A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care SEPTEMBER 2020 AUTHORS Amber Christ, JD and Georgia Burke, JD, Justice in Aging Contents About the Authors 3Introduction Justice in Aging is a national nonprofit orga- 4Characteristics of California’s Dual-Eligible nization that uses the power of law to fight Enrollees senior poverty by securing equitable access to affordable health care and economic secu- Demographics rity for older adults with limited resources. Health Status Amber Christ, JD, and Georgia Burke, JD, are directing attorneys at Justice in Aging. 6Financing and Spending Financing and Oversight Responsibilities About the Foundation Payment and Spending The California Health Care Foundation is 7How Dual-Eligible Enrollees Receive Their dedicated to advancing meaningful, measur- Benefits able improvements in the way the health care delivery system provides care to the people of 8Medi-Cal Models for Administering Benefits California, particularly those with low incomes Medi-Cal Delivery Models: Managed Care and and those whose needs are not well served Fee-for-Service by the status quo. We work to ensure that people have access to the care they need, Carve-Outs and Carve-Ins of Medi-Cal Plan Benefits when they need it, at a price they can afford. 12Medicare Models for Administering Benefits Fee-for-Service Medicare CHCF informs policymakers and industry leaders, invests in ideas and innovations, Medicare Advantage and connects with changemakers to create a more responsive, patient-centered health 14Medicare-Medicaid Integrated Models care system. Cal MediConnect FIDE-SNPs For more information, visit www.chcf.org. PACE 16Policy and Operational Imperatives During Program Transitions 18 Conclusion 19 Appendices A. Glossary of Medi-Cal Long-Term Services and Supports B. Tables 28 Endnotes California Health Care Foundation www.chcf.org 2 Introduction C alifornia is home to nearly 20% of the country’s compared with Medicare-only enrollees.5 When the older adults with low incomes and persons with state reexamines ways to reform how dual-eligible disabilities who receive health care coverage enrollees receive their care, learnings from the pan- from both Medicare and Medicaid. These 1.4  mil- demic will be a critical element in that review. lion Californians enrolled in Medicare and full-benefit Medi-Cal, California’s Medicaid program, are known This paper seeks to assist policymakers and stakehold- as dual-eligible enrollees.1 ers when the state revisits and reassesses the CalAIM proposal by providing a comprehensive overview of the Restructuring administration of the delivery of health characteristics of the dual-eligible enrollee population care benefits to this population is a priority for the in California and the current structures for administra- Medi-Cal program. On average, dual-eligible enroll- tion and delivery of services. The goal of the paper is to ees constitute the highest-need, highest-cost segment help stakeholders understand the complexities of ser- of both the Medicare and Medi-Cal enrollee popula- vice delivery for dual-eligible enrollees and to assess tions, with wide variation in need and cost within the the impact of proposed changes on how enrollees population. Because these enrollees receive health can access care under both Medicare and Medi-Cal. care services through two programs, each with its own The paper identifies transition challenges and areas of complex rules, accessing services and integrating care complexity and suggests measures to protect enroll- present unique challenges. Further, variations in pro- ees from interruptions in care during any change. gram design, particularly on the Medi-Cal side, exist in different regions in California, complicating both Specifically, the paper presents information on the delivery of services and state oversight functions. For current landscape of delivery of benefits for dual-eligi- enrollees, the result is that the systems they currently ble enrollees, including variations within the state. The navigate and the options available to them depend following topics are discussed: largely on where they live and what services they need to access. $ Characteristics of California’s dual-eligible enrollees. The paper reviews demographic and In 2019, California’s Department of Health Care Services health data on California’s dual-eligible population (DHCS) announced a Medi-Cal restructuring initiative, compared with enrollees who qualify only for the Advancing and Innovating Medi-Cal (CalAIM).2 The ini- Medicare benefit, as well as data on dual-eligible tiative included proposals to develop program options enrollees’ cost to both programs. that would integrate Medicare and Medi-Cal benefits available throughout the state, to mandate enrollment $ Current benefit delivery structures for dual- in Medi-Cal managed care for virtually all dual-eligible eligible enrollees. The paper describes the different enrollees, and to realign a number of programs affect- ways dual-eligible enrollee groups currently receive ing the dual-eligible population.3 both Medicare and Medi-Cal services, including more granular data, where available, showing the Because of the COVID-19 emergency, the CalAIM numbers enrolled in various models. This section proposal has been put on hold for a minimum of looks at the complex array of enrollment options 12 months.4 COVID-19 has had a disproportionate for both Medicare and Medi-Cal that vary depend- and devastating impact on the dual-eligible popu- ing on which services the enrollee needs and where lation. Initial data show that dual-eligible enrollees, an enrollee resides. This section also identifies ben- for example, are more than four times more likely to efits available in Medi-Cal managed care and those be diagnosed with and hospitalized for COVID-19 that are carved out of the managed care model. A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 3 $ Policy and operational imperatives to reduce dis- ruption to dual-eligible enrollees in transitions. Dual-Eligible Enrollees Defined This discussion draws from the experience of the In this paper, dual-eligible enrollees are transition of dual-eligible enrollees in California’s those individuals who qualify for both Coordinated Care Initiative to identify areas of Medicare and full Medi-Cal benefits. particular importance for ensuring enrollee protec- (Some people qualify for Medicare tion and access to care during transitions to new and partial Medi-Cal benefits; they are systems. not included in the data in this paper.) Accordingly, dual-eligible enrollees must be age 65 and over, or, if under age 65, have been receiving disability benefits Characteristics of for 24 months from the Social Security Administration. In order to qualify for California’s Dual-Eligible Medi-Cal, dual-eligible enrollees also must have low incomes and limited Enrollees assets. In California, those eligible for Medi-Cal must have assets below $2,000 and monthly income below 123% of the Demographics federal poverty level.10 Some Medi-Cal In California, seven in 10 dual-eligible enrollees are age programs have higher income limits, 65 and over, and nearly six in 10 are female (Figure 1).6 including, for example, Medi-Cal for Populations of color in California are disproportionately long-term care and certain home and community-based waiver services. more likely to be dually eligible in comparison with the state’s total Medicare population (Figure  2).7 Factors contributing to the overrepresentation of women and people of color among dual-eligible enrollees include systemic racial and gender discrimination, AGE which con- tribute to lower incomes and less access to health care and other services, and the economic burdens of women’s longer life span.8 Dual-eligible enrollees Under 65are 30% also more likely to have limited English proficiency. 9 65 and over 70% Figure 1. P roportion of California Dual-Eligible Enrollees, Figure 2. C overage Type, California’s Medicare Enrollees, by Demographic, 2012 (data released in 2019) by Race, 2012 (data released in 2019) AGE GENDER ■ White ■ Asian ■ Latinx ■ Black ■ Native American Medicare and Medi-Cal Under 65 33% 34% 21% 10% 30% Male <1% 42% Medicare only Female 65 and over 58% 70% 14% 7% 5% 70% Notes: Data source uses Non-Hispanic White, Asian or Pacific Islander, Hispanic, African American, and American Indian or Alaska Native. Segments do not sum to 100% due to rounding and omission of Other (less than 2.5% in both categories). GENDER FIGURES 1 AND 2: Source: “PUF_2012” tab in Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) Public Use File (PUF) Version 2.0 (2006–2012) (02/2019) (XLSX), Centers for Medicare & Medicaid Services (CMS), “MMCO Statistical & Analytic Reports.” Male California Health Care Foundation 42% www.chcf.org 4 Female 58% Health Status Figure 3. C onditions of California Medicare Enrollees, by Coverage Type, 2012 (data released in 2019) Under most measures, compared with the general Medicare population, dual-eligible enrollees are in poorer health. For example, dual-eligible enrollees Depression are nearly twice as likely to have three or more chronic 11% conditions compared with Medicare-only enrollees 22% (48% versus 27%).11 Dual-eligible enrollees are also more likely to have a condition resulting in a functional Anxiety limitation or disability, including, for example, mobility impairments, intellectual disabilities, depression, anxi- 7% ety, bipolar disorder, and schizophrenia (Figure 3).12 14% COVID-19, as noted previously, has had a dis- Schizophrenia proportionate impact on dual-eligible enrollees, <1% particularly for certain subpopulations. Preliminary ■ Medicare-Only 7% ■ Dual-Eligible national Medicare data show that, compared with Medicare-only enrollees, people who are dually Bipolar disorder enrolled in Medicare and Medicaid are more than four 1% times as likely to be diagnosed with and hospitalized for COVID-19.13 Among dual-eligible enrollees, Black 6% enrollees are nearly two times as likely and Latinx enrollees 1.5 times as likely as white enrollees to be Mobility impairment hospitalized. (Source data uses the term Hispanic.)14 2% COVID-19 diagnosis and hospitalizations increase 6% with age. Dual-eligible enrollees age 85 and over, for example, are nearly four times more likely to be hos- Intellectual disability pitalized than dual-eligible enrollees under age 65.15 <1% California’s dual-eligible enrollees are also more likely 4% to have underlying health conditions making them Source: “PUF_2012” tab in Medicare-Medicaid Linked Enrollee Analytic more susceptible to COVID-19. National data show Data Source (MMLEADS) Public Use File (PUF) Version 2.0 (2006–2012) that 76% of COVID-19 decedents had an underly- (02/2019) (XLSX), CMS, “MMCO Statistical & Analytic Reports.” ing health condition.16 The most common conditions among COVID-19 decedents are cardiovascular dis- ease, diabetes mellitus, chronic kidney disease, and chronic lung disease, all of which are more preva- lent among dual-eligible enrollees compared with Medicare-only enrollees.17 For example, 40% of dual- eligible enrollees in California are diagnosed with diabetes compared with 22% of Medicare-only enroll- ees, and 21% of dual-eligible enrollees have chronic kidney disease compared with 15% of Medicare-only A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 5 enrollees (Figure 4).18 Twice as many dual-eligible enrollees in California use dialysis facilities compared Financing and Spending with Medicare-only enrollees.19 The kidney disease statistics for California’s dual-eligible enrollees raise Financing and Oversight particular concerns because, nationally, dual-eligible Responsibilities enrollees with end-stage renal disease are 2.5 times Medicare is a federal program, and costs are borne more likely to be hospitalized for COVID-19 than entirely by the federal government. For Medi-Cal, fed- Medicare-only enrollees with the disease.20 eral matching funds cover more than half of the state’s expenditures (exact matching percentages can vary depending on the Medi-Cal program involved). The Figure 4. U nderlying Conditions Connected to COVID-19 Medicare program is administered and overseen by Risk Among California Medicare Enrollees, the Centers for Medicare & Medicaid Services (CMS). by Coverage Type, 2012 (data released in 2019) Medi-Cal is also overseen by CMS and administered in California through DHCS. DHCS delegates certain Diabetes aspects of the program’s operation to county enti- 22% ties. California’s Department of Managed Health Care (DMHC) also provides oversight of managed care 40% plans in the state, including Medicare plans and most Medi-Cal plans.21 Chronic kidney disease 15% 21% ■ Medicare-Only In California, dual-eligible enrollees ■ Dual-Eligible Heart failure represent just 25% of all Medicare 13% enrollees, but account for 39% of 20% Medicare expenditures. COPD* 8% 14% Payment and Spending Medicare is the primary payer for most services for *Chronic obstructive pulmonary disease. dual-eligible enrollees, including most hospital and Source: “PUF_2012” tab in Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) Public Use File (PUF) Version 2.0 (2006–2012) medical services and prescription drugs. Medicare (02/2019) (XLSX), CMS, “MMCO Statistical & Analytic Reports.” also pays for limited long-term services and supports (LTSS), including up to the first 100 days in a nursing facility and home health care when an individual is deemed home-bound (see Appendix A). In California, dual-eligible enrollees represent just 25% of all Medicare enrollees, but account for 39% of Medicare expenditures.22 California Health Care Foundation www.chcf.org 6 Medi-Cal is the payer of last resort for dual-eligible enrollees and fills in gaps for services not covered by How Dual-Eligible Medicare, the most costly of which are long-term ser- Enrollees Receive vices and supports, including longer stays in nursing facilities and home and community-based services.23 Their Benefits Examples of other Medi-Cal services that Medicare While dual-eligible enrollees have fairly comprehen- does not cover include nonemergency transportation sive coverage for health services, they often face to medical services; certain durable medical equip- barriers to receiving those services because their ben- ment and supplies; some behavioral health services; efits are delivered through two different programs and dental, hearing, and vision services. Medi-Cal also with different provider networks, standards of medical helps to pay for Medicare premiums and cost shar- necessity, and means of delivering covered benefits. ing so that dual-eligible enrollees generally have no responsibility for out-of-pocket costs for any Medicare Provider networks. Many Medicare providers (par- or Medi-Cal covered benefit, with the exception of ticularly physicians) who serve dual-eligible enrollees small copayments for some Medicare-covered drugs. do not participate in Medi-Cal, and many providers of Medi-Cal services — such as home and community- based service providers, dentists, mental health profes- sionals, and others — do not participate in Medicare. Dual-eligible enrollees make up Having different providers operating in and paid by just 11% of Medi-Cal enrollees two different, complex insurance programs contrib- utes to lack of coordination between providers and but account for 32% of total services, creating barriers for enrollees to access care. Medi-Cal expenditures. Standards. The two programs also have different rules and standards of medical necessity, so issues can Dual-eligible enrollees make up just 11% of Medi- arise when both programs cover a service but cover- Cal enrollees but account for 32% of total Medi-Cal age criteria differ. For example, Medicare coverage of expenditures.24 Medi-Cal spending is lower for enroll- wheelchairs and other durable medical equipment is ees whose eligibility for Medicare is based on age (65 limited to what is needed for functioning in the home, and over) compared with those whose eligibility for while Medi-Cal will also consider whether an item is Medicare is based on disability.25 These data are con- needed so an individual can function in the commu- sistent with the findings of national research looking nity. A dual-eligible enrollee needs to navigate both at the highest-cost dual-eligible enrollees. Those stud- sets of criteria, first trying Medicare before seeking ies have found that only 5% of dual-eligible enrollees Medi-Cal coverage, because Medicare is primary and account for persistently high costs and that persis- Medi-Cal is the payer of last resort.28 tently high spending is primarily for individuals with disabilities with significant long-term care needs.26 Similarly, the intersection between the Medicare home While most cost containment efforts have historically health benefit and Medi-Cal’s home and community- focused on reducing hospitalizations and emergency based services, which are meant to wrap around department use, research on high-cost dual-eligible Medicare coverage, also can be particularly challeng- enrollees suggests that costs would better be con- ing, because qualifying criteria for program services trolled by more effectively coordinating care and differ both between Medicare and Medi-Cal and also utilizing strategies that help individuals live indepen- among different Medi-Cal program options. dently in the community with proper supports.27 A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 7 Delivery of benefits. Compounding this complex- Figure 5. F ee-for-Service and Managed Care Enrollment ity is the fact that dual-eligible enrollees receive their Among Dual-Eligible Californians, by Coverage Type, 2020 Estimates Medicare and Medi-Cal benefits in different ways depending on where they live, what services they are receiving, and their own enrollment choices. In both MEDI-CAL ENROLLMENT N=1.4 MILLION Medicare and Medi-Cal, there are two basic mod- ■ Fee-for-Service els: fee-for-service and managed care health plans. ■ Managed Care Currently, an estimated 60% of California’s dual-eligi- ble enrollees receive their Medicare benefits through 29% fee-for-service Medicare, but 71% receive their Medi- Cal benefits through managed care health plans (Figure 5). 71% Medi-Cal Models for Administering Benefits MEDICARE ENROLLMENT N=1.4 MILLION California has been transitioning the Medi-Cal pro- gram from fee-for-service to managed care over the past 40 years. California was the first state to enter into contracts with health plans to deliver the Medicaid benefit in the early 1970s,29 and California is now pre- 39% dominantly a managed care state: As of September 61% 2019, 82% of California’s 12.4 million Medi-Cal recipi- ents30 and an estimated 71% of dual-eligible enrollees were enrolled in managed care plans responsible for delivering the bulk of their Medi-Cal benefits (see Figure 5).31 Sources: California Health and Human Services (CHHS) Open Data For dual-eligible enrollees, a significant driver for tran- Portal, ”Month of Eligibility, Dual Status, by County, Medi-Cal Certified Eligibility” (June 2020 data); CHHS Open Data Portal, “Medi-Cal Managed sitioning to Medi-Cal managed care came in 2014 with Care Enrollment Report” (May 2020 data); CMS, Special Needs Plan Comprehensive Report (June 2020) (n.d.); and Integrated Care Resource the launch of the Coordinated Care Initiative (CCI) in Center, Program of All-Inclusive Care for the Elderly (PACE) Total seven of the state’s most populous counties: Los Enrollment by State and by Organization (June 2020 data). Angeles, Orange, San Diego, San Mateo, Riverside, San Bernardino, and Santa Clara Counties. In those counties, with limited exceptions, Medi-Cal managed care enrollment became mandatory for dual-eligible enrollees. California Health Care Foundation www.chcf.org 8 The Coordinated Care Initiative In 2014, California implemented the Coordinated Care Long-term services and supports integration. Long- Initiative (CCI) to better integrate and coordinate health term services and supports (LTSS) historically have not benefits (including behavioral health benefits) and been included in the Medi-Cal managed care benefit long-term services and supports (LTSS) to dual-eligible package, with the exception of Community-Based enrollees and other seniors and persons with disabilities Adult Services (CBAS) and the nursing facility benefit living in seven California counties:32 in County Organized Health System (COHS) counties. $ Los Angeles Under the CCI, Medi-Cal managed care plans in CCI counties became responsible or partly responsible for $ Orange financing or coordinating nursing facility care, In-Home $ Riverside Supportive Services (IHSS), and the Multipurpose Senior Services Program (MSSP). As a practical mat- $ San Bernardino ter, however, LTSS integration has largely remained $ San Diego the same as it was prior to the CCI. IHSS integration $ San Mateo was ended in 2017, and to date only one health plan has fully integrated MSSP. Only institutional long-term $ Santa Clara care has become a newly integrated LTSS benefit in all The CCI features three core aspects: CCI counties. (For a more detailed description of LTSS programs, see Appendix A.) Mandatory enrollment in Medi-Cal managed care. When California began mandatory enrollment of many Cal MediConnect. The CCI created a new type of man- Medi-Cal enrollees into managed care in 2011, certain aged care program in the seven CCI counties, known populations were excluded from mandatory enroll- as Cal MediConnect, which combines a dual-eligible ment, including enrollees living in nursing facilities, enrollee’s Medi-Cal and Medicare benefits into one those responsible for paying a portion of their Medi-Cal integrated managed care plan. Cal MediConnect was costs, and dual-eligible enrollees. The CCI expanded initially a three-year demonstration program, which the mandatory enrollment into Medi-Cal managed care by state subsequently opted to extend through December requiring those previously excluded groups living in the 2022.33 Dual-eligible enrollees in the seven CCI coun- seven CCI counties to enroll in a managed care plan to ties have the option to enroll in a Cal MediConnect receive Medi-Cal benefits. plan. For more information on Cal MediConnect, see the section on integrated delivery models on page 14. A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 9 Medi-Cal Delivery Models: Managed Care and Fee-for-Service Mateo Counties — are also COHS counties). As of Dual-eligible enrollees receive their Medi-Cal benefits June 2020, 1,011,086 dual-eligible enrollees reside through fee-for-service Medi-Cal or through a man- in the 27 counties in which Medi-Cal enrollment is aged care plan. California has six managed care models mandatory.35 operating in different counties: County Organized Health System (COHS); Geographic Managed Care; In the remaining 31 counties, most dual-eligible enroll- Regional Model; Two-Plan Model; San Benito Model; ees have the option to enroll in a Medi-Cal plan. The and Imperial Model.34 Enrollment of dual-eligible approximately 410,000 enrollees who reside in these enrollees in Medi-Cal plans differs among these man- counties largely continue to receive their Medi-Cal aged care models. Figure 6 describes the six models through fee-for-service.36 (See Appendix B: Table B1 of managed care in California. provides dual-eligible enrollee residence by county as of June 2020; Table B2 provides enrollment by Dual-eligible enrollees are required to enroll in a Medi-Cal plan and county as of 2017; and Table B3 Medi-Cal plan in all 22 COHS counties and in the provides enrollment by Medi-Cal plan parent com- seven CCI counties (two of which — Orange and San pany as of 2017.) Figure 6. Medi-Cal Managed Care Models in California Del Norte Siskiyou Modoc Del Norte Siskiyou Modoc ◾ COHS County Organized Health System Del Norte ◾ COHS SiskiyouShasta Modoc ◾ Geographic The Medi-Cal plan is operated Managed by the county Care Del Lassen and there is only one plan serving the entire Norte Trinity ◾ Geographic Siskiyou Managed Care ◾ Two-Plan Trinity Shasta Humboldt Lassen ◾ Two-Plan Modoc ◾ ◾ COHS Medi-Cal population. Regional Humboldt ◾ Regional TehamaShasta ◾ Geographic COHS Managed Geographic Managed Care Care Del Plumas ◾ Imperial ◾ Geographic Tehama Lassen Plumas ◾ Imperial Trinity The state Two-Plan Managed contracts with Care multiple plans. Mendocino Butte NorteMendocino SiskiyouShastaButte Humboldt ◾ San Glenn Benito Modoc LassenSierra◾ San Benito Glenn Sierra Trinity ◾ Two-Plan Two-Plan Regional Lake Colusa Yuba Nevada Humboldt Placer Tehama Colusa Yuba Plumas Nevada ◾ COHS ◾ Regional The state contracts with one county-organized Sutter Placer Imperial Sutter Del Yolo El DoradoNorte LakeTehama Mendocino SiskiyouShastaButte Plumas ◾ Geographic Managed plan, called a local ◾ Imperial Careand with initiative plan, ◾ San Sonoma Napa Sacra- mento Amador Alpine Trinity Glenn Yolo Modoc ElLassen Dorado Sierra Benito Sonoma Napa ButteSacra- Nevada Alpine Two-Plan one commercial plan. Solano Del Mendocino Humboldt ◾ San COHS Benito s ra Glenn r o Sierra ◾ Regional Marin ave San Norte Tuolumne Mono Siskiyou Colusa Yuba mento AModoc adPlacer mNevada Regional Cal Contra Joaquin r tter LakeTehama Solano ◾ s Costa Geographic Managed Carecontracts ra San Francisco Marin ◾ SutteSu Shasta YubaSan Plumas ave Alameda Stanislaus Mariposa For these rural counties, Imperial the state Colusa Lassen Joaquin El Dorado ◾ PlacerTuolumne Mono COHS Cal San Mateo Santa Merced Trinity Lake Contra MendocinoSonoma San FranciscoGlenn Napa Yolo Costa ButteSacra- El Dorado Alpine ◾ ◾ Two-Plan with two commercial plans serving two or San Benito Managed Care Clara Humboldt Madera Yolo mento Alameda Stanislaus ◾ ◾ Geographic ador Sierra Mariposa Regional more contiguous counties. Sacra- AmNevada Santa Cruz Sonoma Shasta Napa Lassen Alpine ◾ Fresno Solano ras ras San San Trinity Mateo Tehama o r Two-Plan Benito Humboldt Marin SantaYuba Inyo mento d ◾MonoImperial maPlacerTuolumne ave ave Colusa San Plumas AMerced Imperial Sutter Cal Cal TulareLake Contra SolanoClaraJoaquin Monterey Kings Marin Mendocino San Francisco SantaGlenn CostaButte San CruzContra El Dorado ◾ ◾MonoRegional Madera In Imperial San Tuolumne BenitoCounty, the state contracts with Yolo TehamaAlameda Stanislaus Joaquin Sierra Sonoma San Francisco Napa San Mateo Costa Plumas Sacra-SanNevada ◾ Imperial Inyo plans. Mariposa two or Mariposa Fresno commercial Alpine Alameda Santa Stanislausa d Yuba ◾Tulare San Luis mento Benito Obispo MendocinoKern Colusa Butte m AMercedPlacer Sutter LakeGlenn SolanoClara San Benito San Benito s San Mateo Sierra ra CCI Marin Santa Monterey Madera ave Santa CruzContra San Merced Nevada El Dorado Tuolumne MonoIn San Benito County, the state contracts with Cal Yolo Clara Joaquin YubaSan Bernardino Kings Santa Barbara Sonoma Napa Colusa Costa Placer Madera Fresno Alpine Sutter SanVentura Francisco Santa Lake Cruz Sacra- San one commercial Inyo plan. Los Angeles Alameda mento Stanislaus dor Mariposa AmElaDorado Benito Fresno Solano San San Luis ras San Mateo Marin Yolo Santa Sacra- Tulare Inyo ave Sonoma NapaContra SanBenito Monterey Merced Obispo Alpine Tuolumne MonoKern Cal Claramento Riverside o r Kings Tulare CCI Costa JoaquinAmad Madera San Francisco Cruz Solano Monterey SantaOrange ras Marin Alameda San Stanislaus Mariposa Kings ave Fresno San Bernardino San Diego San San LuisTuolumne Santa Barbara Mono Cal San Mateo Contra Santa JoaquinBenito Costa Imperial Inyo San Francisco Merced Obispo VenturaKernLos Angeles AlamedaClara Stanislaus San LuisMariposa Tulare CCI Santa Cruz Monterey Obispo Madera Kern Note: CCI is Coordinated Care Initiative. San Mateo CCI Santa Kings Fresno Merced San Bernardino Sources: DHCS Medi-Cal Managed Care Models (PDF) (June 3, 2019); Clara andSan Santa Barbara DHCS, ”Coordinated Inyo Care Initiative Overview” Riverside (last modified June 16, 2020). Benito Madera Ventura San Bernardino Santa Cruz SanSantaLuis Barbara LosOrange Angeles Tulare Fresno VenturaKern San Obispo Monterey Los Angeles Inyo CCI Benito Kings California Health Care Foundation Imperial San Diego www.chcf.org 10 Tulare Riverside San Bernardino Monterey SanSanta Barbara Luis Kings Orange Riverside Obispo VenturaKernLos Angeles CCI Orange San Diego Imperial Carve-Outs and Carve-Ins of two counties, Medi-Cal enrollees are either required Medi-Cal Plan Benefits or have the option to enroll in separate dental man- aged care plans.38 Medi-Cal managed care plans do not provide all Medi-Cal benefits to their members. Some significant $ Specialty Mental Health. County mental health benefits are carved out of managed care, meaning departments provide services related to serious managed care plans are not responsible for providing behavioral health conditions. Behavioral health ser- or paying for these services, and they are instead pro- vices for mild to moderate conditions are included vided or paid for by other state or local entities. (See services in Medi-Cal plans and in fee-for-service Table 1.) The carve-out picture is particularly complex Medi-Cal. for certain long-term services and supports for which some carve-outs depend on the county. (For a more The following two benefits are provided by Medi-Cal detailed description of the LTSS programs listed, see managed care plans in some counties but are avail- Appendix A.) able through fee-for-service in others. $ Long-term care benefit. This benefit, which covers Three major Medi-Cal benefits are carved out of, or nursing home and other institutional care, is part of provided separately from, Medi-Cal managed care the Medi-Cal managed care plan benefit package and from Cal MediConnect in all counties. in COHS counties and in the seven CCI counties. In $ In-Home Supportive Services (IHSS). The state’s all other counties, enrollees needing nursing home personal care service is delivered through fee-for- or other institutional placement are disenrolled service in all counties and administered through the from Medi-Cal managed care one month after the Department of Social Services rather than DHCS, month of admission to a facility and placed in fee- which oversees the Medi-Cal program. for-service Medi-Cal for all their Medi-Cal benefits. $ Dental benefit. Oral health services are pro- $ Multipurpose Senior Services Program (MSSP). vided through fee-for-service Medi-Cal except in MSSP is available through Medi-Cal plans in the Sacramento and Los Angeles Counties.37 In those seven CCI counties. In the rest of the state, this Table 1. Medi-Cal Plan Carve-Ins/Carve-Outs: Who Is Responsible COHS COUNTIES CCI COUNTIES (NON-CCI) OTHER COUNTIES Core Medi-Cal services MC MC Both FFS and MC Specialty Mental Health Counties Counties Counties IHSS DSS DSS DSS Dental FFS (DMC available in Los Angeles) FFS FFS (DMC required in Sacramento County) LTC institutional benefit MC MC FFS after first month following admission MSSP MC FFS FFS (not available in all counties) CBAS MC MC MC HCBS waivers FFS (MC responsible for coordination) FFS FFS (some services not available in all counties) Definitions: CBAS is Community-Based Adult Services; DMC is dental managed care; DSS is Department of Social Services; FFS is fee-for-service; HCBS is Home and Community-Based Services; IHSS is In-Home Supportive Services; LTC is long-term care; MC is Medi-Cal managed care; MSSP is Multipurpose Senior Services Program. Source: Author analysis. A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 11 program is available only through fee-for-service CCI counties, however, dual-eligible enrollees cannot Medi-Cal. Dual-eligible enrollees who are already be enrolled in both a waiver and Cal MediConnect, enrolled in a Medi-Cal plan remain enrolled but because simultaneous enrollment would result in receive MSSP through fee-for-service. duplication of services.41 One Medi-Cal benefit, Community-Based Adult Services (CBAS), is available only through Medi-Cal managed care. Dual-eligible enrollees living in coun- Medicare Models for ties where Medi-Cal managed care enrollment is not mandatory must enroll in a Medi-Cal managed care Administering Benefits plan in order to access CBAS services.39 Medicare is the primary payer for most inpatient and outpatient medical costs, prescription drugs, and post- Individuals enrolled in Medi-Cal Home and acute skilled care services (e.g., home health, limited Community-Based Services (HCBS) waivers, nursing facility stays) for dual-eligible enrollees. Under including the Assisted Living Waiver, Home and federal law, dual-eligible enrollees have freedom Community-Based Alternatives Waiver, AIDS Waiver, to choose how they want to receive their Medicare and HCBS Waiver for the Developmentally Disabled, benefits: through original fee-for-service Medicare or receive services through the contracted waiver agency. through private health plan options called Medicare In CCI and COHS counties, enrollees can remain in Advantage plans. Dual-eligible enrollees also can a Medi-Cal managed care plan and also receive enroll in highly integrated models, which in California waiver services separately outside the plan through include Cal MediConnect plans, Fully Integrated the contracted waiver agency. In these cases, the Dual Eligible Special Needs Plans (FIDE-SNPs), and Medi-Cal plans have no responsibility to coordinate Programs of All-Inclusive Care for the Elderly (PACE). with the waiver agency, except in CCI counties.40 In Figure 7 provides enrollment estimates for these Figure 7. C alifornia Dual-Eligible Enrollee Enrollment Estimates, by Medicare Delivery Model, 2020 870,956 I N T E G R AT E D 179,000 120,795 119,547 108,675 14,541 8,098 Fee-for-service Other D-SNP D-SNPs Cal MediConnect FIDE-SNP PACE Medicare Advantage look-alike plans plans Sources: CHHS Open Data Portal, “Medi-Cal Managed Care Enrollment Report” (May 2020); CMS, SNP Comprehensive Report (June 2020) (n.d.); and Integrated Care Resource Center, Program of All-Inclusive Care for the Elderly (PACE) Total Enrollment by State and by Organization (June 2020 data). California Health Care Foundation www.chcf.org 12 Medicare models and Table 2 (see page 16) provides Medicare Advantage enrollment estimates in the various Medicare and Enrollment in Medicare Advantage plans among dual- Medi-Cal models. eligible enrollees has been growing.46 Dual-eligible enrollees participating in a plan, in contrast to fee- for-service Medicare, generally must use providers Fee-for-Service Medicare within the plan’s network, and many plan benefits More than 60% of dual-eligible enrollees in California, require preauthorization. Medicare Advantage plans or approximately 871,000 Californians (see Figures 5 often offer additional benefits that are not covered by and 7), receive their Medicare benefits through fee- fee-for-service Medicare, including, for example, gym for-service Medicare.42 In fee-for-service Medicare, a memberships and supplemental dental and vision dual-eligible enrollee may obtain Medicare-covered packages. Medicare Advantage plans typically include services from any Medicare provider. There are no the Part D prescription drug benefit as part of the plan network restrictions, generally no prior authorization offering. As in fee-for-service Medicare, dual-eligi- requirements, and no requirement that the provider ble enrollees in Medicare Advantage are protected participate in Medi-Cal. All dual-eligible enrollees, from all deductible and copayment responsibility.47 including those in fee-for-service Medicare, are pro- The enrollee is responsible for plan premiums, if any. tected by federal and state law from any liability for In contrast to fee-for-service Medicare, Medicare co-insurance and deductibles, and Medi-Cal acts as a Advantage providers may not deny services to dual- secondary payer after Medicare.43 eligible enrollees because of their Medi-Cal status.48 The freedom to use any Medicare provider, however, Different Medicare Advantage products are avail- is limited in practice. Many dual-eligible enrollees in able to dual-eligible enrollees, including Dual Eligible fee-for-service Medicare report that providers, particu- Special Needs Plans (D-SNPs), which limit enrollment larly specialists, refuse to serve the enrollees because to dual-eligible enrollees, and standard Medicare the providers are unable to collect the co-insurance Advantage plans, which are available to all Medicare for their Medicare services to dual-eligible enrollees.44 enrollees. Standard Medicare Advantage plans include Though Medi-Cal will process their charges as a sec- some that have been marketed almost exclusively to ondary payer, federal law permits the state to cap its dual-eligible enrollees and have become known as reimbursement at Medi-Cal rates, which usually are D-SNP look-alike plans. lower than what Medicare has already paid, leaving the provider with no additional payment. Dual Eligible Special Needs Plans (D-SNPs) D-SNPs are specialized Medicare Advantage plans Dual-eligible enrollees in fee-for-service Medicare that have contracts with the state and are intended must enroll in a Medicare Part D prescription drug to meet the special needs of dual-eligible enroll- plan for prescription drug coverage. They automati- ees. D-SNPs are responsible only for the delivery of cally receive the Low-Income Subsidy, which offers Medicare benefits, but D-SNPs are required to coor- premium protection and sets modest copayments for dinate Medi-Cal services for their members. These prescription drugs.45 care coordination requirements and the level of inte- gration requirements have been expanded through federal legislation and Medicare regulations that will be effective in plan year 2021.49 As of June 2020, 32 D-SNPs were available in 25 California counties, with 119,547 dual-eligible enrollees.50 (See Appendix B, Table B4 for the service area of each D-SNP and its plan enrollment.) A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 13 Medi-Cal’s policy is that dual-eligible enrollees who features that make them unattractive to anyone with- enroll in a D-SNP should be in an “aligned” Medi-Cal out the co-insurance payment protections dual-eligible plan to facilitate coordination of Medicare and Medi- enrollees have, and their supplemental benefits pack- Cal benefits. Typically, an aligned Medi-Cal plan is age is likely to attract dual-eligible enrollees.54 From operated by the same plan sponsor; however, in some 2017 to 2020, the number of look-alike plans oper- circumstances, the aligned plan is operated by a differ- ating in California doubled (from 19 to 38) and the ent plan sponsor that has entered into an agreement number of dual-eligible enrollees grew from 90,294 to work together to coordinate services.51 As a general to 120,975, an increase of 34%.55 Despite significant matter, dual-eligible enrollees who enroll in a D-SNP dual-eligible enrollment, the look-alike plans are not that is not aligned with their Medi-Cal managed care subject to any of the federal D-SNP requirements plan are disenrolled from the Medi-Cal plan and get regarding integration and coordination of Medicare their Medi-Cal benefits through fee-for-service. In CCI and Medi-Cal benefits and are not required to enter and COHS counties, however, such enrollees continue into contracts with the state.56 Both the state and CMS in Medi-Cal managed care despite the misalignment have expressed concern that look-alikes undermine and are therefore enrolled in two different managed D-SNP requirements, impede efforts to improve care care plans operated by different sponsors. coordination, and confuse enrollees.57 In response, CMS recently finalized regulations designed to curb Standard Medicare Advantage Plans look-alikes and to transition current enrollees out of Dual-eligible enrollees can enroll in other Medicare look-alike plans.58 Advantage products that are not subject to D-SNP requirements. Standard Medicare Advantage plans are available to any Medicare enrollee. These plans are not required to coordinate benefits for dual-eligi- Medicare-Medicaid ble enrollees and have no contractual obligation to the state with respect to care coordination. Despite Integrated Models these limitations, nearly 300,000 dual-eligible enroll- There are currently three options in California to enroll ees in California are enrolled in standard Medicare in health plans that are responsible for delivering Advantage plans.52 A variety of factors may play a role both Medicare and Medi-Cal benefits for members: in decisions by dual-eligible enrollees to join standard Cal MediConnect; Program of All-Inclusive Care for Medicare Advantage plans, including marketing by the Elderly (PACE); and Fully Integrated Dual Eligible brokers and agents; attractive supplemental benefits; Special Needs Plans (FIDE-SNPs). (See Figure  7, and networks that include providers preferred by the page 12.) Enrollees in these plan options receive enrollee. Further, in some areas, particularly in rural the bulk of their benefits through a single health parts of the state, few or no D-SNPs are available. plan. Approximately 9% of dual-eligible enrollees in Enrollees who are concerned that fee-for-service pro- California are in an integrated Medicare-Medicaid viders will not serve them sometimes join Medicare plan type.59 Advantage plans to obtain access to providers, because Medicare Advantage plans have to abide by network adequacy standards. Cal MediConnect Cal MediConnect, part of the CCI initiative (see More than 40% of dual-eligible enrollees in standard page 9), is available in seven counties: Los Angeles, Medicare Advantage plans (approximately 121,000 Orange, Riverside, San Bernardino, San Diego, San Californians) are enrolled in plans known as D-SNP Mateo, and Santa Clara Counties. These plans deliver look-alike plans, a term now used by both federal both Medicare and Medi-Cal benefits, including long- and state agencies.53 While available to any Medicare term services and supports, with the goal of better enrollee, these plans have premium and co-insurance integrating and coordinating care to improve health California Health Care Foundation www.chcf.org 14 outcomes for plan members. Additionally, plans can contract with CMS and DHCS and have flexibility to provide services not generally covered by Medi-Cal use the combined funding stream for either service. aimed at helping plan members to continue living in As of June 2020, 14,541 dual-eligible enrollees were their communities, like meal delivery, home modifica- enrolled in a FIDE-SNP.62 (See Appendix B, Table B6.) tions, and additional services. Plans are specifically required to coordinate care across the spectrum of benefits — including carved-out benefits that the PACE plans do not deliver. These carved-out benefits include Programs of All-Inclusive Care for the Elderly (PACE) Medi-Cal specialty mental health and substance use are integrated managed care plans available to enroll- disorder services, which are managed by the counties; ees age 55 or older who live within a PACE center’s Medicare-covered hospice services; dental benefits; service area and meet the level of care requirement for and IHSS. Cal MediConnect members cannot enroll skilled nursing facility coverage but can live safely in in waiver services; instead, the plans have the flexibil- the community with PACE services. PACE provides its ity to provide services that are similar to those offered members with almost all Medicare and Medi-Cal ser- in the waivers. Cal MediConnect is currently sched- vices and uses an interdisciplinary team to coordinate uled to expire in December 2022. As of May 2020, the care of each participant. PACE is similar to a FIDE- Cal MediConnect plan enrollment was 108,675 enroll- SNP in terms of financial integration, but PACE differs ees.60 (See Appendix B, Table B5.) in that it integrates care delivery by directly employing physicians and other frontline clinicians and provides most care on-site at a PACE center. PACE is the old- FIDE-SNPs est of the integrated program options, having begun Fully Integrated Dual Eligible Special Needs Plans more than 40 years ago.63 Though PACE has grown (FIDE-SNPs) are, as the name implies, fully integrated, over time, its reach remains relatively small. There providing both Medicare and Medi-Cal services. These are 17 PACE plans available in 16 California coun- plans differ from Cal MediConnect plans in that FIDE- ties.64 As of June 2020, 8,098 dual-eligible enrollees SNPs have no carve-outs. FIDE-SNP plans contract were enrolled in PACE plans in California.65 (See with all provider types, including medical, behavioral Appendix B, Table B7.) (including specialty mental health and substance use treatment), long-term services and supports, dental, Table 2 summarizes the availability and enrollment transportation, and the plans’ own contracted personal of dual-eligible enrollees in each of the Medicare, care assistants in lieu of IHSS. California’s FIDE-SNPs, Medi-Cal, and integrated Medicare-Medi-Cal benefit SCAN Connections and SCAN Connections at Home, delivery models described above. (See page 16.) operate in three California counties: Los Angeles, Riverside, and San Bernardino Counties. The SCAN plans currently operating are available only to dual- eligible enrollees age 65 and over who need a nursing home level of care, although CMS rules do not require those limitations.61 A primary difference between FIDE-SNPs and Cal MediConnect plans is financing: FIDE-SNPs have separate contracts with CMS for Medicare services and DHCS for Medi-Cal services. In contrast, Cal MediConnect plans have a three-way A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 15 Table 2. A vailability of and Enrollment in Benefit Delivery Models for Dual-Eligible Californians Policy and Operational AVAILABILITY ENROLLMENT Imperatives During Medi-Cal Program Transitions Fee-for-service 31 counties 410,526 Although the CalAIM proposal for system changes that Medi-Cal managed care 22 COHS* counties 1,011,086 would affect all of California’s 1.4 million dual-eligible and CCI† counties enrollees has been postponed, California remains (enrollment mandatory) committed to a broad restructuring of systems serving Medicare dual-eligible enrollees. Policymakers and stakeholders Fee-for-service Statewide 870,956 can take several steps to plan for the implementation of any changes in systems or benefits serving dual- D-SNP 25 counties ‡ 119,547 eligible enrollees and to ensure that changes are D-SNP look-alike Unknown 120,795 implemented in a manner that would minimize disrup- Other Medicare Unknown 179,000 tion and harm to dual-eligible enrollees. In particular, Advantage the state’s experience with transitions in the CCI offers Integrated Medicare-Medi-Cal Plans guideposts for planning for major benefit delivery sys- tem changes specific to older adults and people with Cal MediConnect 7 CCI counties 108,675 disabilities. FIDE-SNP 3 counties§ 14,541 PACE 14 counties # 8,098 Elevating equity to drive system changes. Experience with COVID-19 has brought racial inequities and health *COHS counties: Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, disparities into sharp focus. As California determines Merced, Modoc, Monterey, Napa, Orange, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Shasta, Siskiyou, Solano, Sonoma, Trinity, how it will move forward with programs to serve dual- Ventura, Yolo. eligible enrollees, who are disproportionately people † CCI counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, Santa Clara. of color, it is critical that the state apply a racial justice ‡ D-SNP counties: Alameda, Contra Costa, Fresno, Imperial, Kern, Kings, and health equity lens to its planning. Los Angeles, Madera, Marin, Napa, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Ventura. Planning focused on how dual-eligible enrollees will § FIDE-SNP counties: Los Angeles, Riverside, San Bernardino. experience the transition. Simple transition processes # PACE counties: Alameda, Contra Costa, Fresno, Humboldt, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, that are easy for enrollees to navigate with reasonable San Francisco, San Joaquin, Santa Clara, Stanislaus, Tulare. timelines are critical to success. Incorporating dual- Source: Author analysis; sources noted in endnotes in text descriptions in eligible enrollees meaningfully in the planning pro- preceding sections. cess and testing planned procedures with enrollees can help ensure that the enrollee perspective stays in the forefront. It also is important to think through spe- cial obstacles that persons with disabilities and those with limited English proficiency may have in getting assistance and information that will facilitate under- standing of the changes and smooth their transitions. Transparent planning process and evaluation. Extensive and transparent work with all stakehold- ers throughout the process — including planning at the front end, implementing accountability metrics California Health Care Foundation www.chcf.org 16 throughout, and evaluating outcomes at the back portal for advocates and enrollees to submit health end — helps to ensure transitions proceed smoothly. care coverage problems, and provided for retroactive Experience has shown that any changes in Medicare disenrollments when enrollment was improper.66 and Medicaid systems have ripple effects that, if not anticipated and addressed, can harm enrollees. An Consumer protections and robust oversight. Strong open process with opportunities for meaningful and consumer protections, including effective appeals and sustained stakeholder participation throughout the grievance processes, adequate and accurate provider process, from conception to evaluation, including directories, and strong quality and safety standards, public reporting of data on an ongoing and frequent have proved effective in ensuring enrollees are not basis, offers the best opportunity to ensure that the harmed by changes. Such protections are most effec- transitions and changes work as designed without tive when accompanied by robust oversight and adverse impact on enrollees. enforcement by DHCS and CMS. Systems testing and readiness reviews. The initial Ombudsman. Experience with the CCI has dem- months in any delivery system transition are when onstrated that an adequately funded ombudsman enrollee access to care can be most at risk; issues program with specific expertise in Medicare and often arise from systems errors, such as the failure of Medi-Cal issues for dual-eligible enrollees can play data transfers among participating entities to function an important role in identifying systemic issues, both properly, coding errors, or unanticipated communica- during transitions and beyond, as well as in resolving tion issues between systems or programs. Rigorous many issues that otherwise would require appeals.67 In and extensive systems testing before the start of a the first year of the CCI implementation alone, the CCI significant transition can help prevent these types ombudsman program identified 52 systemic issues of failures and disruptions in care. Such testing is impacting tens of thousands of enrollees.68 particularly critical in California because the state is also implementing a massive upgrade in its benefits Continuity of care. Even with notices, many enroll- computer network used to determine eligibility for a ees are caught unaware when elements of their care wide range of programs, including Medicaid. Robust delivery change. Having care continuity protections readiness review procedures for participating pro- in place is essential so enrollee health is not endan- viders, plans, and the state can also help ensure the gered: for example, allowing dual-eligible enrollees to transition proceeds smoothly. Readiness reviews that retain access to providers for a minimum of 12 months address computer systems and personnel as well as regardless of whether the providers are contracted assess providers’ understanding of new processes are with their new plan. For protections to work, provid- essential. ers must be well educated on the mechanics of how they can participate in care continuity, and the protec- Safety nets, backstops, and overrides. It is inevitable tions must be easy for both providers and enrollees to that some unexpected anomalies will occur during a navigate. major transition, no matter how rigorous the prepa- ration. Developing backstops, overrides, and safety Clear communication and outreach with enrollees nets with staff assigned to be responsible for imple- and providers. An important learning in both the mentation in both the state and health plans can CCI and Medicare-Medicaid demonstration projects significantly minimize interruptions in care for enroll- in other states has been that clear and straightfor- ees because of systems issues, particularly during the ward notices to enrollees and physicians are essential first months of a transition. For example, during the for trust in and support of the changes. Notices and CCI implementation, DHCS set up an email address communications should be written in plain language. for certain provider types to report issues, created a Drafting schedules should build in adequate time for A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 17 consumer testing of all notices. It is also particularly important that providers, including Medicare provid- ers, fully understand all changes so misunderstandings do not disrupt care or result in improper billing of dual- eligible enrollees for covered services. In the transition to Medi-Cal managed care in the CCI, for example, many Medicare providers refused to continue to serve their Medi-Cal patients, erroneously believing that they could not get paid unless they were part of the Medi-Cal managed care plan’s network. Provider mis- trust also played a role in the high opt-out rate for Cal MediConnect plans. Conclusion Dual-eligible enrollees constitute a heterogeneous population that differs substantially from the general Medicare population in demographics and health status. How these enrollees currently access their ben- efits varies according to where they live in the state, which benefits they receive, and personal choice. Understanding the characteristics of California’s dual- eligible population, the complex current system that serves them, and areas in particular need of attention is an important first step in analyzing and planning for any changes in benefit design and delivery for dual-eligible enrollees. This information is essential for successful transitions that minimize disruptions in needed care and ensure that enrollees fully understand changes so they can use new programs effectively. California Health Care Foundation www.chcf.org 18 Appendix A. Glossary of Medi-Cal Long-Term Services and Supports Long-term services and supports (LTSS) are a wide range of services provided in the home, in community-based settings, or in nursing homes or other facilities such as those for individuals with developmental disabilities. The following are the most common Medicare- and Medi-Cal-funded LTSS programs and services, organized alpha- betically, with approximate enrollment figures if known. Note that all waiver programs (ALW, HCBA, HCBA AIDS, HCBS-DD, MSSP) have enrollment caps but only the Assisted Living Waiver (ALW) and the Home and Community Based Alternatives Waiver (HCBA) have current waiting lists. Assisted Living Waiver (ALW). This waiver provides counseling; family caregiver training; and occupa- a limited number of slots for dual-eligible enrollees tional, speech, and physical therapy services. CBAS and other Medi-Cal recipients to receive services in replaced the adult day health care benefit in 2012, a Residential Care Facility (RCF), an Adult Residential and, with few exceptions, the benefit is available only Care Facility (ARF), or public subsidized housing, utiliz- through enrollment in a Medi-Cal managed care plan. ing ALW services. The waiver is available in 15 counties: Approximate number of participants: 38,304.73 Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Home and Community-Based Alternatives (HCBA) Diego, San Francisco, San Joaquin, San Mateo, Santa Waiver. This waiver has a limited number of slots and Clara, and Sonoma Counties. The waiver is available is administered by DHCS, which contracts with waiver to individuals age 21 and over. Approximate number providers. These contracted providers offer care man- of participants: 4,685. Number on waiting list: 4,670.69 agement services to people at risk of nursing home or institutional placement, including a multidisciplinary California Community Transitions (CCT). This pro- care team that coordinates and arranges for other gram is supported by federal funding through the long-term services and supports available in the local Money Follows the Person rebalancing demonstra- community. The waiver is available to individuals of tion. The program transitions individuals out of skilled any age. Approximate number of participants: 4,688. nursing facilities into the community using contracted Number on waiting list: 836.74 CCT lead organizations throughout the state.70 The program pays for pre- and post-transition coordina- Home and Community-Based Services AIDS (HCBS tion, home setup, home modifications, habilitation, AIDS) Waiver. This waiver is operated by DHCS in col- personal care services, family and informal caregiver laboration with the Department of Public Health and training, vehicle adaptation, and assistive devices. provides case management and a range of health and Individuals eligible for services must reside in a nurs- care services, home-delivered meals, nutrition coun- ing facility (for a period of not less than 90 days); must seling and supplements, and transportation and other be receiving Medicaid benefits during the facility stay; services for enrollees who have an HIV or AIDS diagno- and, but for the receipt of home and community- sis and require a nursing home level of care. Services based services, would need the level of care received are available for individuals of any age. Approximate in a nursing facility.71 The program is currently funded number of participants: 1,500.75 to provide transitions through December 31, 2021.72 Home and Community-Based Services for the Community-Based Adult Services (CBAS). This Developmentally Disabled (HCBS-DD) Waiver. This Medi-Cal benefit, formerly known as adult day health waiver is administered by the California Department care, is offered to eligible seniors and persons with of Developmental Services (DDS) and authorizes disabilities age 18 and over who require a nursing home and community-based services  for develop- facility level of care. Services are provided at CBAS mentally disabled  persons who are  regional center centers and include, for example, nursing services; consumers.  The 21 regional centers throughout the mental health services; social services; nutritional state purchase and coordinate services and supports A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 19 for individuals with developmental disabilities of any Long-term care benefit. Medicare provides coverage age. The DD waiver is currently the largest HCBS for nursing facility care for up to 100 days following an waiver program in California as well as in the nation. acute care hospital stay as long as the enrollee needs Approximate number of participants: 120,000.76 skilled care.82 Medi-Cal covers longer nursing facility stays, subacute facility stays, and stays in intermediate Home health. Medicare pays for home health ser- care facilities. Medi-Cal pays for room and board as vices when an individual is deemed homebound and well as needed medical care in the facility, including requires skilled intermittent nursing care or physical skilled therapy. The long-term care benefit is available therapy, speech-language pathology, or continued to individuals of all ages. occupational therapy services. Home health services can include part-time skilled nursing care, therapy, Multipurpose Senior Services Program (MSSP). medical social services, and part-time or intermittent MSSP is a waiver program with a limited number of home health aide services. Medicare does not pay slots that provides social and health care management for 24-hour care, meal delivery, homemaker services to frail seniors 65 and over to enable them to remain (cleaning, shopping), or assistance with activities of living in the community rather than being placed in a daily living if this is the only care needed.77 Medi-Cal nursing facility or other institution. MSSP is predomi- also must provide home health services to any individ- nantly delivered through fee-for-service Medi-Cal. In ual who is entitled to skilled nursing facility services.78 CCI counties, Medi-Cal plans had been in the pro- There is no homebound requirement for Medi-Cal cess of transitioning the benefit into managed care. home health benefits.79 Medi-Cal coverage of home However, under the currently postponed CalAIM health includes intermittent skilled nursing care; in- proposal, the Department of Health Care Services home medical care services; physical, occupational, announced that it would carve this benefit back out of or speech therapy; medical social services; services managed care. Approximate number of participants: of a home health aide; medical supplies; and medical 11,789.83 appliances.80 In-Home Supportive Services (IHSS). This program, administered through the California Department of Social Services, provides personal care services to qualified Medi-Cal enrollees that allow them to remain safely in the home. Some of the services offered through IHSS include housecleaning, shopping, meal preparation, laundry, personal care services, accom- paniment to medical appointments, and protective supervision for individuals with cognitive impairments. Seniors and people with disabilities (including children) are eligible for IHSS. The local county Department of Social Services assesses the enrollee’s level of dependence and determines how much time should be allotted for each needed service. IHSS is a fee- for-service benefit and is not provided by Medi-Cal plans. People enrolled in managed care can enroll in IHSS without having to disenroll from their plan. IHSS is available for individuals of any age. Approximate number of participants: 630,000.81 California Health Care Foundation www.chcf.org 20 Appendix B. Tables Table B1. Dual-Eligible Enrollee Residence, by County, June 2020 NUMBER OF NUMBER OF DUAL-ELIGIBLE MANAGED CARE DUAL-ELIGIBLE MANAGED CARE ENROLLEES MODEL ENROLLEES MODEL Alameda 57,103 Two-Plan Placer 7,558 Regional Alpine 43 Regional Plumas 914 Regional Amador 1,017 Regional Riverside 73,784 Two-Plan Butte 10,149 Regional Sacramento 61,975 Geographic Calaveras 1,407 Regional San Benito 1,510 San Benito Colusa 956 Regional San Bernardino 74,728 Two-Plan Contra Costa 29,893 Two-Plan San Diego 94,111 Geographic Del Norte 1,600 COHS San Francisco 47,489 Two-Plan El Dorado 4,258 Regional San Joaquin 26,856 Two-Plan Fresno 40,751 Two-Plan San Luis Obispo 6,515 COHS Glenn 1,452 Regional San Mateo 17,376 COHS Humboldt 6,296 COHS Santa Barbara 12,238 COHS Imperial 14,142 Imperial Santa Clara 56,605 Two-Plan Inyo 662 Regional Santa Cruz 8,136 COHS Kern 31,792 Two-Plan Shasta 9,252 COHS Kings 4,998 Two-Plan Sierra 164 Regional Lake 4,756 COHS Siskiyou 2,686 COHS Lassen 1,011 COHS Solano 13,702 COHS Los Angeles 451,208 Two-Plan Sonoma 13,250 COHS Madera 5,259 Two-Plan Stanislaus 21,912 Two-Plan Marin 5,289 COHS Sutter 4,721 Regional Mariposa 677 Regional Tehama 3,562 Regional Mendocino 4,376 COHS Trinity 688 COHS Merced 11,248 COHS Tulare 20,625 Two-Plan Modoc 486 COHS Tuolumne 1,991 Regional Mono 158 Regional Ventura 22,038 COHS Monterey 12,560 COHS Yolo 6,132 COHS Napa 4,025 COHS Yuba 3,571 Regional Nevada 2,961 Regional Total 1,421,612 Orange 96,990 COHS Note: COHS is County Organized Health System. Source: CHHS Open Data Portal, “Month of Eligibility, Dual Status, by County, Medi-Cal Certified Eligibility” (June 2020 data). A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 21 Table B2. Dual-Eligible Enrollment, by Medi-Cal Managed Care Model, Plan, and County, 2017 MODEL / MEDI-CAL PLAN COUNTY ENROLLMENT MODEL / MEDI-CAL PLAN COUNTY ENROLLMENT COHS 231,199 Two-Plan 595,176 Cal Optima* Orange 78,365 Alameda Alliance for Health Alameda 19,997 CenCal* San Luis Obispo 6,529 Anthem Blue Cross 2,573 Santa Barbara 12,076 Anthem Blue Cross Contra Costa 827 Central California Alliance Merced 10,720 Contra Costa Health Plan 10,273 for Health* Anthem Blue Cross Fresno 3,778 Monterey 12,333 CalViva Health 10,050 Santa Cruz 7,818 Health Net Kern 2,974 Gold Coast* Ventura 21,569 Kern Family Health Care 6,776 Health Plan of San Mateo* San Mateo 9,059 Anthem Blue Cross Kings 575 Partnership Health Plan* Del Norte 1,568 CalViva Health 886 Humboldt 5,941 Health Net* Los Angeles 139,007 Lake 4,682 LA Care* 231,201 Lassen 955 Anthem Blue Cross Madera 470 Marin 5,294 CalViva Health 1,038 Mendocino 4,459 Inland Empire Health Plan* Riverside 32,718 Modoc 456 Molina* 9,989 Napa 3,702 Inland Empire Health Plan* San Bernardino 33,593 Shasta 8,944 Molina* 8,084 Siskiyou 2,539 Anthem Blue Cross San Francisco 2,435 Solano 13,333 San Francisco Health Plan 11,423 Sonoma 14,114 Health Net San Joaquin 516 Trinity 652 Health Plan of San Joaquin 9,041 Yolo 6,091 Anthem Blue Cross* Santa Clara 13,477 Santa Clara Family Health Plan* 30,690 Health Net Stanislaus 2,437 Health Plan of San Joaquin 3,824 Anthem Blue Cross Tulare 3,118 Health Net 3,406 *These Medi-Cal Plans are responsible for the delivery of long-term services and supports (LTSS). Note: COHS is County Organized Health System. California Health Care Foundation www.chcf.org 22 Table B2. Dual-Eligible Enrollment, by Medi-Cal Managed Care Model, Plan, and County, 2017, continued MODEL / MEDI-CAL PLAN COUNTY ENROLLMENT MODEL / MEDI-CAL PLAN COUNTY ENROLLMENT Geographic Managed Care 92,395 Anthem Blue Cross Mariposa 99 Anthem Blue Cross Sacramento 7,083 California Health and Wellness 29 Health Net 5,565 Anthem Blue Cross Mono 32 Kaiser 5,946 California Health and Wellness 17 Molina 3,925 Anthem Blue Cross Nevada 463 Care1st* San Diego 14,133 California Health and Wellness 269 (now Blue Shield Promise) Anthem Blue Cross Placer 833 Community Health Group* 19,178 California Health and Wellness 306 Health Net* 15,054 Kaiser 161 Kaiser* 6,473 Anthem Blue Cross Plumas 114 Molina* 15,038 California Health and Wellness 101 Regional Managed Care 9,135 Anthem Blue Cross Sierra 24 Anthem Blue Cross Alpine 10 California Health and Wellness 8 California Health and Wellness 2 Anthem Blue Cross Sutter 607 Anthem Blue Cross Amador 188 California Health and Wellness 242 California Health and Wellness 26 Anthem Blue Cross Tehama 259 Kaiser 2 California Health and Wellness 347 Anthem Blue Cross Butte 1,061 Anthem Blue Cross Tuolumne 152 California Health and Wellness 1,212 California Health and Wellness 178 Anthem Blue Cross Calaveras 120 Anthem Blue Cross Yuba 413 California Health and Wellness 203 California Health and Wellness 211 Anthem Blue Cross Colusa 104 Imperial 2,662 California Health and Wellness 51 California Health and Wellness Imperial 2,004 Anthem Blue Cross El Dorado 210 Molina 658 California Health and Wellness 659 San Benito 79 Kaiser 42 Anthem Blue Cross San Benito 79 Anthem Blue Cross Glenn 119 California Health and Wellness 156 Anthem Blue Cross Inyo 40 California Health and Wellness 65 *These Medi-Cal Plans are responsible for the delivery of long-term services and supports (LTSS). Note: COHS is County Organized Health System. Source: CMS, Medicaid Managed Care Enrollment and Program Characteristics, 2017 (PDF) (Winter 2019). A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 23 Table B3. Dual-Eligible Enrollment, by Medi-Cal Parent Company, 2017 MEDI-CAL PARENT COMPANY ENROLLMENT Alameda Alliance for Health 19,997 Anthem Blue Cross 39,263 CalOptima 78,365 CalViva Health 11,974 Care 1st (now Blue Shield Promise) 14,133 CenCal 18,605 Centene (Health Net & California Health & Wellness) 175,045 Central California Alliance for Health 30,871 Community Health Group 19,178 Contra Costa Health Plan 10,273 Gold Coast 21,569 Health Plan of San Joaquin 12,865 Health Plan of San Mateo 9,059 Inland Empire Health Plan 66,311 Kaiser 12,624 Kern Family Health Care 6,776 LA Care 231,201 Molina 37,694 Partnership Health Plan 72,730 San Francisco Health Plan 11,423 Santa Clara Family Health Plan 30,690 Source: CMS, Medicaid Managed Care Enrollment and Program Characteristics, 2017 (PDF) (Winter 2019). California Health Care Foundation www.chcf.org 24 Table B4. Dual-Eligible Enrollment in Dual Eligible Special Needs Plans (D-SNP), by Contract Number, June 2020 PLAN ID PLAN NAME COUNTIES OF OPERATION ENROLLMENT H0524 029 Kaiser Senior Advantage Medicare Los Angeles, Kern, Riverside, San Bernardino, 29,510 Medi-Cal Plan South San Diego, Ventura 030 Kaiser Senior Advantage Medicare Alameda, Contra Costa, Fresno, Marin, Sacramento, 43,518 Medi-Cal Plan North San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus H0544 003 Anthem MediBlue Connect Los Angeles and Santa Clara 178 052 Anthem MediBlue Dual Advantage Fresno, Kings, Madera, Tulare 884 053 Anthem MediBlue Dual Advantage Kern County 776 054 Anthem MediBlue Dual Advantage San Francisco, Sacramento 4,851 055 Anthem MediBlue Dual Advantage Ventura 880 087 Anthem MediBlue Dual Plus Fresno, Kings, Madera, Tulare 771 088 Anthem MediBlue Dual Plus Kern 504 089 Anthem MediBlue Dual Plus San Francisco, Sacramento 4,217 090 Anthem MediBlue Dual Plus Ventura 456 100 Anthem MediBlue Dual Advantage San Joaquin 525 H0562 055 Health Net Seniority Plus Amber I Los Angeles, Kern, Orange, Riverside, San Bernardino, 928 Fresno, San Diego, San Francisco, Tulare 121 Health Net Seniority Plus Amber II Parts of southern and northern California 3,966 H0571 005 CCHP Senior Select Program San Francisco 2,848 H0838 024 Brand New Day Dual Access Plan Fresno, Imperial, Kern, Kings, Los Angeles, Orange, 2,167 Riverside, San Bernardino, Tulare H1375 001 UnitedHealthcare Dual Complete Alameda 314 002 UnitedHealthcare Dual Complete Fresno, Kings, Madera 397 H3561 001 Health Net Seniority Plus Amber II Premier Fresno 99 H5087 001 WellCare Freedom Select counties 3,910 H5433 001 OneCare Orange 1,431 H5619 038 Humana Gold Plus SNP-DE H5619-038 Select counties in California 7,895 H5649 002 Central Health Medi-Medi Plan Los Angeles, San Bernardino 3,409 009 Central Health Ventura Medi-Medi Plan Ventura 434 014 Central Health Elite San Joaquin 16 H5810 001 Molina Medicare Complete Care Los Angeles, San Diego, parts of Riverside and 1,121 San Bernardino 013 Molina Medicare Complete Care Imperial 1,029 A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 25 Table B4. Dual-Eligible Enrollment in Dual Eligible Special Needs Plans (D-SNP), by Contract Number, June 2020, continued PLAN ID PLAN NAME COUNTIES OF OPERATION ENROLLMENT H5928 001 Blue Shield Promise TotalDual Plan Los Angeles 504 005 Blue Shield Promise TotalDual Plan Orange, San Bernardino 172 009 Blue Shield Promise TotalDual Plan San Diego 244 054 Blue Shield Promise TotalDual Plan Fresno, San Joaquin, Stanislaus 32 H8552 030 Anthem MediBlue Dual Access Select counties 1,561 Total D-SNP Enrollment 119,547 Source: SNP Comprehensive Report (June 2020), CMS (n.d.). Table B5. Cal MediConnect Plan Enrollment, by County, May 2020 PLAN NAME ENROLLMENT Los Angeles Anthem 2,208 Promise Health Plan 2,730 Health Net 7,332 LA Care 16,302 Molina 1,710 Orange Cal Optima 14,184 Riverside IEHP 14,388 Molina 1,620 San Bernardino IEHP 13,821 Molina 1,496 San Diego Promise Health Plan 2,209 Community Health Group 6,328 Health Net 1,296 Molina 3,963 San Mateo Health Plan of San Mateo 8,538 Santa Clara Anthem 1,999 Santa Clara Family Health Plan 8,551 Total Cal MediConnect Plan Enrollment 108,675 Source: CHHS Open Data Portal, “Medi-Cal Managed Care Enrollment Report” (May 2020 data) (last updated September 2, 2020). California Health Care Foundation www.chcf.org 26 Table B6. D ual-Eligible Enrollment in Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNP) Contract Number H5425, June 2020 PLAN ID PLAN NAME COUNTIES OF OPERATION ENROLLMENT 010 SCAN Connections Los Angeles, Riverside, San Bernardino 12,236 029 SCAN Connections at Home Los Angeles 1,509 030 SCAN Connections at Home Riverside 476 031 SCAN Connections at Home San Bernardino 320 Total FIDE-SNP Enrollment 14,541 Source: SNP Comprehensive Report (June 2020), CMS (n.d.). Table B7. PACE Plan Enrollment, by County, June 2020 PLAN NAME COUNTIES OF OPERATION ENROLLMENT AltaMed Health Services Los Angeles 2,116 Brandman Centers for Senior Care Los Angeles 223 CalOptima PACE Orange 208 Center for Elders’ Independence Alameda, Contra Costa 698 FamilyHealth-Center for Older Adults San Diego 36 Innovative Integrated Health Fresno, Kern, Tulare 484 (Fresno PACE; Bakersfield PACE) Gary and Mary West PACE San Diego 59 InnovAge California PACE Riverside, San Bernardino 734 LA Coast PACE Los Angeles ≤10 On Lok Lifeways Alameda, San Francisco, Santa Clara 1,392 Pacific PACE Los Angeles 58 Redwood Coast PACE Humboldt 185 San Diego PACE San Diego 601 St. Paul’s PACE San Diego 811 Stockton PACE San Joaquin, Stanislaus 123 Sutter SeniorCare PACE Sacramento 360 Total PACE Enrollment 8,098 Source: Integrated Care Resource Center, Program of All-Inclusive Care for the Elderly (PACE) Total Enrollment by State and by Organization (June 2020 data). A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 27 Endnotes 1.As of June 2020, there are 1,421,612 full-benefit dual-eligible 21.County Organized Health Systems (COHS) plans are enrollees in California. California Health and Human Services not required to obtain Knox-Keene licensure. Those that (CHHS), CHHS Open Data Portal, “Month of Eligibility, Dual have not obtained such licensure are not overseen by the Status, by County, Medi-Cal Certified Eligibility,” 2010 to the Department of Managed Health Care. Abbi Coursolle and Most Recent Reportable Month (June 2020). Rachel Landauer, County Organized Health System Medi-Cal Plans (PDF) (National Health Law Program, September 2014). 2.California Department of Health Care Services (DHCS), California Advancing & Innovating Medi-Cal (CalAIM) 22.CMS, Medicare-Medicaid Enrollee Information. Proposal (PDF) (October 28, 2019). 23.CMS, Medicare-Medicaid Enrollee Information; see also 3.DHCS, Expanding Access to Integrated Care for Dual Eligible CMS, Medicare-Medicaid Enrollee State Profile, California Californians (PDF) (December 9, 2019). (PDF), accessed July 18, 2020. 4.DHCS, Proposed 12-Month Extension Request to 24.CMS, Medicare-Medicaid Enrollee Information. Medi-Cal 2020 Section 1115 Waiver (PDF) (July 22, 2020); 25.KFF (Kaiser Family Foundation), ”Medicaid Spending per see also DHCS, 2020–21 May Revision Highlights (PDF) Dual Eligible per Year,” (FY 2013) (n.d.). (May 14, 2020). 26.CMS, Medicare-Medicaid Enrollee State Profile, 5.Centers for Medicare & Medicaid Services (CMS), Preliminary California (PDF) (n.d.); see also Teresa Coughlin, Timothy Medicare COVID-19 Data Snapshot (PDF). Waidmann, and Lokendra Phadera, ”Among Dual Eligibles, 6.“PUF_2012” tab in Medicare-Medicaid Linked Enrollee Identifying the Highest-Cost Individuals Could Help in Analytic Data Source (MMLEADS) Public Use File (PUF) Crafting More Targeted and Effective Responses,” Health Version 2.0 (2006–2012) (02/2019) (XLSX), Centers for Affairs 31, no. 5 (May 2012), doi:10.1377/hlthaff.2011.072. Medicare & Medicaid Services (CMS), “MMCO Statistical & 27.Jose Figueroa et al., “Persistence and Drivers of High- Analytic Reports.” Cost Status Among Dual-Eligible Medicare and Medicaid 7.CMS, ”Medicare-Medicaid Linked.” Beneficiaries: An Observational Study,” Annals of Internal Medicine 169, no. 8 (October 2018): 528, doi:10.7326/ 8.Amber Christ and Tracey Gronniger, Older Women & Poverty, M18-0085. (PDF) Justice in Aging (December 2018); and sources cited therein. 28.Justice in Aging, Durable Medical Equipment: What You Need to Know (PDF) (April 2016). 9.DHCS, Medi-Cal’s Coordinated Care Initiative Population Combined Medicare & Medi-Cal Cost, Utilization, and 29.Margaret Tater, Julia Paradise, and Rachel Garfield, Disease Burden (PDF) (November 2012). Medi-Cal Managed Care: An Overview and Key Issues (KFF, March 2016). 10.The income limit will increase to 138% of the federal poverty level pursuant to California Senate Bill 104 30.DHCS, Medi-Cal Monthly Enrollment Fast Facts (PDF), (Chapter 67, Statutes of 2019) effective December 2020. March 2020 data (released June 2020). DHCS, Stakeholder Communication Update, August 3, 2020. 31.CHHS Open Data Portal, ”Month of Eligibility, Dual 11.CMS, Medicare-Medicaid Enrollee Information: Status, by County, Medi-Cal Certified Eligibility” (June 2020 California, 2011 (PDF) (n.d.). data), accessed July 19, 2020. Note that this is likely an undercount of dual-eligible enrollment in Medi-Cal managed 12.CMS, Medicare-Medicaid Linked. care. Available data only capture the number of dual-eligible 13.CMS, Preliminary Medicare. enrollees who reside in counties in which Medi-Cal enrollment is mandatory. Dual-eligible enrollment in managed care in 14.CMS, Preliminary Medicare. counties where enrollment is optional is not available. 15.CMS, Preliminary Medicare. 32.For an extensive discussion of the elements 16.Jonathan M. Wortham et al., “Characteristics of Persons of the CCI, see Amber Christ, Advocates Guide to Who Died with COVID-19 — United States, February 12 – California’s Coordinated Care Initiative, Justice in Aging May 18, 2020” (PDF), Morbidity and Mortality Weekly Report (December 2017). 69, no. 21 (July 17, 2020): 923. 33.CMS, Contract Between United States Department of 17.Wortham et al., “Characteristics of Persons.” Health and Human Services Centers for Medicare & Medicaid Services In Partnership with California Department of Health 18.CMS, Medicare-Medicaid Linked. Care Services (PDF) (September 1, 2019). 19.CMS, Medicare-Medicaid Linked. 34.DHCS, Medi-Cal Managed Care Program Fact Sheet – 20.CMS, Preliminary Medicare. Managed Care Models (PDF) (January 2, 2020). California Health Care Foundation www.chcf.org 28 35.CHHS Open Data Portal, “Month of Eligibility.” 49.Bipartisan Budget Act of 2018 (Public Law No. 115–123), § 50311 (February 9, 2018) (amending 42 U.S.C. § 1395w- 36.CHHS Open Data Portal, “Month of Eligibility.” 28(f)); and 84 Fed. Reg. 15, 680 (April 16, 2019): 15,696–744. 37.In Sacramento County, Medi-Cal enrollees must enroll in See also Justice in Aging, CMS Regulations Set Ground Rules a separate dental managed care plan. In Los Angeles County, for D-SNPs (PDF) (April 2019). Medi-Cal enrollees have the option to enroll in a dental 50.CMS, SNP Comprehensive Report — February 2020 managed care plan or receive dental benefits through fee- (n.d.). for-service. In both counties, there are three dental managed care plans available: HealthNet, Liberty, and Access. 51.DHCS, 2013 MA/SNP Matching Plans (PDF) (n.d.). 38.In 2018, legislation was enacted (Cal. Welf. & Inst. Code 52.Data note: The Medicare Advantage enrollment § 14184.90) to pilot the integration of the Medi-Cal dental estimate in this paper is derived from data obtained from the benefit for the Health Plan of San Mateo. Health Plan of Medicaid and CHIP Payment Access Commission (MACPAC), San Mateo, HPSM Dental Integration Program (PDF) by custom data request, Availability of and Projected Total (January 27, 2020). The pilot is in the planning stage. Enrollment in Medicare Advantage Plan Types in California, 2019 and 2020, received April 27, 2020, available from the 39.For background on the CBAS program, see Settlement authors. The estimate used MACPAC’s analysis of 2019 and Agreement in Darling v. Douglas (PDF) (N.D. CA, Dec. 13, 2020 Medicare Advantage bid data from CMS and, based 2011), which preserved adult day health care by transitioning on historical enrollment, the authors estimated that dual- the program to the Community-Based Adult Services eligible enrollees constituted 10% of enrollment in Medicare program available only through Medi-Cal managed care. Advantage plans, excluding D-SNP look-alikes. The D-SNP 40.The Home and Community-Based Services Waiver for look-alike exclusion was calculated using a conservative the Developmentally Disabled is an exception. Enrollees in estimate that dual-eligible enrollees represented 80% of the HCBS-DD waiver do not enroll in Medi-Cal managed enrollment in D-SNP look-alike plans. care except in San Mateo County. See DHCS, “Home and 53.MedPAC, Managed Care Plans for Dual-Eligible Community-Based Services Waiver for the Developmentally Beneficiaries, June 2018, 274. Disabled,” last modified December 17, 2019. 54.MedPAC, Managed Care Plans, 273. 41CMS, Memorandum of Understanding, California Demonstration to Integrate Care for Dual Eligible 55.MedPAC, Managed Care Plans, 274. Beneficiaries Between CMS and the State of California (PDF), 56.MedPAC, Managed Care Plans, 274. In California, look- (n.d.). alike plans were first introduced by plan sponsors in 2014 42.Data note: The Medicare enrollment figures for as a way around state restrictions on D-SNP enrollment in California dual-eligible enrollees are estimates. The Medicare counties where Cal MediConnect plans were offered. These managed care enrollment estimate is based on several data restrictions were intended to promote enrollment in Cal sets and represents an estimate of total dual-eligible enrollees MediConnect. Instead, look-alike plans increased from 4 at in Medicare managed care. The fee-for-service estimate is that time to 38 today. derived from subtracting dual-eligible enrollment in D-SNPs, 57.See, e.g., 85 Fed. Reg. 9002, 9020 (PDF) D-SNP look-alike plans, other Medicare Advantage plans, (February 18, 2020). FIDE-SNPs, Cal MediConnect plans, and PACE from the June 2020 total number of dual-eligible enrollees. The fee-for- 58.85 Fed. Reg. 9002, 9020. service number as presented is an overestimate, because the 59.Numerator is total number enrolled in integrated look-alike and other Medicare Advantage data are not current products and denominator is total number of dual-eligible and are estimates. enrollees: 131,314 ÷ 1,421,612 = 9%. 43.42 U.S.C. § 1396a(n)(3)(B); and Cal. Welf. & Inst. Code 60.CHHS Open Data Portal, “Month of Eligibility.” § 14019.4 61.42 C.F.R. § 422.2. 44.CMS, Access to Care Issues Among Qualified Medicare Beneficiaries (QMB) (PDF) (July 2015), 50. 62.CMS, SNP Comprehensive Report. 45.42 C.F.R. § 423.782. 63.National PACE Association, ”The History of PACE” (n.d.). 46.Gretchen Jacobson et al., ”A Dozen Facts About Medicare Advantage in 2019” (KFF, June 6, 2019). 64.DHCS, “California Program of All-Inclusive Care for the Elderly Plans” (last modified June 16, 2020). 47.42 C.F.R. § 422.504(g)(1)(iii). 65.Integrated Care Resource Center, Program of All-Inclusive 48.“Anti-Discrimination,” chap. 4, sec. 10.5.2 in CMS, Care for the Elderly (PACE) Total Enrollment by State and Medicare Managed Care Manual (PDF) (April 2016). by Organization (June 2020 data). A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care www.chcf.org 29 66.Justice in Aging, Coordinated Care Initiative Fix List (PDF) (last modified March 9, 2015). 67.The CalAIM proposal did not discuss funding for an ombudsman program, indicating only that the state would provide education and training to the long-term care ombudsman. DHCS, Expanding Access to Integrated Care for Dual Eligible Californians. 68.Justice in Aging, Coordinated Care. 69.DHCS, Assisted Living Waiver (ALW) Year to Date Enrollment and Waitlist January 2019 Through March 2020 (PDF) (data as of March 1, 2020). 70.DHCS, California Community Transitions (CCT) Lead Organizations and Contact Information (PDF) (updated March 19, 2020). 71.DHCS, Money Follows the Person Rebalancing Demonstration: California Community Transitions Operational Protocol 1.5 (PDF) (updated February 2017). 72.CARES Act, H.R. 748, 116th Cong. § 3811 (March 27, 2020). 73.California Department of Aging, Community-Based Adult Services (CBAS): Program Statistical Fact Sheet (February 2020). 74.DHCS, Home and Community-Based Alternatives Waiver (HCBA) Monthly Dashboard: March 2020 (PDF). 75.California Department of Public Health, ”AIDS Medi-Cal Waiver Program” (updated June 11, 2018). 76.DHCS, Overview of Medi-Cal Home and Community- Based Services (copy available from the author). 77.CMS, “Home Health Services” (n.d.). 78.42 C.F.R. § 440.220(a)(3). 79.42 C.F.R. § 440.70. 80.22 C.C.R. § 51337. 81.California Department of Social Services, “IHSS Program Data” (June 2020 data). 82.CMS, “Skilled Nursing Facility (SNF) Care” (accessed July 19, 2020). 83.DHCS, Overview of Medi-Cal Home. California Health Care Foundation www.chcf.org 30