Aw

Issue Brief

CHCF

Meeting the Moment:

 

APRIL 2021

Strengthening Managed Care's Capacity to Serve
California's Seniors and Persons with Disabilities

Introduction

Like their counterparts across the country, California's
Seniors and Persons with Disabilities (SPDs) face serious
obstacles and challenges navigating fragmented systems
of medical and long-term services and supports to get
the care they need.' Yet, through the reform elements
proposed in its California Advancing and Innovating
Medi-Cal (CalAIM) initiative, the state has the potential to
increase system integration and coordination of care for
the approximately two million SPDs - including those
with Medi-Cal only and those enrolled in both Medicare
and Medi-Cal (dually eligible enrollees).?

The state's commitment to improving how the Medi-Cal
program works for SPDs is underscored by the 2021-22
budget proposal of California Governor Gavin Newsom,
which allocates significant funding for CalAIM and inte-
gration efforts, and the Governor' recently released
Master Plan for Aging, which includes recommendations
for improvements and innovation in care delivery for
SPDs.*4 In addition, the California Department of Health
Care Services continues to solicit input and feedback from
relevant stakeholders - including Medi-Cal managed
care plans, long-term services and supports providers,
and SPDs and their families - that can inform CalAIM
implementation.

To support stakeholders in preparing for these changes,
this issue brief reviews foundational challenges that the
state, its Medi-Cal managed care partners, and other
stakeholders face in implementing proposed reforms;
highlights key success factors for the innovation and
integration of care from the perspective of representa-
tives from Medi-Cal managed care plans interviewed
by the authors; and describes opportunities to advance
capacity to develop an integrated system of medical and
long-term services and supports for all SPDs.°

Proposed Reforms to Improve Care
Integration and Delivery for Dually
Eligible Enrollees and Other SPDs

Most SPDs in California must navigate a fragmented
and uncoordinated network of services to access the full
range of Medi-Cal benefits, including long-term services
and supports (LTSS). Most Medi-Cal-only SPDs and
some dually eligible individuals are required to enroll in
a Medi-Cal managed care plan (MCP), yet many LTSS
are administered outside the managed care delivery
system, through fee-for-service Medi-Cal, counties, or
waiver agencies. For dually eligible enrollees in particu-
lar, the administration and delivery of Medi-Cal benefits
vary significantly statewide (Figure 1 on page 2).

Of California's 58 counties, only 27 have mandatory
enrollment into Medi-Cal managed care for dually eligible
enrollees - those that are part of the Coordinated Care
Initiative (CCl) or have a County Organized Health System
(COHS) Medi-Cal managed care model (see boxed text
on page 2).° Dually eligible enrollees in the remaining
31 counties currently have the option of enrolling in an
MCP or receiving their Medi-Cal benefits through fee-for-
service, and most choose the latter." This complexity has
motivated the state to test policy and financing options
that increase coordination across systems with the goal
of reduced fragmentation and improved care delivery.
However, existing initiatives have not been implemented
statewide, and several rely on time-limited federal fund-
ing for demonstrations or pilot programs. California now
has the opportunity, as part of the CalAIM initiative, to
take lessons learned across the various models and pilots
to develop a statewide approach to the delivery of care
for SPDs.
Figure 1. Current Landscape of Medi-Cal Managed Care Enrollment, Long-Term Care Benefit Integration, and Pilot Programs
Impacting Seniors and Persons with Disabilities

 

 
 
  
  
  
  
 
 
  
 
  
  
 
 
 
  
 

Siskiyou Niece |_| Limited Managed Care Model
¢ Mandatory MCP enrollment for only specified non-dually eligible individuals

Shasta MM County Organized Health System (COHS)
sin) ~~ * Mandatory MCP enrollment for dually eligible individuals
¢ Institutional long-term care carve-in

Mi COHS with Health Homes Program (HHP),
Whole Person Care (WPC), or both
© Mandatory MCP enrollment for dually eligible individuals
* Institutional long-term care carve-in
* HHP/WPC benefits available to target populations

Alpine ™@ HHP WPC, or both
¢ HHP/WPC benefits available to target populations

TUN N(eI8

Marin Tuolumne we
Mono : Coordinated Care Initiative

« Mandatory MCP enrollment for dually eligible individuals
* Institutional long-term care carve-in
Experience with Medicare/Medi-Cal Plans (Cal MediConnect)

Madera © MLTSS integration experience

Monterey

San Luis
oso

SCNT IC) STM nar CIN

nic Los Angeles

VaR

ASTID tO TY
Notes: MCP is Medi-Cal managed care plan;

MLTSS is managed long-term services and supports.

Source: Author analysis based on California Department of Health Care Services sources.

Background on Select Medi-Cal Managed Care Models

The Coordinated Care Initiative (CCI) was implemented in California in 2014 with the goal of improving the integration and
coordination of medical benefits and long-term services and supports (LTSS) for dually eligible enrollees and other Medi-

Cal Seniors and Persons with Disabilities (SPDs) through mandatory enrollment in managed care, broader integration of
LTSS, and development of Cal MediConnect (CMC). CMC is California's capitated model demonstration under the Financial
Alignment Initiative, which is operated in partnership with the Centers for Medicare & Medicaid Services. This demonstration
coordinates the service delivery of both Medicare and Medi-Cal benefits - including limited LTSS and carved-out benefits
- under one plan for full-benefit dually eligible enrollees. Seven counties participate in CCI (Los Angeles, Orange, Riverside,
San Bernardino, San Diego, San Mateo, and Santa Clara). CMC is currently set to expire December 31, 2022.

In the County Organized Health System (COHS) model, a single managed care plan (MCP) is operated by the county and
is the sole plan serving the Medi-Cal population in that county. Dually eligible enrollees are required to enroll in a Medi-Cal
plan in all 22 COHS counties, and under this model, institutional long-term care benefits are carved into MCP contracts.
(Note: Two COHS counties, Orange and San Mateo, also participate in CCI.)

 

California Health Care Foundation www.chcf.org
CalAIM is a comprehensive framework developed to
build on several reforms authorized under the state's
current federal 1115 Medicaid Waiver (Medi-Cal 2020),
which is set to expire on December 31, 2021.8 As pro-
posed, CalAIM would address broad delivery system and
payment reforms across the Medi-Cal program, while also
advancing policy and program changes aimed at improv-
ing care integration and person-centered care delivery for
Medi-Cal enrollees. Although the California Department
of Health Care Services (DHCS) formally released the
CalAIM proposal in October 2019, efforts were paused
to focus on COVID-19 response efforts. A revised CalAIM
proposal was released in early January 2021 with the core
components of the original proposal intact. Targeted
reforms that are expected to improve care for dually eli-
gible enrollees and other SPDs are described below.'
Figure 2 provides detail on the implementation timelines
for each of these reforms (see page 4).

» Statewide mandatory enrollment of dually eligible
enrollees. Dually eligible enrollees in all non-CCl and
non-COHS counties will be mandatorily enrolled into
Medi-Cal managed care by January 2023 as a key step
toward expanding access to integrated care statewide.

» Statewide institutional Long-Term Care (LTC) carve-
in. By January 2023, institutional LTC will become a
statewide benefit under Medi-Cal managed care,
expanding beyond the CCI and COHS counties that
currently deliver this benefit. All MCPs will need con-
tracting and oversight capacity for LTC facility benefits
beyond the first two months, including skilled nursing
facilities, intermediate care facilities, and subacute
facility care. All MCPs will then bear risk as payment
will transition from a distinct capitation rate for mem-
bers in institutional LTC to a single blended capitation
rate for all SPDs.

» Transition to aligned Dual Eligible Special
Needs Plans (D-SNPs) and MCPs. To address
the December 31, 2022, sunsetting of the Cal
MediConnect (CMC) program, DHCS has proposed
developing an aligned D-SNP and MCP model.
MCPs in CCl counties would be required to operate
a D-SNP by January 1, 2023, to ensure that current
CMC enrollees have the option to enroll in a Medicare
product that is aligned with their MCP. Under CalAIM

as currently proposed, DHCS would require all MCPs
to offer an aligned D-SNP by 2025.

» Enhanced Care Management (ECM).'° ECM is a pro-
posed statewide Medi-Cal managed care benefit that
would provide intensive, comprehensive care man-
agement and access to social services and supports
for Medi-Cal members with the most complex needs.
Implementation of this benefit is intended to replace
the current Health Homes Program (HHP) and Whole
Person Care (WPC) Pilot program. ECM will be imple-
mented through a phased-in approach beginning with
the transition of populations served under the HHP
and WPC pilots in January 2022, with full statewide
implementation for all target populations expected
by January 2023. See the appendix for the mandatory
ECM target populations.

> In Lieu of Services (ILOS)."' Implementation of ILOS
will enable MCPs to receive payment to provide flexible
wraparound services that address medical and social
determinants of health (SDOH) issues. Many of these
services are currently provided via waivers but are not
currently reimbursable for MCPs as Medi-Cal benefits.
These services would function as a substitute for - or
in lieu of - higher levels of care, including hospitaliza-
tion or nursing facility care. Under ILOS, MCPs could
choose to offer and be reimbursed for alternative sup-
portive services that are likely to decrease costs over
time. Plans may begin offering ILOS in 2022, but per
federal regulation, ILOS is optional for both the MCP
and for the enrollee, so these services may not be
offered consistently statewide. See the appendix for
the proposed menu of ILOS.

» Statewide managed LTSS (MLTSS) benefit as a lon-
ger-range goal. The above transitions and reforms
are intended to serve as incremental steps toward
establishing a statewide MLTSS model under the
Medi-Cal program by 2027. This approach of phasing
both Medi-Cal enrollees and benefits into managed
care gives the delivery system time to develop the
infrastructure needed to expand LTSS access and bet-
ter coordinate its delivery. Over time, dually eligible
enrollees and other SPDs would be able to access
more LTSS services through their MCP.

 

Meeting the Moment: Strengthening Managed Care's Capacity to Serve California's Seniors and Persons with Disabilities

www.chcf.org 3
Figure 2. Implementation Milestones for CalAIM Reforms Expected to Impact Seniors and Persons with Disabilities

 

Bryy JANUARY 1

JULY 1

PIER JANUARY 1

boy JANUARY 1

 

Po JANUARY 1
~
NX
JANUARY 1

*See appendix.

Mandatory Enrollment into a Managed Care Plan (MCP)
Aligned Dual Eligible Special Needs Plan (D-SNP) Transition
Enhanced Care Management (ECM)
In Lieu of Services (ILOS)
Institutional Long-Term Care (LTC) Carve-In
Statewide Managed Long-Term Services and Supports (LTSS)

Mandatory MCP Enrollment: Statewide mandatory MCP enrollment of non-dually eligible Medi-Cal
enrollees across all Medi-Cal aid codes

Aligned D-SNP Transition: MCPs in CCI counties may transition enrolled dually eligible individuals into
affiliated D-SNPs that were approved for that service area as of January 1, 2013

Mandatory MCP Enrollment: Statewide mandatory MCP enrollment of dually eligible individuals

Aligned D-SNP Transition:

e MCPs in CCI counties must have aligned D-SNPs operating and available to enrolled dually
eligible individuals

e Dually eligible individuals in CCl counties who are not already enrolled in another D-SNP
for contract year 2022 can only enroll in a D-SNP if it is aligned with their MCP

 

Institutional LTC Carve-In: Institutional long-term care services carved in for MCPs statewide

Aligned D-SNP Transition:

@ Dually eligible individuals in non-CCl counties who are not already enrolled in another D-SNP for the
prior contract year can only enroll in a D-SNP if it is aligned with their MCP

e D-SNPs statewide that are not aligned with an MCP in the same county may not accept new enrollment
of dually eligible individuals

Aligned D-SNP Transition: MCPs in non-CCl counties must operate D-SNPs

Statewide Managed LTSS: All Medi-Cal enrollees are eligible for managed LTSS

TILOS are optional for both enrollees and MCPs, meaning that MCPs can choose which ILOS to offer, and enrollees can elect not to use an ILOS. If an MCP chooses
to offer ILOS, the offered services must be made available to all of their enrollees.

Notes: CCI is Coordinated Care Initiative; HHP is Health Homes Program; WPC is Whole Person Care.

Source: Author analysis of California Advancing & Innovating Medi-Cal (CalAIM) Proposal (PDF), California Department of Health Care Services, January 2021.

 

California Health Care Foundation www.chcf.org

ih
In parallel to CalAIM development and implementa-
tion, a re-procurement process for commercial MCPs is
slated to occur. A request for proposal (RFP) for this MCP
procurement process is expected to be released in late
2021, with planned implementation of new MCP con-
tracts in 2024. While re-procurement is distinct from the
broader CalAIM initiative, the process should serve as
an opportunity to incorporate CalAIM policy elements,
including efforts to integrate care, into all MCP contracts.

Core Elements of an Integrated
System of Care for Dually Eligible
Enrollees and Other SPDs

Foundational Elements -

Addressing Current Challenges

California's proposed reforms have significant potential
to improve care delivery for dually eligible enrollees and
other SPDs, building on the current LTSS and Medi-Cal
managed care systems while expanding access to inte-
grated care. As policymakers, MCPs, and key partners
work together to advance these important reforms, fun-
damental challenges in the current California landscape
should be considered.

» Consolidating accountability across the continuum
of care. Having a single accountable entity that can
effectively integrate care and manage benefits and
costs across the care continuum is expected to result
in better outcomes and reduced costs over time -
although California's experiences with such efforts
(e.g., through CCI, CMC, HHP, and WPC) have varied.
Fully understanding and applying the lessons from
these demonstrations and pilots would, however,
provide a strong foundation for the development of
statewide integrated care models. Additionally, with
the responsibility for financing and delivery of ser-
vices - physical health, dental, behavioral health,
and LTSS for SPDs - being shared across a wide
array of programs and providers, meeting the chal-
lenge of coordinating the full continuum of care will
not be easy. MCPs will benefit from sharing replicable
best practices that are focused on assuming greater
accountability for both delivery and coordination of
these benefits.

» Ensuring statewide access to high-quality Medi-Cal
home- and community-based services (HCBS). As
California aims to increase access to community-based
care as an alternative to institutional care, significant
disparities in the availability of HCBS - including
variation in the breadth and depth of HCBS coverage
and provider experience - present challenges. Some
aspects impacting statewide access include:

Unequal availability of HCBS options due to the
current Medi-Cal benefit structure, where HCBS
waiver services are only offered in certain service
areas or counties and often with limited capacity;'?

Low Medi-Cal reimbursement rates and the nega-
tive impact this has on HCBS provider network
development and direct care workforce capacity
necessary to meet demand;

Inadequacy of home and community placement
options due in large part to the limited supply of
sustainable supportive housing and tenancy sup-
ports for SPDs; and

Reliance on the presence of informal (unpaid)
caregivers in discharge planning and determining
whether home-based care is offered, given the criti-
cal role caregivers play in HCBS settings.

» Streamlining coordination and strengthening data-
sharing capacity. Considerable investment will be
needed at the state, county, MCP, and provider levels
to develop the capacity to collect, share, and ana-
lyze data that would support care coordination and
integration across the delivery system. This will be
needed most when a single point of accountability
for an enrollee is not feasible given various Medi-Cal
managed care benefit carve-outs, which will require
solutions that help coordinate with services excluded
from capitated MCP reimbursement.'* In addition,
clear expectations and requirements for information
sharing could create access to real-time data to inform
policy and financing changes and, over the longer
term, would support development of evidence-based
care approaches. Specific challenges that would need
to be overcome include:

 

Meeting the Moment: Strengthening Managed Care's Capacity to Serve California's Seniors and Persons with Disabilities

www.chcf.org 5
Limited platforms and capacity for robust data
sharing across MCPs, network providers, commu-
nity-based organizations, and partially integrated
behavioral health and LTSS providers;

Gaps in the ability to collect and effectively use
LTSS needs assessment data to connect Medi-Cal
enrollees with social services and supports in the
community; and

Lack of standardized data-sharing agreements and
a need for consistent interpretation of state and
federal law regarding permissible data sharing
between entities and across the delivery system.

Key Success Factors for Medi-Cal Managed
Care to Achieve Integrated Care

Many of the state's proposed reforms seek to leverage
managed care as an avenue for achieving more coordi-
nated and integrated care for dually eligible enrollees
and other SPDs."* In interviews with MCPs and stake-
holders about the reforms, several themes emerged
regarding key success factors that would help advance
these changes.

» Supporting tailored approaches to care manage-
ment. Incentives and pathways to offer more tailored
strategies for care management would give MCPs
the flexibility to respond to individual needs and pro-
vide more effective care. The proposed transition to
the aligned D-SNP/MCP platform will require MCPs
to respond to a higher threshold of collaborative and
interdisciplinary care management requirements that
promote integration across medical and nonmedical
services and aim to close gaps in care across Medicare
and Medi-Cal service delivery. Additionally, the pro-
posed ECM benefit will expand the responsibility of
MCPs to identify needs and coordinate care to holisti-
cally address medical, social, and LTSS needs. To do
this successfully, plans would value having flexibility to
create individualized approaches to care that reflect
the heterogeneity of SPDs and the diversity of their
needs.

» Leveraging flexible capitated financing to align
incentives and address social needs across the con-
tinuum of care. When MCPs have financial risk in a
person-centered model that integrates benefits and

financing across the continuum of care, there can be:
(a) an increased ability to meet enrollee preferences
for care in community settings, (b) funding to help
build adequate LTSS and social services provider net-
works, and (c) increased accountability and oversight
by a single responsible entity. The statewide carve-in
of institutional LTC benefits alongside flexible ILOS
would position MCPs and provider partners to build
amore integrated system of medical, LTSS, and social
services. ILOS, as proposed, also creates incentives for
MCPs statewide to offer new flexible services that can
address social determinants of health (SDOH) needs.
Together with the proposed ECM benefit, reimburse-
ment for ILOS under capitated MCP payments will be
central to the ability of MCPs to build or expand net-
works and infrastructure that can meet the diverse and
often complex needs of SPDs.

Building capacity to prevent avoidable stays in
institutional settings. Increasing access to HCBS as
an alternative to institutionalization is a central focus
of proposed reforms, particularly salient given the dis-
proportionate impact of COVID-19 on LTC facilities.
The proposed ECM benefit and ILOS flexibility offers
opportunities to better support SPDs eligible for insti-
tutional care in the setting of their choice - which can
benefit Medi-Cal enrollees, MCPs, and the state. In
addition, the statewide carve-in of institutional LTC
benefits will further focus MCPs' attention on man-
aging care transitions to prevent unnecessary use of
institutional care. To achieve this, MCPs, particularly
those newly at risk for institutional LTC benefits, will
need to develop a thorough understanding of the
institutional and home- and community-based care
continuum. They also will need to establish or expand
programs aimed at diversion from institutional LTC
settings and transition from institutions to commu-
nity-based services. Insights from MCPs and provider
partners that have developed successful models in
this area would provide helpful guidance to all parties
newly working to manage these transitions.

» Addressing health disparities. Addressing health

disparities, especially racial inequities in access to
services and health outcomes, will be an essential
component for achieving effective person-centered
care for dually eligible enrollees and other SPDs.

 

California Health Care Foundation

www.chcf.org 6
Understanding and addressing the mechanisms con-
tributing to these inequities would help MCPs and
providers more readily respond to consumer needs
and develop targeted outreach strategies. Although
ECM and ILOS may offer increased opportunities to
support member needs and could serve as tools to
help address health disparities, DHCS could bolster
these efforts with clear expectations for MCPs regard-
ing equitable approaches to care delivery and service
coverage. Additionally, the aligned D-SNP/MCP plat-
form and the eventual goal of statewide MLTSS also
could expand opportunities to address inequities,
including supporting comprehensive data collection
and reporting across entities on service use by race
and ethnicity.

Opportunities to Advance
Managed Care's Capacity to Serve
California's Dually Eligible Enrollees
and Other SPDs

Californias MCPs have varying levels of experience
with building LTSS networks, integrating Medicare and
Medicaid benefits and financing, and coordinating the
full continuum of care for SPDs with complex needs.
Therefore, implementation of the reforms highlighted
in this issue brief will require different MCP capacity-
building activities based on plan experience with existing
Medi-Cal demonstration or pilot programs, delivery of
institutional LTC, and operation of Medicare products,
including D-SNPs. While significant opportunities exist
for federal, state, local, and philanthropic partners to
help identify lessons and replicable best practices that
can contribute to the success of proposed reforms, MCPs
will need to: (1) identify their own capabilities and gaps,
(2) devise internal capacity-building strategies, and (3)
support provider partners to ensure the capability of their
networks. The following are suggested areas for MCPs to
focus on, with the goal of increasing their potential for
success as they work with provider partners and other
key stakeholders.

» Integrated care operations and workflows. Truly
integrating medical, LTSS, and social services requires
that MCPs and providers build system capacities
that include, but are not limited to: (a) conducting

comprehensive needs assessments, (b) developing
interdisciplinary care management teams across set-
tings and providers, (c) engaging in data collection
and sharing, and (d) implementing robust quality
reporting between MCPs, providers, and any del-
egated care managers. MCPs will need to identify
and work with a broad array of provider contractors
to develop needed skills and capacity to provide ser-
vices to SPDs while working toward higher standards
for care coordination and data sharing to enhance
members' experience of care.

HCBS and Community-Based Organization (CBO)
network development and oversight. Expanding
beyond the medical model will require new MCP
network development strategies. Some MCPs will be
navigating HCBS and social service systems for the
first time, so they will need to build capacity to con-
tract with and oversee HCBS providers and CBOs that
can deliver ILOS and other services to their enrollees.
Similarly, HCBS providers and CBOs will need to build
or expand capacity and capabilities to collaborate
with MCPs. Collaborative learning across MCPs, HCBS
providers, and other social service providers around
billing processes, assessment and care planning, data
sharing, reporting capacity, and other managed care
program elements will aid these efforts.

Oversight and value-based contracting for institu-
tional LTC and HCBS. The development of greater
institutional LTC expertise - including renegotiating
facility contracts and developing new relationships to
support diversion and transition to community set-
tings - will be particularly important for MCPs in the
non-CCI and non-COHS counties whose responsibil-
ity for covering institutional LTC will expand. MCPs
newly facing institutional care risk also will need to
build oversight capacity across a broad range of LTSS
to help identify individuals that could best be served
in community settings and advance value-based con-
tracting strategies to support high-quality HCBS and
diversion and transition efforts.

Medicare operations and contracting expertise.
MCPs without prior experience operating D-SNPs will
need to better understand Medicare coverage and
rules, how to align the operation of disparate MCP

 

Meeting the Moment: Strengthening Managed Care's Capacity to Serve California's Seniors and Persons with Disabilities | www.chcf.org 7
and D-SNP products, and how to establish Medicare
Advantage provider networks as the state shifts to the
aligned D-SNP/MCP platform. MCPs new to enrolling
dually eligible enrollees will also have to establish pro-
cesses to effectively coordinate care delivery across
Medicare and Medicaid, despite benefit carve-outs
and potential data-sharing hurdles. Building Medicare
knowledge among MCPs and key partners by leverag-
ing MCP experience under the CMC program would
provide useful insights, particularly around coordi-
nating care across the full spectrum of benefits and
designing value-based contracting strategies to sup-
port this new aligned model.

Conclusion

Over the next few years, California is primed to advance
several Medi-Cal reforms that hold significant promise to
improve care for its dually eligible enrollees and other
SPDs. With the reactivation of proposals under CalAIM
and related steps to reinforce the initiative's goals, the
state and its partners (federal agencies, MCPs, and pro-
viders) have numerous opportunities to advance more
integrated and person-centered care delivery that can
holistically address the needs of SPDs. With insights
from the MCPs themselves, this issue brief highlights pri-
orities for the state and its stakeholders to keep top of
mind as this work unfolds over the next several years.
Fortunately, DHCS is well positioned to address most
of these priorities via ongoing and active engagement
with stakeholders. As efforts to design and implement
proposed reforms continue, it is vital that stakeholders
support this momentum and elevate these and other pri-
orities to help shape this new system of care for dually
eligible enrollees and other SPDs.

About the Authors

Giselle Torralba, MPH, is a program associate and
Alexandra Kruse, MS, MHA, is the associate director
for integrated care, state programs at the Center for
Health Care Strategies, a national nonprofit policy cen-
ter dedicated to improving the health of low-income
Americans, including those dually eligible for Medicare
and Medicaid and in need of Medicaid long-term ser-
vices and supports. Athena Chapman, MPP, is president
and Elizabeth Evenson is policy director at Chapman
Consulting, which provides strategic planning, meeting
facilitation, organizational support, market research, and
regulatory and statutory analysis to organizations in the
health care field.

About the Foundation

The California Health Care Foundation is dedicated to
advancing meaningful, measurable improvements in the
way the health care delivery system provides care to the
people of California, particularly those with low incomes
and those whose needs are not well served by the status
quo. We work to ensure that people have access to the

care they need, when they need it, at a price they can
afford.

CHCF informs policymakers and industry leaders, invests
in ideas and innovations, and connects with changemak-
ers to create a more responsive, patient-centered health
care system.

 

California Health Care Foundation

www.chcf.org 8
Appendix. Overview of Enhanced Care Management (ECM) Target Populations and Proposed In Lieu of
Services (ILOS)

The California Department of Health Care Services (DHCS) has presented its vision for Enhanced Care Management
(ECM) and In Lieu of Services (ILOS) in its California Advancing and Innovating Medi-Cal (CalAIM) proposal documents."
DHCS describes ECM as a whole-person, interdisciplinary approach to comprehensive care management that addresses
the clinical and nonclinical needs of high-cost, high-need managed care members through systematic coordination of
services that is community-based, interdisciplinary, high-touch, and person-centered. Table A1 presents DHCS's pro-
posed mandatory target populations for ECM. These are subject to further refinement by DHCS, and managed care
plans (MCPs) may propose additional populations or propose expansions of criteria within populations to increase eli-
gibility for ECM. It will be the responsibility of the MCPs to risk-stratify their members, assess their needs, apply criteria,
determine eligibility, and oversee the delivery of the ECM benefit.

Table A1. Mandatory Enhanced Care Management (ECM) Target Populations

» Children or youth with complex physical, behavioral, developmental and/or oral health needs
(i.e., California Children Services, foster care, youth with Clinical High-Risk syndrome or first episode of psychosis).

Individuals experiencing homelessness, chronic homelessness, or who are at risk of becoming homeless.
High utilizers with frequent hospital admissions, short-term skilled nursing facility stays, or emergency room visits.
Individuals at risk for institutionalization who are eligible for long-term care services.

Nursing facility residents who want to transition to the community.

vvvvyy

Individuals at risk for institutionalization with Serious Mental Illness (SMI), children with Serious Emotional Disturbance (SED)
or Substance Use Disorder (SUD) with co-occurring chronic health conditions.

» Individuals transitioning from incarceration who have significant complex physical or behavioral health needs requiring
immediate transition of services to the community.

DHCS describes ILOS as: (1) medically appropriate and cost-effective alternatives to services covered under the State
Plan, and (2) optional services for Medi-Cal MCPs to provide and for enrollees to accept.'* Table A2 presents DHCS's
proposed ILOS offerings that MCPs can propose to offer to their members. These proposed services are subject to fur-
ther refinement by DHCS, and additional ILOS can be proposed for DHCS approval beyond what is listed here. Starting
in January 2022, DHCS will authorize 14 preapproved ILOS in its contracts with MCPs.

Table A2. Proposed Menu of In Lieu of Services (ILOS)
Housing Transition Navigation Services

Housing Deposits

Housing Tenancy and Sustaining Services

Short-term Post-Hospitalization Housing

Recuperative Care (Medical Respite)

Respite Services

Day Habilitation Programs

vvvvvrvvyiy

Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly (RCFE)
and Adult Residential Facilities (ARF)

Community Transition Services/Nursing Facility Transition to a Home

Personal Care and Homemaker Services

Meals/Medically Tailored Meals

>
>
» Environmental Accessibility Adaptations (Home Modifications)
>
» Sobering Centers

» Asthma Remediation

 

Meeting the Moment: Strengthening Managed Care's Capacity to Serve California's Seniors and Persons with Disabilities | www.chcf.org 9
Endnotes

1.

11.
12.

Long-term services and supports (LTSS) available to Medi-

Cal enrollees include care provided in both institutional and
home- and community-based settings. Medi-Cal LTSS benefits
include, but are not limited to, skilled nursing facility services,
personal care services, self-directed personal assistance services,
Community First Choice Option (In-Home Supportive Services),
and Home and Community-Based Services. For additional
detail, see: Athena Chapman and Elizabeth Evenson, /Viedi-Cal
Explained Fact Sheet: Long-Term Services and Supports in
Medi-Cal (PDR, California Health Care Foundation (CHCF),
October 2020.

. California Department of Health Care Services (DHCS), Summary

Table of Medi-Cal Certified Eligibles, Seniors and Persons with
Disabilities, by County and Age Group, December 2016 Month
of Enrollment (PDR, California Health Care Foundation (CHCF},
June 2017.

. California Budget, 2021-2022, California Department of Finance,

accessed March 22, 2021.

. Master Plan for Aging, California Department of Aging, accessed

March 22, 2021.

. The themes explored in this issue brief emerged from a

series of interviews that the Center for Health Care Strategies
conducted with a diverse set of managed care plans (MCPs)

and other stakeholders in 2020, with support from the California
Health Care Foundation. In May 2020, the state released a
Long-Term Care at Home (LTCAH) proposal in response to
COVID-19 impacts; therefore, a significant focus of the interviews
conducted in the summer of 2020 includes the LTCAH benefit,
which was eventually withdrawn from further consideration by
DHCS in August 2020. However, the themes of integrated care
and the tools that are necessary to successfully implement Medi-
Cal reforms remain consistent for the pending reforms.

. Amber Christ and Georgia Burke, A Primer on Dual-Eligible

Californians: How People Enrolled in Both Medicare and Medi-
Cal Receive Their Care (PDR, California Health Care Foundation
(CHCF), September 2020.

. Christ and Burke, A Primer on Dual-Eligible Californians, CHCF.

. California Advancing & Innovating Medi-Cal (CalAIM) Proposal

(PDA, California Department of Health Care Services (DHCS),
January 2021.

. CalAIM Proposal, DHCS.

. Enhanced Care Management and In Lieu of Services, California

Department of Health Care Services (DHCS), last updated
March 11, 2021.

Enhanced Care Management, DHCS.

Chapman and Evenson, Medi-Cal Explained Fact Sheet, CHCF.

13.

14.

15.
16.

In-Home Supportive Services, dental, and specialty mental
health for serious behavioral health conditions are three notable
benefits carved out of Medi-Cal managed care in all counties.
The long-term care benefit, which covers nursing home and
other institutional care, is covered in the MCP benefit package in
County Organized Health System (COHS) and Coordinated Care
Initiative (CCI) counties, and only covered for one month after
the month of admission to a nursing home or other institutional
setting in the remaining counties (after which the enrollee
receives all Medi-Cal benefits through fee-for-service). The
Multipurpose Senior Services Program is currently covered by
MCPs in CCl counties and fee-for-service in the rest of the state.
For additional detail, see: Christ and Burke, A Primer on Dual-
Eligible Californians, CHCF.

Michelle Herman Soper, Alexandra Kruse, and Camille Dobson,
The Value of Pursuing Medicare-Medicaid Integration for
Medicaid Agencies (PDR), ADvancing States and Center for
Health Care Strategies, November 22, 2019.

CalAIM Proposal, DHCS.
CalAIM Proposal, DHCS.

 

California Health Care Foundation

www.chcf.org 10