APRIL 2021 Issue Brief Meeting the Moment: Strengthening Managed Care's Capacity to Serve California's Seniors and Persons with Disabilities Introduction Proposed Reforms to Improve Care Like their counterparts across the country, California's Seniors and Persons with Disabilities (SPDs) face serious Integration and Delivery for Dually obstacles and challenges navigating fragmented systems Eligible Enrollees and Other SPDs of medical and long-term services and supports to get Most SPDs in California must navigate a fragmented the care they need.1 Yet, through the reform elements and uncoordinated network of services to access the full proposed in its California Advancing and Innovating range of Medi-Cal benefits, including long-term services Medi-Cal (CalAIM) initiative, the state has the potential to and supports (LTSS). Most Medi-Cal-only SPDs and increase system integration and coordination of care for some dually eligible individuals are required to enroll in the approximately two million SPDs - including those a Medi-Cal managed care plan (MCP), yet many LTSS with Medi-Cal only and those enrolled in both Medicare are administered outside the managed care delivery and Medi-Cal (dually eligible enrollees).2 system, through fee-for-service Medi-Cal, counties, or waiver agencies. For dually eligible enrollees in particu- The state's commitment to improving how the Medi-Cal lar, the administration and delivery of Medi-Cal benefits program works for SPDs is underscored by the 2021–22 vary significantly statewide (Figure 1 on page 2). budget proposal of California Governor Gavin Newsom, which allocates significant funding for CalAIM and inte- Of California's 58 counties, only 27 have mandatory gration efforts, and the Governor's recently released enrollment into Medi-Cal managed care for dually eligible Master Plan for Aging, which includes recommendations enrollees - those that are part of the Coordinated Care for improvements and innovation in care delivery for Initiative (CCI) or have a County Organized Health System SPDs.3, 4 In addition, the California Department of Health (COHS) Medi-Cal managed care model (see boxed text Care Services continues to solicit input and feedback from on page 2).6 Dually eligible enrollees in the remaining relevant stakeholders - including Medi-Cal managed 31 counties currently have the option of enrolling in an care plans, long-term services and supports providers, MCP or receiving their Medi-Cal benefits through fee-for- and SPDs and their families - that can inform CalAIM service, and most choose the latter.7 This complexity has implementation. motivated the state to test policy and financing options that increase coordination across systems with the goal To support stakeholders in preparing for these changes, of reduced fragmentation and improved care delivery. this issue brief reviews foundational challenges that the However, existing initiatives have not been implemented state, its Medi-Cal managed care partners, and other statewide, and several rely on time-limited federal fund- stakeholders face in implementing proposed reforms; ing for demonstrations or pilot programs. California now highlights key success factors for the innovation and has the opportunity, as part of the CalAIM initiative, to integration of care from the perspective of representa- take lessons learned across the various models and pilots tives from Medi-Cal managed care plans interviewed to develop a statewide approach to the delivery of care by the authors; and describes opportunities to advance for SPDs. capacity to develop an integrated system of medical and long-term services and supports for all SPDs.5 Figure 1. C urrent Landscape of Medi-Cal Managed Care Enrollment, Long-Term Care Benefit Integration, and Pilot Programs Impacting Seniors and Persons with Disabilities Del Norte Siskiyou Modoc ◾ Limited Managed Care Model • Mandatory MCP enrollment for only specified non-dually eligible individuals Shasta ◾ County Organized Health System (COHS) Trinity Lassen • Mandatory MCP enrollment for dually eligible individuals Humboldt • Institutional long-term care carve-in Tehama Plumas ◾ COHS with Health Homes Program (HHP), Mendocino Butte Whole Person Care (WPC), or both Glenn Sierra • Mandatory MCP enrollment for dually eligible individuals Nevada Yuba Placer • Institutional long-term care carve-in Lake Colusa • HHP/WPC benefits available to target populations Sutter Yolo El Dorado Sonoma Napa Sacra- Alpine ◾ HHP, WPC, or both mento Amador • HHP/WPC benefits available to target populations Solano Calaveras Marin San Tuolumne San Francisco Contra Joaquin Costa Mono ◾ Coordinated Care Initiative Alameda Stanislaus Mariposa • Mandatory MCP enrollment for dually eligible individuals San Mateo Santa • Institutional long-term care carve-in Merced • Experience with Medicare/Medi-Cal Plans (Cal MediConnect) Clara Santa Cruz Madera • MLTSS integration experience Fresno San Inyo Benito Tulare Monterey Kings San Luis Obispo Kern Santa Barbara San Bernardino Ventura Los Angeles Riverside Orange San Diego Imperial 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 2 CalAIM is a comprehensive framework developed to as currently proposed, DHCS would require all MCPs build on several reforms authorized under the state's to offer an aligned D-SNP by 2025. current federal 1115 Medicaid Waiver (Medi-Cal 2020), which is set to expire on December 31, 2021.8 As pro- A Enhanced Care Management (ECM). 10 ECM is a pro- posed, CalAIM would address broad delivery system and posed statewide Medi-Cal managed care benefit that payment reforms across the Medi-Cal program, while also would provide intensive, comprehensive care man- advancing policy and program changes aimed at improv- agement and access to social services and supports ing care integration and person-centered care delivery for for Medi-Cal members with the most complex needs. Medi-Cal enrollees. Although the California Department Implementation of this benefit is intended to replace of Health Care Services (DHCS) formally released the the current Health Homes Program (HHP) and Whole CalAIM proposal in October 2019, efforts were paused Person Care (WPC) Pilot program. ECM will be imple- to focus on COVID-19 response efforts. A revised CalAIM mented through a phased-in approach beginning with proposal was released in early January 2021 with the core the transition of populations served under the HHP components of the original proposal intact. Targeted and WPC pilots in January 2022, with full statewide reforms that are expected to improve care for dually eli- implementation for all target populations expected gible enrollees and other SPDs are described below.9 by January 2023. See the appendix for the mandatory Figure 2 provides detail on the implementation timelines ECM target populations. for each of these reforms (see page 4). A In Lieu of Services (ILOS). 11 Implementation of ILOS A Statewide mandatory enrollment of dually eligible will enable MCPs to receive payment to provide flexible enrollees. Dually eligible enrollees in all non-CCI and wraparound services that address medical and social non-COHS counties will be mandatorily enrolled into determinants of health (SDOH) issues. Many of these Medi-Cal managed care by January 2023 as a key step services are currently provided via waivers but are not toward expanding access to integrated care statewide. currently reimbursable for MCPs as Medi-Cal benefits. These services would function as a substitute for - or A Statewide institutional Long-Term Care (LTC) carve- in lieu of - higher levels of care, including hospitaliza- in. By January 2023, institutional LTC will become a tion or nursing facility care. Under ILOS, MCPs could statewide benefit under Medi-Cal managed care, choose to offer and be reimbursed for alternative sup- expanding beyond the CCI and COHS counties that portive services that are likely to decrease costs over currently deliver this benefit. All MCPs will need con- time. Plans may begin offering ILOS in 2022, but per tracting and oversight capacity for LTC facility benefits federal regulation, ILOS is optional for both the MCP beyond the first two months, including skilled nursing and for the enrollee, so these services may not be facilities, intermediate care facilities, and subacute offered consistently statewide. See the appendix for facility care. All MCPs will then bear risk as payment the proposed menu of ILOS. will transition from a distinct capitation rate for mem- bers in institutional LTC to a single blended capitation A Statewide managed LTSS (MLTSS) benefit as a lon- rate for all SPDs. ger-range goal. The above transitions and reforms are intended to serve as incremental steps toward A Transition to aligned Dual Eligible Special establishing a statewide MLTSS model under the Needs Plans (D-SNPs) and MCPs. To address Medi-Cal program by 2027. This approach of phasing the December 31, 2022, sunsetting of the Cal both Medi-Cal enrollees and benefits into managed MediConnect (CMC) program, DHCS has proposed care gives the delivery system time to develop the developing an aligned D-SNP and MCP model. infrastructure needed to expand LTSS access and bet- MCPs in CCI counties would be required to operate ter coordinate its delivery. Over time, dually eligible a D-SNP by January 1, 2023, to ensure that current enrollees and other SPDs would be able to access CMC enrollees have the option to enroll in a Medicare more LTSS services through their MCP. product that is aligned with their MCP. Under CalAIM 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 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) 2022 JANUARY 1 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 ECM: MCPs in counties with HHP/WPC Pilots must implement ECM for existing HHP/WPC target populations* ILOS: ILOS rate methodology available to MCPs statewide; (optional) ILOS implementation begins*† JULY 1 ECM: MCPs in counties with HHP/WPC must expand ECM implementation to additional target populations MCPs in counties without HHP/WPC must begin ECM implementation for select target populations 2023 JANUARY 1 Mandatory MCP Enrollment: Statewide mandatory MCP enrollment of dually eligible individuals Aligned D-SNP Transition: MCPs in CCI counties must have aligned D-SNPs operating and available to enrolled dually eligible individuals Dually eligible individuals in CCI 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 ECM: Implementation expanded to all target populations statewide Institutional LTC Carve-In: Institutional long-term care services carved in for MCPs statewide 2024 JANUARY 1 Aligned D-SNP Transition: Dually eligible individuals in non-CCI 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 D-SNPs statewide that are not aligned with an MCP in the same county may not accept new enrollment of dually eligible individuals 2025 JANUARY 1 Aligned D-SNP Transition: MCPs in non-CCI counties must operate D-SNPs 2027 JANUARY 1 Statewide Managed LTSS: All Medi-Cal enrollees are eligible for managed LTSS * See appendix. †  ILOS 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 4 In parallel to CalAIM development and implementa- A Ensuring statewide access to high-quality Medi-Cal tion, a re-procurement process for commercial MCPs is home- and community-based services (HCBS). As slated to occur. A request for proposal (RFP) for this MCP California aims to increase access to community-based procurement process is expected to be released in late care as an alternative to institutional care, significant 2021, with planned implementation of new MCP con- disparities in the availability of HCBS - including tracts in 2024. While re-procurement is distinct from the variation in the breadth and depth of HCBS coverage broader CalAIM initiative, the process should serve as and provider experience - present challenges. Some an opportunity to incorporate CalAIM policy elements, aspects impacting statewide access include: including efforts to integrate care, into all MCP contracts. $ Unequal availability of HCBS options due to the current Medi-Cal benefit structure, where HCBS Core Elements of an Integrated waiver services are only offered in certain service System of Care for Dually Eligible areas or counties and often with limited capacity;12 Enrollees and Other SPDs $ Low Medi-Cal reimbursement rates and the nega- Foundational Elements - tive impact this has on HCBS provider network Addressing Current Challenges development and direct care workforce capacity California's proposed reforms have significant potential necessary to meet demand; to improve care delivery for dually eligible enrollees and $ Inadequacy of home and community placement other SPDs, building on the current LTSS and Medi-Cal options due in large part to the limited supply of managed care systems while expanding access to inte- sustainable supportive housing and tenancy sup- grated care. As policymakers, MCPs, and key partners ports for SPDs; and work together to advance these important reforms, fun- damental challenges in the current California landscape $ Reliance on the presence of informal (unpaid) should be considered. caregivers in discharge planning and determining whether home-based care is offered, given the criti- A Consolidating accountability across the continuum cal role caregivers play in HCBS settings. of care. Having a single accountable entity that can effectively integrate care and manage benefits and A Streamlining coordination and strengthening data- costs across the care continuum is expected to result sharing capacity. Considerable investment will be in better outcomes and reduced costs over time - needed at the state, county, MCP, and provider levels although California's experiences with such efforts to develop the capacity to collect, share, and ana- (e.g., through CCI, CMC, HHP, and WPC) have varied. lyze data that would support care coordination and Fully understanding and applying the lessons from integration across the delivery system. This will be these demonstrations and pilots would, however, needed most when a single point of accountability provide a strong foundation for the development of for an enrollee is not feasible given various Medi-Cal statewide integrated care models. Additionally, with managed care benefit carve-outs, which will require the responsibility for financing and delivery of ser- solutions that help coordinate with services excluded vices - physical health, dental, behavioral health, from capitated MCP reimbursement.13 In addition, and LTSS for SPDs - being shared across a wide clear expectations and requirements for information array of programs and providers, meeting the chal- sharing could create access to real-time data to inform lenge of coordinating the full continuum of care will policy and financing changes and, over the longer not be easy. MCPs will benefit from sharing replicable term, would support development of evidence-based best practices that are focused on assuming greater care approaches. Specific challenges that would need accountability for both delivery and coordination of to be overcome include: these benefits. 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 financing across the continuum of care, there can be: sharing across MCPs, network providers, commu- (a) an increased ability to meet enrollee preferences nity-based organizations, and partially integrated for care in community settings, (b) funding to help behavioral health and LTSS providers; build adequate LTSS and social services provider net- works, and (c) increased accountability and oversight $ Gaps in the ability to collect and effectively use by a single responsible entity. The statewide carve-in LTSS needs assessment data to connect Medi-Cal of institutional LTC benefits alongside flexible ILOS enrollees with social services and supports in the would position MCPs and provider partners to build community; and a more integrated system of medical, LTSS, and social $ Lack of standardized data-sharing agreements and services. ILOS, as proposed, also creates incentives for a need for consistent interpretation of state and MCPs statewide to offer new flexible services that can federal law regarding permissible data sharing address social determinants of health (SDOH) needs. between entities and across the delivery system. Together with the proposed ECM benefit, reimburse- ment for ILOS under capitated MCP payments will be Key Success Factors for Medi-Cal Managed central to the ability of MCPs to build or expand net- Care to Achieve Integrated Care works and infrastructure that can meet the diverse and Many of the state's proposed reforms seek to leverage often complex needs of SPDs. managed care as an avenue for achieving more coordi- nated and integrated care for dually eligible enrollees A Building capacity to prevent avoidable stays in and other SPDs.14 In interviews with MCPs and stake- institutional settings. Increasing access to HCBS as holders about the reforms, several themes emerged an alternative to institutionalization is a central focus regarding key success factors that would help advance of proposed reforms, particularly salient given the dis- these changes. proportionate impact of COVID-19 on LTC facilities. The proposed ECM benefit and ILOS flexibility offers A Supporting tailored approaches to care manage- opportunities to better support SPDs eligible for insti- ment. Incentives and pathways to offer more tailored tutional care in the setting of their choice - which can strategies for care management would give MCPs benefit Medi-Cal enrollees, MCPs, and the state. In the flexibility to respond to individual needs and pro- addition, the statewide carve-in of institutional LTC vide more effective care. The proposed transition to benefits will further focus MCPs' attention on man- the aligned D-SNP/MCP platform will require MCPs aging care transitions to prevent unnecessary use of to respond to a higher threshold of collaborative and institutional care. To achieve this, MCPs, particularly interdisciplinary care management requirements that those newly at risk for institutional LTC benefits, will promote integration across medical and nonmedical need to develop a thorough understanding of the services and aim to close gaps in care across Medicare institutional and home- and community-based care and Medi-Cal service delivery. Additionally, the pro- continuum. They also will need to establish or expand posed ECM benefit will expand the responsibility of programs aimed at diversion from institutional LTC MCPs to identify needs and coordinate care to holisti- settings and transition from institutions to commu- cally address medical, social, and LTSS needs. To do nity-based services. Insights from MCPs and provider this successfully, plans would value having flexibility to partners that have developed successful models in create individualized approaches to care that reflect this area would provide helpful guidance to all parties the heterogeneity of SPDs and the diversity of their newly working to manage these transitions. needs. A Addressing health disparities. Addressing health A Leveraging flexible capitated financing to align disparities, especially racial inequities in access to incentives and address social needs across the con- services and health outcomes, will be an essential tinuum of care. When MCPs have financial risk in a component for achieving effective person-centered person-centered model that integrates benefits and care for dually eligible enrollees and other SPDs. California Health Care Foundation www.chcf.org 6 Understanding and addressing the mechanisms con- comprehensive needs assessments, (b) developing tributing to these inequities would help MCPs and interdisciplinary care management teams across set- providers more readily respond to consumer needs tings and providers, (c) engaging in data collection and develop targeted outreach strategies. Although and sharing, and (d) implementing robust quality ECM and ILOS may offer increased opportunities to reporting between MCPs, providers, and any del- support member needs and could serve as tools to egated care managers. MCPs will need to identify help address health disparities, DHCS could bolster and work with a broad array of provider contractors these efforts with clear expectations for MCPs regard- to develop needed skills and capacity to provide ser- ing equitable approaches to care delivery and service vices to SPDs while working toward higher standards coverage. Additionally, the aligned D-SNP/MCP plat- for care coordination and data sharing to enhance form and the eventual goal of statewide MLTSS also members' experience of care. could expand opportunities to address inequities, including supporting comprehensive data collection A HCBS and Community-Based Organization (CBO) and reporting across entities on service use by race network development and oversight. Expanding and ethnicity. beyond the medical model will require new MCP network development strategies. Some MCPs will be navigating HCBS and social service systems for the Opportunities to Advance first time, so they will need to build capacity to con- Managed Care's Capacity to Serve tract with and oversee HCBS providers and CBOs that can deliver ILOS and other services to their enrollees. California's Dually Eligible Enrollees Similarly, HCBS providers and CBOs will need to build and Other SPDs or expand capacity and capabilities to collaborate California's MCPs have varying levels of experience with MCPs. Collaborative learning across MCPs, HCBS with building LTSS networks, integrating Medicare and providers, and other social service providers around Medicaid benefits and financing, and coordinating the billing processes, assessment and care planning, data full continuum of care for SPDs with complex needs. sharing, reporting capacity, and other managed care Therefore, implementation of the reforms highlighted program elements will aid these efforts. in this issue brief will require different MCP capacity- building activities based on plan experience with existing A Oversight and value-based contracting for institu- Medi-Cal demonstration or pilot programs, delivery of tional LTC and HCBS. The development of greater institutional LTC, and operation of Medicare products, institutional LTC expertise - including renegotiating including D-SNPs. While significant opportunities exist facility contracts and developing new relationships to for federal, state, local, and philanthropic partners to support diversion and transition to community set- help identify lessons and replicable best practices that tings - will be particularly important for MCPs in the can contribute to the success of proposed reforms, MCPs non-CCI and non-COHS counties whose responsibil- will need to: (1) identify their own capabilities and gaps, ity for covering institutional LTC will expand. MCPs (2) devise internal capacity-building strategies, and (3) newly facing institutional care risk also will need to support provider partners to ensure the capability of their build oversight capacity across a broad range of LTSS networks. The following are suggested areas for MCPs to to help identify individuals that could best be served focus on, with the goal of increasing their potential for in community settings and advance value-based con- success as they work with provider partners and other tracting strategies to support high-quality HCBS and key stakeholders. diversion and transition efforts. A Integrated care operations and workflows. Truly A Medicare operations and contracting expertise. integrating medical, LTSS, and social services requires MCPs without prior experience operating D-SNPs will that MCPs and providers build system capacities need to better understand Medicare coverage and that include, but are not limited to: (a) conducting 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 About the Authors Advantage provider networks as the state shifts to the Giselle Torralba, MPH, is a program associate and aligned D-SNP/MCP platform. MCPs new to enrolling Alexandra Kruse, MS, MHA, is the associate director dually eligible enrollees will also have to establish pro- for integrated care, state programs at the Center for cesses to effectively coordinate care delivery across Health Care Strategies, a national nonprofit policy cen- Medicare and Medicaid, despite benefit carve-outs ter dedicated to improving the health of low-income and potential data-sharing hurdles. Building Medicare Americans, including those dually eligible for Medicare knowledge among MCPs and key partners by leverag- and Medicaid and in need of Medicaid long-term ser- ing MCP experience under the CMC program would vices and supports. Athena Chapman, MPP, is president provide useful insights, particularly around coordi- and Elizabeth Evenson is policy director at Chapman nating care across the full spectrum of benefits and Consulting, which provides strategic planning, meeting designing value-based contracting strategies to sup- facilitation, organizational support, market research, and port this new aligned model. regulatory and statutory analysis to organizations in the health care field. Conclusion About the Foundation Over the next few years, California is primed to advance The California Health Care Foundation is dedicated to several Medi-Cal reforms that hold significant promise to advancing meaningful, measurable improvements in the improve care for its dually eligible enrollees and other way the health care delivery system provides care to the SPDs. With the reactivation of proposals under CalAIM people of California, particularly those with low incomes and related steps to reinforce the initiative's goals, the and those whose needs are not well served by the status state and its partners (federal agencies, MCPs, and pro- quo. We work to ensure that people have access to the viders) have numerous opportunities to advance more care they need, when they need it, at a price they can integrated and person-centered care delivery that can afford. holistically address the needs of SPDs. With insights from the MCPs themselves, this issue brief highlights pri- CHCF informs policymakers and industry leaders, invests orities for the state and its stakeholders to keep top of in ideas and innovations, and connects with changemak- mind as this work unfolds over the next several years. ers to create a more responsive, patient-centered health Fortunately, DHCS is well positioned to address most care system. 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. California Health Care Foundation www.chcf.org 8 Appendix. O verview of Enhanced Care Management (ECM) Target Populations and Proposed In Lieu of Services (ILOS) he California Department of Health Care Services (DHCS) has presented its vision for Enhanced Care Management T (ECM) and In Lieu of Services (ILOS) in its California Advancing and Innovating Medi-Cal (CalAIM) proposal documents.15 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. $ 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.16 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 $ 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 $ Environmental Accessibility Adaptations (Home Modifications) $ Meals/Medically Tailored Meals $ 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.Long-term services and supports (LTSS) available to Medi- 13.In-Home Supportive Services, dental, and specialty mental Cal enrollees include care provided in both institutional and health for serious behavioral health conditions are three notable home- and community-based settings. Medi-Cal LTSS benefits benefits carved out of Medi-Cal managed care in all counties. include, but are not limited to, skilled nursing facility services, The long-term care benefit, which covers nursing home and personal care services, self-directed personal assistance services, other institutional care, is covered in the MCP benefit package in Community First Choice Option (In-Home Supportive Services), County Organized Health System (COHS) and Coordinated Care and Home and Community-Based Services. For additional Initiative (CCI) counties, and only covered for one month after detail, see: Athena Chapman and Elizabeth Evenson, Medi-Cal the month of admission to a nursing home or other institutional Explained Fact Sheet: Long-Term Services and Supports in setting in the remaining counties (after which the enrollee Medi-Cal (PDF), California Health Care Foundation (CHCF), receives all Medi-Cal benefits through fee-for-service). The October 2020. Multipurpose Senior Services Program is currently covered by MCPs in CCI counties and fee-for-service in the rest of the state. 2.California Department of Health Care Services (DHCS), Summary For additional detail, see: Christ and Burke, A Primer on Dual- Table of Medi-Cal Certified Eligibles, Seniors and Persons with Eligible Californians, CHCF. Disabilities, by County and Age Group, December 2016 Month of Enrollment (PDF), California Health Care Foundation (CHCF), 14.Michelle Herman Soper, Alexandra Kruse, and Camille Dobson, June 2017. The Value of Pursuing Medicare-Medicaid Integration for Medicaid Agencies (PDF), ADvancing States and Center for California Budget, 2021–2022, California Department of Finance, 3. Health Care Strategies, November 22, 2019. accessed March 22, 2021. 15.CalAIM Proposal, DHCS. Master Plan for Aging, California Department of Aging, accessed 4. March 22, 2021. 16.CalAIM Proposal, DHCS. 5.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. 6.Amber Christ and Georgia Burke, A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi- Cal Receive Their Care (PDF), California Health Care Foundation (CHCF), September 2020. 7.Christ and Burke, A Primer on Dual-Eligible Californians, CHCF. California Advancing & Innovating Medi-Cal (CalAIM) Proposal 8. (PDF), California Department of Health Care Services (DHCS), January 2021. 9. CalAIM Proposal, DHCS. 10.Enhanced Care Management and In Lieu of Services, California Department of Health Care Services (DHCS), last updated March 11, 2021. 11.Enhanced Care Management, DHCS. 12.Chapman and Evenson, Medi-Cal Explained Fact Sheet, CHCF. California Health Care Foundation www.chcf.org 10