify for Medi-Cal (California’s Medicaid program) on the basis of being aged, blind, or disabled,...

In this chapter, we discuss the policies and payment rates for the other Medi-Cal–covered home health care services. Medi-Cal, the name for the Medicaid program in California, is a health care program for low-income individuals. It is jointly funded by the federal government and the state and is administered by the state. The Department of Health Care Services administers the Medi-Cal program other than the IHSS program discussed in Chapter Four. The other home health services covered by the Medicaid program have a medical component. We include these services in our assessment of potential OMFS fee schedule options because...

The provision of home health care has become an integral part of the services provided by the Department of Veterans Affairs (VA) to enrolled veterans. The services provided are intended to meet both the short- and long-term needs of injured or ill veterans and may include skilled home health care, homemaker and/or home health aide services, and other services. Recently, the “Caregivers and Veterans Omnibus Health Services Act of 2010” made additional VA services available to seriously injured post-9/11 veterans and their family caregivers. Several aspects of the VA policies inform potential WC home health fee schedule policies, including the...

To identify policy alternatives from other jurisdictions, we searched state statutes and administrative codes using LEXIS to identify jurisdictions that have policies in this area. We found that while some states have statutes and regulations that specifically address the issue of WC and home care services, others have created policy only through judicial interpretation of WC statutes that did not explicitly address home care services. Table 6.1 contains a listing of states that we identified as having policies pertaining to home health care services. In addition, we reviewed the policies of the federal Office of Workers’ Compensation Program (OWCP).

We...

Based on discussions with DWC, our stakeholder interviews, and our review of home health fee schedules used by other programs, we developed the following framework to guide our analysis of potential options for a home health care fee schedule:

To cover the home health care needs of the WC patient population, the fee schedule should address the range of home health services, including (1) temporary skilled and/or nonskilled supportive care services typically needed on a part-time or intermittent basis for a finite period of time following an acute care medical event, (2) more extensive (e.g., full-time or longer-term) skilled care,...

DWC asked RAND for technical assistance in developing fee schedule policies for home health care services. We first consulted with stakeholders in the California WC system to outline key concerns with home health care services provided to injured workers that the fee schedule should address. Once we identified the main issues, we reviewed home health fee schedule rates and policies used by other payers to determine how they had addressed similar problems and conducted interviews with WC administrators from other jurisdictions to elicit their experiences in implementing home health care policies in the WC context. We used this information to...