CalAIM Overview 1
CalAIM ❑ CalAIM: California Advancing and Innovating Medi-Cal ❑ Waiver renewal, program and payment reform in Medi-Cal ❑ Initiatives and reforms for: ❖ Medi-Cal Managed Care ❖ Behavioral Health ❖ Dental ❖ Other County Programs and Services 2
CalAIM Goals ❑ Identify and manage member risk and need through Whole Person Care approaches and addressing social determinants of health ❑ Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility ❑ Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems and payment reform 3
CalAIM Advancing Key Priorities ❑ Aligns with and advances several key priorities of the Newsom Administration ❑ Leveraging Medi-Cal as a tool to help address: ❖ Health for All ❖ High Utilizers (5%) ❖ Behavioral Health ❖ Vulnerable Children ❖ Homelessness and Housing ❖ Justice-involved Populations ❖ Aging Population 4
From Medi-Cal 2020 to CalAIM: A Crosswalk* 2015-2020 Waiver Planned for CalAIM Timeline Component Medi-Cal Managed Care Transition to new 1915(b) waiver January 1, 2021 Whole Person Care Pilots Transition to new 1915(b) waiver January 1, 2021 EMC/ILOS/Incentives QIP 2.0 – July 1 – December 31, 2020 Public Hospital Redesign Transition to managed care directed QIP 3.0 – January 1, 2021 and Incentives in Medi- payment under the Quality Incentive Cal (PRIME) Program (QIP) Global Payment Program 1115 waiver renewal GPP program year ends June 30, 2020; 5-year renewal request to begin GPP extension on July 1, 2020 Health Homes Program Transition to new 1915(b) waiver January 1, 2021 ECM/ILOS Dental Transformation Transition authority to Medi-Cal State January 1, 2021 Initiative Plan Coordinated Care Managed care authority to new 1915(b)/1115A to continue current CCI program Initiative and Cal 1915(b) waiver with end date of Dec. 31, 2022 MediConnect Extension of 1115A demonstration for January 2021 - carve out Multi-purpose Senior Cal MediConnect through 2022 Services Programs; Long-term care carved in January 2023 – full transition all duals into Eventual Medicare- Duals Special Needs Plans (D- SNPs) managed care statewide; all Medi-Cal managed care plans to operate DSNPs * Not an all-inclusive list. 5
Initial Set of CalAIM Proposals 1. Population Health Management 12. Annual Medi-Cal Open Enrollment 2. Enhanced Care Management 13. NCQA Accreditation of Medi-Cal Managed care plans 3. Mandatory Medi-Cal Applications and 14. Regional Medi-Cal Rates Behavioral Health Coordination 4. In Lieu of Services 15. Behavioral Health Payment Reform 5. Incentive Payments 16. Revisions to Behavioral Health Medical Necessity 6. Institutions for Mental Disease Serious Mental 17. Administrative Behavioral Health Integration Illness/Serious Emotional Disturbance (IMD Statewide SMI/SED) Waiver 7. Full Integration Plans 18. Behavioral Health Regional Contracting 8. Long Term Plan for Foster Care 19. Substance Use Disorder Managed Care Renewal 9. Standardize Managed Care Benefit 20. Future of Dental Transformation Initiative 10. Standardize Managed Care Enrollment 21. Enhancing County Oversight and Monitoring 11. Statewide Managed Long-Term Services and 22. Improving Beneficiary Contact and Demographic Supports Information Note: Green highlight indicates current key focus of AHS. 6
Population Health Management ❑ The population health management proposal focuses on: ❖ Initial Risk Assessment ❖ Risk Stratification ❖ Provider Referrals ❖ Actions to Address Risk and Need ❖ Skilled Nursing Facility Coordination ❖ Plan Oversight and Health Information Technology Support 7
Enhanced Care Management ❑ Establish a new, statewide enhanced care management (ECM) benefit administered by Medi-Cal managed care plans - intensive and comprehensive care management services to individuals ❑ WPC pilots identified care management/coordination as the most important service ❑ Builds on the current Health Homes Program (HHP) and Whole Person Care (WHC) pilots and transitions those pilots to this new statewide benefit to provide a broader platform to build on positive outcomes from those program ❑ Required state-wide care management benefit ❖ Replaces HHP, WPC care coordination ❖ Built into rates; no separate PMPM (per member per month) ❖ State DHCS preference for care delivery in community ❖ Housing navigation address through in lieu of services ❑ ECM services include, but are not limited to: identifying population, care plan, care coordination, identify/coordinate in lieu of services, member & family supports, coaching/health promotion ❑ Ending targeted case management for Medi-Cal managed care beneficiaries January 1, 2021 8
In Lieu of Services ❑ WPC Pilots used health funding to cover social needs that impact health ❑ In lieu of services (ILOS) are medically appropriate and cost-effective alternatives to services that can be covered under the State Medicaid Plan ❑ An ILOS can only be covered if: ❖ Service is a medically appropriate and cost-effective substitute or setting for the State Plan service ❖ Services are optional for beneficiaries - they are not required to use the in lieu of services and ❖ Services are authorized and identified in the State’s Medi -Cal managed care plan contracts ❑ ILOS are non-covered services in place of covered services ❖ For example, medical respite in lieu of IP/OP hospital services ❖ Rate setting tool to cover social needs through managed care plan rates ❑ ILOS are voluntary for plans and patients 9
In Lieu of Services ❑ DHCS is proposing to cover the following distinct services as in lieu of service under Medi-Cal managed care ❑ Services selected to address homeless and LTC populations Housing-related 1. Housing Transition/Navigation Services 2. Housing Deposits 3. Housing Tenancy and Sustaining Services 4. Short-Term Post-Hospitalization Housing 5. Recuperative Care (Medical Respite) Diversion 6. Sobering Centers LTC-related 7. Respite 8. Day Habilitation 9. Nursing Facility Transition/Diversion to Assisted Living Facilities 10. Nursing Facility Transition to a Home 11. Personal Care (beyond IHSS) and Homemaker Services 12. Environmental Accessibility Adaptations (Home Modifications) 13. Meals/Medically Tailored Meals 10
Incentive Payments ❑ Incentive payments linked to investment in enhanced care management and in lieu of services infrastructure ❑ Based on quality and performance improvements and reporting in areas such as care coordination, long-term services and supports, and other cross delivery system metrics ❑ Medi-Cal managed care plans would need to partner and share the incentive dollars with providers in the community ❑ Shared Savings/Incentives ❖ SHARED SAVINGS: State not building savings assumptions into rates initially ❖ INCENTIVES: Only at conceptual level – dollars and metrics not specified ❖ GOAL: Permanent MLTSS managed care program by 2026; no such specific goals for WPC-related services ❖ FINANCING: TBD, awaiting details in the Governor’s January 2020 budget 11
Full Integration Plans ❑ Currently, Medi-Cal beneficiaries must navigate multiple complex delivery systems in order to meet all of their health care needs ❑ Fragmentation can lead to gaps in care and disruptions in treatment, cost inefficiencies, and generally fails to be patient-centered and convenient for most beneficiaries ❑ Test the effectiveness of full integration of physical health, behavioral health, and oral health under one contracted entity ❑ Complex set of policy considerations – eligibility, administrative requirements, provider network, quality and reporting requirements, financial considerations, etc. ❑ Given the complexity of this proposal, DHCS assumes the selected plans would not go live until 2024. 12
NCQA Accreditation of Medi-Cal Managed Care Plans ❑ State recommends requiring all Medi-Cal managed care plans and their subcontractors (delegated entities) to be NCQA accredited by 2025 ❑ Streamlines Medi-Cal managed care plan oversight and increase standardization across plans ❑ State would use NCQA findings to certify or deem that Medi-Cal managed care plans meet certain State and federal Medicaid requirements ❑ Considering requiring that accreditation include Long Term Services and Supports Distinction Survey ❑ Interested in discussing the addition of the Medicaid module to routine NCQA health plan accreditation - could potentially maximize the opportunity for streamlining State compliance and deeming 13
Regional Medi-Cal Rates ❑ Simplification of the rate-setting process for the Medi-Cal managed care ❑ Phased approach for implementation ❑ Implement Regional Rates in Targeted Counties (Phase I) ❖ Calendar years 2021 and 2022 for targeted counties & Medi-Cal managed care plans ❖ Utilize Phase I as a means of identifying strategies and further improvements for seamless transition to regional rate setting statewide ❑ Fully Implement Regional Rates Statewide ❖ Proposes to fully implement regional rates no sooner than calendar year 2023 ❖ Will consider health care market dynamics when determining regional boundaries 14
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