CalAIM Overview 1 CalAIM CalAIM: California Advancing and - - PowerPoint PPT Presentation
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
CalAIM Overview
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5 2015-2020 Waiver Component Planned for CalAIM Timeline Medi-Cal Managed Care Transition to new 1915(b) waiver January 1, 2021 Whole Person Care Pilots Transition to new 1915(b) waiver EMC/ILOS/Incentives January 1, 2021 Public Hospital Redesign and Incentives in Medi- Cal (PRIME) Transition to managed care directed payment under the Quality Incentive Program (QIP) QIP 2.0 – July 1 – December 31, 2020 QIP 3.0 – January 1, 2021 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 ECM/ILOS January 1, 2021 Dental Transformation Initiative Transition authority to Medi-Cal State Plan January 1, 2021 Coordinated Care Initiative and Cal MediConnect Managed care authority to new 1915(b) waiver Extension of 1115A demonstration for Cal MediConnect through 2022 Eventual Medicare- Duals Special Needs Plans (D- SNPs) 1915(b)/1115A to continue current CCI program with end date of Dec. 31, 2022 January 2021 - carve out Multi-purpose Senior Services Programs; Long-term care carved in January 2023 – full transition all duals into managed care statewide; all Medi-Cal managed care plans to operate DSNPs
* Not an all-inclusive list.
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plans
Behavioral Health Coordination
Illness/Serious Emotional Disturbance (IMD SMI/SED) Waiver
Statewide
Supports
Information
Note: Green highlight indicates current key focus of AHS.
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❑ 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
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❑ 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
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❑ 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
❑ 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
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❑ Currently, Medi-Cal beneficiaries must navigate multiple complex delivery systems in
❑ 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.
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❑ 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
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❑ 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
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❑ Reform the Medi-Cal behavioral health payment methodologies via a multi-phased approach ❑ Allow for the possibility to incentivize outcomes and quality, as well as, potential to increase reimbursement ❑ Shift away from the cost-based Certified Public Expenditure (CPE) to other rate-based/value-based structures that instead utilize intergovernmental transfers (IGT) to fund County non-federal share ❑ Implement the shift in methodology in two initial phases:
❖ Transition specialty mental health and substance use disorder services ❖ Establish reimbursement rates and ongoing methodology with non- federal share being provided by via IGT instead of CPE, eliminating the need for reconciliation to actual costs
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Benefit Changes Effective January 1, 2020 Benefits Currently Provided by Medi-Cal Managed Care Plans that will be Carved-Out to FFS Category/Benefit Impact Fabrication of Optical Lenses Currently only covered by CenCal and Health Plan of San Mateo in managed care Benefit Changes Effective January 1, 2021 Benefits Currently Provided by Medi-Cal Managed Care Plans that will be Carved-Out to FFS Category/Benefit Impact Pharmacy All drugs or pharmacy claims billed by a pharmacy, including HIV/AIDS and psychotherapeutic drugs Specialty Mental Health Services Currently full benefit in Partnership Solano (Kaiser members only) and Kaiser Sacramento Multipurpose Senior Services Program Currently full benefit in CCI counties (Los Angeles, Orange, San Bernardino, San Diego, San Mateo, Santa Clara, and Riverside) Benefits to be Carved-In Managed Care Statewide Category/Benefit Impact
Habilitative, and Disabled Nursing
Currently full benefit in county operated health systems and/or CCI counties (Los Angeles, Orange, San Bernardino, San Diego, San Mateo, Santa Clara, and Riverside) In non-county operated health systems/Non- CCI counties Medi-Cal managed care plans are responsible for the month of admission and the month following Major Organ Transplant Currently full benefit in county operated health systems counties, non- county operated health systems counties currently only cover kidney transplants 16
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❑ Summer 2020: State submission to federal Center for Medicare and Medicaid Services ❑ July 2020: Global Payment Program extended through Dec. 31, 2025 ❑ Dec. 31, 2020: Medi-Cal 2020 1115 waiver expires along with: Whole Person Care, PRIME, the Health Homes Program, California Children’s Services pilot, designated state health programs, safety-net care pool, tribal uncompensated care ❑
❑ 2021 – 2026: Implementation of remaining CalAIM activities
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❑ Significant transformation and change proposed – thoughtful reforms ❑ Builds on learnings and successes of Waiver ❑ Movement and consolidation of services and programs under Medi-Cal managed care and health plans ❑ Encompasses a broader delivery system (e.g., social services) ❑ Continued State focus on care coordination, quality, simplification and effectiveness ❑ Additional clarity needed regarding total financing picture of public hospital systems to replace lost Waiver funding ❑ Initial start of process, unanswered questions, likely modifications
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❑ Participate in Alameda County-wide discussions with key stakeholders ❑ Monitor and track State CalAIM activities ❑ Work with public hospital association (i.e., CAPH) ❑ Conduct appropriate financial analyses ❑ Keep Board of Trustees and key elected officials informed about impact to AHS ❑ Create internal AHS CalAIM Committee
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