CALIFORNIA Health Care Almanac AUGUST 2021 Medi-Cal Facts and Figures: Essential Source of Coverage for Millions Medi-Cal Facts and Figures Executive Summary Medi-Cal, California's Medicaid program, is the state's health insurance program for Californians with low income, including nearly 4 in 10 children, one in five nonelderly adults, and two million seniors and people with CONTENTS disabilities. It also pays for more than 50% of all births in the state and 55% of all patient days in long-term care facilities.* In total, over 13 million Californians - one in three - rely on the program for health coverage. Medi- Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Cal pays for essential primary, specialty, acute, behavioral health, and long-term care services. The Affordable Care Act allowed states the option to expand Medicaid, and California added over four million Eligibility and Enrollment. . . . . . . . . . . . . . . . 19 adults with low income to the program. Using only state resources, California also expanded Medi-Cal to cover three groups in households with low income regardless of immigration status: children, adults under 26, and in Benefits and Cost Sharing . . . . . . . . . . . . . . . 30 2022, adults age 50 and over. Medi-Cal Facts and Figures: Essential Source of Coverage for Millions presents findings about the Medi-Cal program CalAIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 based on the most recent data available. Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . 35 KEY FINDINGS INCLUDE: • In fiscal year 2019–20, Medi-Cal brought in more than $65 billion in federal funds and accounted for nearly Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 16% of all state general fund spending. • People with disabilities composed 9% of Medi-Cal enrollees, but accounted for 31% of spending. Role in the System. . . . . . . . . . . . . . . . . . . . . . 50 Meanwhile, children accounted for 17% of enrollees, but just 6% of spending. • 85% of people served by Medi-Cal were enrolled in one of six managed care models. Access and Utilization. . . . . . . . . . . . . . . . . . 54 • More than three out of four Medi-Cal enrollees are in households where they or another family member Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 works part- or full-time. • Starting in March 2020, the COVID-19 pandemic, ensuing economic downturn, and related policy changes Looking Ahead. . . . . . . . . . . . . . . . . . . . . . . . . 68 resulted in hundreds of thousands of people enrolling in, or retaining, Medi-Cal coverage. • The state has proposed innovations and changes aimed at improving care for Medi-Cal members. About the Data. . . . . . . . . . . . . . . . . . . . . . . . . 69 The Medi-Cal program faces numerous changes in the coming years, including procuring new contracts with managed care plans, which provide services to 11 million Medi-Cal enrollees in all 58 counties, and transitioning pharmaceutical benefits from managed care plans to the centralized Medi-Cal Rx program. Medi-Cal will also address the needs and costs of an aging population and implement strategies to address disparities in access, quality, and outcomes of care for enrollees of color. * Fee-for-service only. Does not include patient days paid through Medi-Cal managed care contracts. Note: See the current and past editions of Medi-Cal Facts and Figures at www.chcf.org/collection/medi-cal-facts-figures-almanac. CALIFORNIA HEALTH CARE FOUNDATION 2 Medi-Cal Facts and Figures Sources of Insurance Coverage, by Age Group Overview California, 2019 Medi-Cal is an important source of health care coverage for Californians <1%* - 3% 7% 4% 5% ■ Privately Purchased of all ages. According to the California <1% 56% 59% 78% 50% ■ ■ Employment-Based Other Public Health Interview Survey, nearly 40% ■ Medicare of all children in the state, and one in ■ Medicare and Medi-Cal five nonelderly adults, were covered ■ Medi-Cal ■ Uninsured by Medi-Cal. Almost all seniors are eligible for Medicare, and 16% of - 1% Californians over age 65 are reportedly - 1% 1% 12% 38% 1% 1% - 3% also covered by Medi-Cal (known as 20% 22% "dually eligible enrollees"). 16% 2% 11% 1% 1%* 7% Infants and Nonelderly Seniors California Children Adults (age 65+) (up to age 17) (age 18–64) * Indicates that results are statistically unstable. Notes: Insurance status is self-reported. Medi-Cal includes those who reported they have Medi-Cal coverage only, and may include those with restricted-scope benefits. See "About the Data" on page 69 for a full explanation of how this could impact findings. Medicare includes people who have only Medicare as well as Medicare and other. Privately purchased includes those that purchased health insurance directly from an insurance company or HMO, or through Covered California. Other public includes those enrolled in county indigent programs For more information, see A Primer on Dual-Eligible and those with coverage for military personnel, retirees, and dependents. Percentages may not add to 100% due to rounding. Californians: How People Enrolled in Both Medicare and Medi- Source: 2019 California Health Interview Survey, UCLA Center for Health Policy Research. Cal Receive Their Care, CHCF, September 2020. CALIFORNIA HEALTH CARE FOUNDATION 3 Medi-Cal Facts and Figures Health Insurance, by Source of Coverage Overview California, 2013 and 2019 Between 2013 and 2019, the Employment-Based distribution of health insurance 48% 50% coverage shifted, due in part to the Medi-Cal implementation of the Affordable 18% ■ 2013 Care Act in 2014. The percentage 22% ■ 2019 Medicare of Californians who reported being 10% enrolled in Medi-Cal increased from 12% Privately Purchased 18% to 22%, while the percentage 5% of Californians who were uninsured 5% Medicare and Medi-Cal decreased from 14% to 7%. 3% 3% Other Public 3% 1% Uninsured 14% 7% Notes: Insurance status is self-reported. Medi-Cal includes those who reported they had Healthy Families (2013) and may include those with restricted-scope benefits. See "About the Data" on page 69 for a full explanation of how this could impact findings. Medicare includes people who have only Medicare as well as Medicare and other (not Medi-Cal). Other public includes those enrolled in county indigent programs and those with coverage for military personnel, retirees, and dependents. Source: 2019 and 2013 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 4 Medi-Cal Facts and Figures Health Insurance Coverage, by Race/Ethnicity, 2019 Overview Medi-Cal provided health insurance ■ Medi-Cal ■ Uninsured ■ Medicare and Medi-Cal ■ Medicare coverage for about one-third of Latinx ■ Employment-Based ■ Privately Purchased ■ Other Public Californians. Similarly, 28% of Black Latinx Californians were covered by Medi-Cal. 34% 12% 5% 42% 4% 3% 1% Black 28% 4% 7% 12% 46% 3% 1% Asian American 15% 6% 9% 61% 5% 3% 1% White 10% 4% 22% 54% 6% 3% 1% Other 21% 5% 5% 8% 57% 4% 1% Notes: Insurance coverage is self-reported. See "About the Data" on page 69 for a full explanation of how this could impact findings. Other includes those of two or more races, Native Hawaiian / Pacific Islander, and American Indian / Alaska Native. Source uses Black or African American and Asian. Source: 2019 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 5 Medi-Cal Facts and Figures About Medicaid Overview • Federal program created by Title XIX of the Social Security Act in 1965. In California, the The Affordable Care Act gave states program is called Medi-Cal. the option to expand the program • Provides health care coverage to 69 million Americans, including children in families significantly. Medicaid served 69 with low incomes, parents, seniors, people with disabilities, and adults with low million people nationwide in 2020. incomes. • Each state administers its program within federal rules, and financing is shared between state and federal governments. The program must provide benefits to certain mandatory groups meeting eligibility requirements. • Medicaid programs vary significantly across the nation, as states have the option to cover additional groups and use waivers to amend some eligibility requirements, use different care delivery and payment models, and develop other innovations. • Eligibility was expanded to adults with low incomes under the Patient Protection and Affordable Care Act (ACA), passed in 2010 and implemented in 2014. Enrollment has grown by 14.8 million in the 39 states that chose this option. • Nationwide Medicaid expenditures, including both federal and state funds, totaled $604 billion in 2019. Sources: "Program History," Centers for Medicare & Medicaid Services (CMS); "Medicaid Expansion Enrollment" (June 2019), KFF; "Updated July 2020 Applications, Eligibility, and Enrollment Data," CMS, last updated April 2, 2021; "Status of State Medicaid Expansion Decisions: Interactive Map," KFF, last updated May 10, 2021; and "Total Medicaid Spending" (FY 2019), KFF, accessed October 29, 2020. CALIFORNIA HEALTH CARE FOUNDATION 6 Medi-Cal Facts and Figures About Medi-Cal Overview • A source of health care coverage for: Medi-Cal plays a major role in • Nearly one in three Californians the health care system, providing • Nearly 40% of the state's children insurance for one-third of all • 43% of people with disabilities Californians. California has the nation's • About one in six of all California workers age 19 to 64 largest Medicaid program. • Pays for: • More than 50% of all births in the state • 55% of all patient days in long-term care facilities* • Medi-Cal accounts for nearly two-thirds of net patient revenues in California's city/ county hospitals and nearly 75% of net patient revenues for primary care clinics. • Medi-Cal brought in $65 billion in federal funds in FY 2019–20. • Medi-Cal enrollment increased by more than 700,000 between March and December 2020 during the COVID-19 pandemic and economic downturn. * Medi-Cal patient days are fee-for-service only and do not include patient days paid through Medi-Cal managed care contracts. Sources: "Month of Eligibility, Dual Status, by County, Medi-Cal Certified Eligibility," California Dept. of Health and Human Services (CHHS), last updated April 27, 2021; Medicaid in California (PDF), KFF, October 2019; Medi-Cal Explained Fact Sheets: Maternity Care and Paying for Maternity Services, California Health Care Foundation, September 2020; "Long-Term Care Facility Integrated Disclosure and Medi-Cal Cost Report Data & Pivot Tables" (2019), CHHS; "Hospital Annual Financial Data - Selected Data & Pivot Tables" (2019), CHHS; "Primary Care Clinic Annual Utilization Data" (2019), CHHS; and Medi-Cal May 2020 Local Assistance Estimate for Fiscal Years 2019-20 and 2020-21 (PDF), DHCS, accessed August 6, 2020. CALIFORNIA HEALTH CARE FOUNDATION 7 Medi-Cal Facts and Figures Medi-Cal vs. Medicare Overview MEDI-CAL MEDICARE Medi-Cal and Medicare provide Population Children in families with low • Seniors (65+) coverage to different populations, incomes and adults with low • People with permanent disabilities incomes, including but not limited cover different services, and are to: • People with end-stage renal administered separately. However, disease • People who are pregnant 1.4 million California seniors and • People with disabilities • Seniors (65+) with low incomes people with disabilities are eligible • Children, regardless of for both Medi-Cal and Medicare; immigration status they are referred to as "dually eligible Enrollment 13.6 million Californians 6.4 million Californians enrollees."* Services Covered Primary care, specialty care, acute Primary, specialty, and acute care care, long-term care, and mental health and substance use disorder services Cost Sharing No premiums or copayments for Enrollees must pay premiums and enrollees with the lowest incomes deductibles Funded By Federal, state, and county Federal government and enrollees governments Administered By California with oversight by CMS Federal government through CMS * For more information, see A Primer on Dual-Eligible Note: CMS is Centers for Medicare & Medicaid Services. Californians: How People Enrolled in Both Medicare and Medi- Sources: Medi-Cal Monthly Eligible Fast Facts, January 2021. (PDF), California Dept. of Health Care Services, April 2021; and "Total Number of Medicare Beneficiaries" (2020), KFF. Cal Receive Their Care, CHCF, September 2020. CALIFORNIA HEALTH CARE FOUNDATION 8 Medi-Cal Facts and Figures Medi-Cal and the COVID-19 Pandemic Overview As of March 2021, a year after a state of emergency was declared, more than 3.5 million The COVID-19 pandemic has had deep Californians have been diagnosed with COVID-19, and over 54,000 have died from the disease. social, public health, and economic The pandemic dramatically reduced economic activity, resulting in increased unemployment. impacts on California. Medi-Cal Unemployment skyrocketed from 4.3% in February 2020 to 16.4% in May 2020. It has since declined but remained high at 9.0% in December 2020. The Medi-Cal program played a critical provides health services for those role in providing health services to those Californians most affected by the pandemic. disproportionately impacted by the As of April 2021, Latinx Californians represented 56% of cases and 47% of deaths. Medi-Cal pandemic: Latinx Californians and provides health insurance coverage to 34% of all Latinx Californians. residents of long-term care facilities. Black Californians represent 4% of cases and 6% of deaths, and 28% of Black Californians are enrolled in Medi-Cal. Nursing home residents represent 24% of all deaths from COVID-19 in the state, and Medi-Cal paid for 55% of patient days in long-term care facilities. Between March and December 2020, Medi-Cal enrollment increased 8% or just over 1 million.* During the same period in 2019, enrollment decreased by 2%. * It is likely that most of this enrollment increase has resulted from suspending eligibility redeterminations for current enrollees as directed by Executive Orders N-29-20 and N-71-20 during the COVID-19 public health emergency. DHCS assume that about 104,000 enrollees lose eligibility each month and would continue on Medi-Cal due to the redetermination suspension. Sources: "COVID-19: California Case Statistics," California Dept. of Public Health, accessed March 9, 2020; "Tracking the Coronavirus in California Nursing Homes," Los Angeles Times, accessed March 9, 2021; Medi-Cal Enrollment Update (PDF), California Dept. of Health Care Services (DHCS), April 8, 2021; Exec. Order N-29-20 (PDF), State of California, March 17, 2020; Exec. Order N-71-20 (PDF), State of California, June 30, 2020; and Medi-Cal May 2020 Local Assistance Estimate for Fiscal Years 2019-20 and 2020-21, DHCS, accessed July 8, 2021. CALIFORNIA HEALTH CARE FOUNDATION 9 Medi-Cal Facts and Figures Medi-Cal and the COVID-19 Pandemic (continued) Overview Federal COVID-19 emergency resources and regulatory relief has allowed the Medi-Cal program to Federal regulatory flexibilities and temporarily: funding have allowed Medi-Cal to • Provide free COVID-19 testing and treatment to those without insurance play an important role in the COVID- • Pay for services delivered via telehealth at the same rates to those delivered in person 19 pandemic response. • Ease some eligibility and enrollment processes and place a moratorium on redetermining current enrollees' eligibility • Increase payment rates for some services, notably clinical laboratories and skilled nursing facilities • Ease limitations on specific services, such as telehealth and substance use disorder services • Waive requirements such as pre-authorizations and utilization controls Federal COVID-19 funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act has provided emergency resources to Medi-Cal providers, including those that provide health care services to patients with Medi-Cal. Sources: "Federal COVID-19-Related Funding to California," California Legislative Analyst's Office, April 28, 2020; State Plan Amendment #20-0024 (PDF), California Dept. of Health Care Services (DHCS), May 13, 2020; COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children's Health Insurance Program (CHIP) Agencies (PDF), Centers for Medicare & Medicaid Services, last updated January 6, 2021; Request for Section 1135 Waiver Flexibilities Related to Novel Coronavirus Disease (COVID-19) National Emergency/Public Health Emergency (PDF), DHCS, March 16, 2020; "CARES Act Provider Relief Fund: For Providers," US Dept. of Health and Human Services, last reviewed May 7, 2021; "The 2021-22 Budget: Medi-Cal Fiscal Outlook," Legislative Analyst's Office, November 18, 2020. Department of Health Care Services 2020; and Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus (COVID-19), DHCS, January 5, 2021. CALIFORNIA HEALTH CARE FOUNDATION 10 Medi-Cal Facts and Figures The Affordable Care Act (ACA) and Medi-Cal Overview Eligibility Expansions The ACA allows states the option • Starting in 2014, the ACA allowed states to expand Medicaid eligibility to adults under 65 with low incomes. In 2020, California covered four million "expansion" adults, which accounted for 30% of all enrollees. Forty-four percent of to expand Medicaid to adults with expansion adults were Latinx, and over one-third were between age 46 and 64. income levels that made them • The ACA raised the income eligibility threshold for parent and adult caretaker relatives. In addition, eligibility for youth in foster care who are enrolled in Medicaid was extended from age 18 up to age 26. previously ineligible. In 2019, • The ACA included a "maintenance of effort" (MOE) provision prohibiting states from reducing eligibility for children to California had the largest number of levels prior to March 2010, imposing new or increased waiting periods, or increasing premiums. The MOE expired in September 2019. adults enrolled through this expansion Benefit Expansions and has been a leader in enrollment • California expanded benefits to include mild-to-moderate mental health services and substance use disorder services. among the 39 states and the District • California implemented the ACA's Health Homes provision in 12 counties to provide enhanced care management of Columbia that expanded their and coordination for enrollees' complex medical needs and chronic conditions. programs. Eligibility and Enrollment Simplification • The ACA simplified and streamlined eligibility requirements for people without disabilities. California also improved its enrollment system, creating a single online portal to initiate applications for insurance affordability programs, in addition to existing ways to apply. Impact on California • The Medi-Cal expansion contributed significantly to reducing the percentage of Californians without insurance, which declined from 14% in 2013 to 7% in 2019.* • While Medi-Cal's share of the state budget has remained the same, increased federal matching contributions have financed most of the eligibility and enrollment expansions in California. * Self-reported. See "About the Data" on page 69 for a full explanation of how this could impact findings. Sources: Medi-Cal Monthly Eligible Fast Facts (Sept. 2020) (PDF), California Dept. of Health Care Services (DHCS), December 2020; Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 1101, 124 Stat. 119, 141-43 (2010); Summary of the Affordable Care Act, KFF, April 25, 2013; The Maintenance of Effort (MOE) Provision in the Affordable Care Act (PDF), Georgetown Health Policy Institute, May 2017; California Health Homes Program: September 2020 Update (PDF), DHCS; California Health Interview Survey, UCLA Center for Health Policy Research; and "Status of State Medicaid Expansion Decisions: Interactive Map," KFF, last updated May 13, 2021. CALIFORNIA HEALTH CARE FOUNDATION 11 Medi-Cal Facts and Figures Medicaid Legislative History, Selected Milestones Overview FEDERAL CALIFORNIA 1966  Created Medi-Cal Medi-Cal has evolved in response to 1965 Passed Medicaid law changing federal and state policies. 1972 Required states to extend Medicaid to Supplemental Security Income 1973  Established first Medi-Cal managed care plans (SSI) recipients and to seniors and disabled 1980  Created Disproportionate Share Hospital (DSH) Program 1982  Created hospital selective contracting program 1988 Expanded coverage to pregnant women with low 1993 Required most children/parents with Medi-Cal to enroll in managed care plans income and families with infants 1994  Began consolidation of mental health services at county level 1996 Unlinked Medicaid and welfare 1997  Expanded access to family planning services* 1997 Established State Children's Health Insurance Program and 1998  Created Healthy Families program for children limited DSH payments 2000  Extended Medi-Cal to families with incomes at or below 100% FPL 2004  Expanded coverage for home and community-based services 2006 Required applicants to provide proof of citizenship to obtain coverage 2009  Expanded coverage to legal immigrants for up to five years * Family Planning, Access, Care and Treatment (Family PACT) Program Note: FPL is federal poverty level. Source: "Program History," Centers for Medicare & Medicaid Services, accessed July 27, 2021. CALIFORNIA HEALTH CARE FOUNDATION 12 Medi-Cal Facts and Figures Medicaid Legislative History, Selected Milestones (continued) Overview FEDERAL CALIFORNIA Medi-Cal has evolved in response to 2010 Under ACA, expanded coverage for uninsured adults, and required 2010 Under ACA, state option to provide Medicaid coverage for all individuals seniors and people with disabilities to enroll in managed care changing federal and state policies. under 133% FPL at enhanced federal matching rate (excluding those with Medicare) 2012 Supreme Court upholds ACA and rules that Medicaid 2012 Authorized transition of children from Healthy Families to Medi-Cal expansion is optional for states and expansion of managed care to rural counties 2013 Expanded Medi-Cal under ACA state option 2015 Expanded full-scope Medi-Cal to eligible children regardless of immigration status using state funds starting May 16, 2016 2019 Created financial penalty for failure to maintain health coverage starting January 1, 2020 2016 Final Managed Care Rule to align Medicaid with other insurance Medi-Cal eligibility extended to adults 19–25 regardless of regulations and to strengthen consumer protections immigration status starting January 1, 2020 2017 Tax overhaul legislation reduced the penalty for not having Expanded income eligibility up to 138% FPL for seniors and people insurance to $0 with disabilities starting December 1, 2020 Extended Medi-Cal coverage by 12 months after delivery for women 2018 CHIP funding reauthorized through FY 2027 with a maternal mental health condition starting August 1, 2020 Executive order moved pharmacy benefit from managed care to statewide administration 2021 Expanded full-scope Medi-Cal to eligible adults age 50 and over regardless of immigration status starting no earlier than May 2022 State will seek federal approval to eliminate the asset test as an eligibility requirement With newly allowable federal matching funds, extended Medi- Cal eligibility from 60 days to 12 months for eligible postpartum individuals, targeted to start April 2022 * Family Planning, Access, Care and Treatment (Family PACT) Program Note: FPL is federal poverty level. Sources: Quick Summary: The Governor's Special Session Reduction Proposals and Proposed 2009–10 Budget (PDF), Committee on Budget and Fiscal Review, January 6, 2009; "California's Medicaid State Plan (Title XIX)," California Dept. of Health Care Services, last modified May 5, 2020; "The Affordable Care Act in California," California Health Care Foundation, June 28, 2012; Report to Congress on Medicaid and CHIP, Medicaid and CHIP Payment and Access Commission, March 2021; S.B. 78 (Cal. 2019); S.B. 104 (Cal. 2019–20); H.R. 1, 115th Cong. (2017–18); and H.R. 1319 - American Rescue Plan Act of 2021, 117th Cong. (2021).5, 2020; A.B. 133 (Cal. 2021-22). CALIFORNIA HEALTH CARE FOUNDATION 13 Medi-Cal Facts and Figures Medi-Cal Governance Overview Medi-Cal is governed by the federal, FEDERAL COUNTY Centers for Medicare & County Health and Social state, and county governments. Medicaid Services (CMS) Services Department The California legislature provides • Provides regulatory oversight • Conducts eligibility oversight and approves the overall • Reviews and monitors determination waivers to program rules • Oversees enrollment budget. and recertification STATE California Department of Health Care Services (DHCS) • Administers Medi-Cal • Sets eligibility and benefits, contracts with managed care plans and other providers, and determines payments California Legislature • Passes legislation enabling programs, eligibility requirements, waivers, and benefits within federal law • Provides oversight through hearings and audits • Approves overall budget CALIFORNIA HEALTH CARE FOUNDATION 14 Medi-Cal Facts and Figures Financing the Medi-Cal Program Overview Source of Funds Medi-Cal is paid for with a mix of • The federal government contributes a percentage of every dollar states spend on qualified Medicaid federal, state, and local funds. expenditures. This federal medical assistance percentage (FMAP), also known as the federal financial participation, varies by state and is calculated using the state's average per capita income relative to the national average. California's standard FMAP is 50%. • California's nonfederal share of Medi-Cal expenditures is financed through the state general fund, county revenues, and taxes and fees on managed care organizations, hospitals, and tobacco products. FMAP Enhancement • The FMAP may be "enhanced," or increased, for specific services. For example, the FMAP is 90% for services provided through the Health Homes pilots. Other services with enhanced FMAPs include breast and cervical cancer treatment, and Indian Health Services and Tribal Facility Services. • The FMAP is enhanced for specific populations such as refugees, pregnant women, and children. Affordable Care Act (ACA) Effects on FMAP • The ACA enhanced the FMAP for the expansion to nonpregnant, childless adults under age 65. From 2014 to 2016, the federal share was 100% and was reduced to 90% in 2020. • The ACA enhanced the FMAP to 88% for pregnant women and newborns covered by the Children's Health Insurance Program through September 2019 and is reduced to 65% thereafter. Sources: Laura Snyder and Robin Rudowitz, "Medicaid Financing: How Does It Work and What Are the Implications?," KFF, May 20, 2015; and Aid Code Master Chart (PDF), California Dept. of Health Care Services, May 1, 2019. CALIFORNIA HEALTH CARE FOUNDATION 15 Medi-Cal Facts and Figures Medi-Cal Funding Sources Overview FY 2019–20 The federal government provided nearly two-thirds of total Medi-Cal funding. The state contribution to Other State and Local Medi-Cal was 23%, while other 12% state and local funds composed the remaining 12% of the total. State General M ED I- C A L EX PEN D ITU RES 23% $99 Billion Federal 65% Source: Author calculation based on Medi-Cal May 2020 Local Assistance Estimate for Fiscal Years 2019-20 and 2020-21 (PDF), California Dept. of Health of Health Care Services, accessed August 6, 2020. CALIFORNIA HEALTH CARE FOUNDATION 16 Medi-Cal Facts and Figures General Fund Distribution, California Overview FY 2019–20 California invested more than $23 billion from its general fund annually in the Medi-Cal program, making Other Programs Medi-Cal the second-largest category 12% of general fund spending after K–12 Corrections/ education. Rehabilitation K–12 9% Education G E N E R A L F UN D 39% E XP E N D I T UR E S Other Health/Social $150 Billion Services 12% Medi-Cal 16% Higher Education 12% Notes: 2019–20 general fund expenditures as reported in the 2020-21 budget. Includes expenditures for medical care services, eligibility (county administration), fiscal intermediary management, and benefits (medical care and services). Sources: Estimates for 2019-20 Medi-Cal spending are from 2020–21 Governor's Budget: 4260 State Department of Health Care Services (PDF), California Dept. of Finance (DOF) and total general fund spending from Governor's Budget Summary 2020-21: Summary Charts (PDF), DOF. CALIFORNIA HEALTH CARE FOUNDATION 17 Medi-Cal Facts and Figures Medi-Cal Enrollment and Share of General Fund Overview FY 2013 to FY 2020 Over the past eight years, Medi-Cal ENROLLMENT IN MILLIONS has, on average, represented 16% of ■ Enrollment ■ % of General Fund for Medi-Cal all general fund expenditures. 16.4% 16.0% 16.0% 15.4% 15.8% 15.5% 15.3% 14.5% 13.2 13.5 13.3 12.7 12.0 13.0 8.6 7.6 2012–13 2013–14 2014–15 2015–16 2016–17 2017–18 2018–19 2019–20 Sources: Estimates for 2019–20 Medi-Cal spending are from 2020-21 Governor's Budget: 4260 State Department of Health Care Services (PDF), California Dept. of Finance (DOF) and total general fund spending from Governor's Budget Summary 2020-21: Summary Charts (PDF), DOF; estimates for 2018–19 Medi-Cal spending are from 2019-20 Governor's Budget: 4260 State Department of Health Care Services (PDF), DOF, and total general fund spending from Governor's Budget Summary 2019-20: Summary Charts (PDF), DOF; estimates for 2016–17 and 2017– 18 are from Governor's Budget Summary, 2018-19 (PDF), DOF; estimates for 2015–16 are from Governor's Budget Summary, 2017-18 (PDF), DOF; estimates for 2014–15 are from Governor's Budget Summary, 2016-17 (PDF), DOF; estimates for 2013–14 are from Governor's Budget Summary, 2015-16 (PDF), DOF; and estimates for 2012–13 are from Governor's Budget Summary, 2014-15 (PDF), DOF. CALIFORNIA HEALTH CARE FOUNDATION 18 Medi-Cal Facts and Figures Medi-Cal Eligibility Requirements Eligibility and Enrollment Medi-Cal eligibility is based on household income and other financial information, citizenship and immigration status, and For most enrollees, Medi-Cal eligibility enrollment in other public assistance programs. is based on household income and • Income. Household income must be below certain thresholds of the federal poverty guidelines. Income thresholds, size. and factors used in calculating income, vary by eligibility group (see page 21) and take household size into account. • Property. Enrollees in some aid categories must pass an asset test and demonstrate that real and personal property do not exceed thresholds (e.g., countable property worth more than $3,300 for a family of four). Some types of property, such as a principal residence, are exempt.* • Citizenship and immigration status. For adults, US citizenship or "qualifying immigration status" (e.g., lawful permanent resident) is required to be eligible for full-scope benefits. California allows children, teens, young adults under 26, and in 2022, adults age 50 and older who are undocumented and meet other eligibility requirements to also receive full-scope benefits. Full-scope Medi-Cal provides medical, dental, mental health, and vision care. It also covers alcohol and substance use disorder treatment and prescription drugs. Other residents without qualifying immigration status may be eligible for restricted-scope benefits that cover only pregnancy-related and emergency services. (See Immigration Status and Eligibility on page 22 for more information.) • Residence. Enrollees must reside in California. • Public assistance program enrollment. Eligibility for Medi-Cal is automatic for enrollees in the following public assistance programs: CalFresh, Supplementary Security Income / State Supplemental Payment, CalWORKS, Refugee Assistance, Foster Care / Adoption Assistance Program. * AB133 in 2021 directs the state to seek federal approval to eliminate the asset test as an eligibility requirement. Notes: The ACA created a streamlined financial eligibility test based on federal tax rules to determine gross income for all insurance affordability programs. The modified adjusted gross income (MAGI) standard eliminated the asset test for most adults, parents, children, and pregnant women. Sources: "Poverty Guidelines" (2020), US Dept. of Health and Human Services; Medi-Cal General Property Limitations (PDF), California Dept. of Health Care Services (DHCS), April 2014; Jen Flory et al., Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates (PDF), Western Center on Law and Poverty, March 2016; "Medi-Cal Eligibility and Covered California - Frequently Asked Questions," DHCS, last modified March 23, 2021; and "Do You Qualify for Medi-Cal Benefits?," DHCS, last modified March 23, 2021. CALIFORNIA HEALTH CARE FOUNDATION 19 Eligibility Groups Medi-Cal Facts and Figures Eligibility and Enrollment MANDATORY GROUPS – REQUIRED BY FEDERAL LAW INCOME THRESHOLD NOTES Children and youth under age 26 receiving adoption assistance None or foster care Federal law requires all state Medicaid Children under age 19 133% FPL cap Income threshold is below 142% FPL for children age 1 to 5. programs to cover the mandatory groups, People in long-term care 100% FPL cap Subject to asset test* Parents and caretaker relatives 108% FPL cap and allows states to receive federal matching Aged, blind, and people with disabilities Must receive SSI Subject to asset test* funds for the optional groups. Under the Pregnant women, newborns, and infants under age 1 213% FPL cap Medicare enrollees with low incomes FPL cap varies Three categories: Qualified Medicare Beneficiary (100% FPL), ACA, California expanded eligibility to adults Specified Low-Income Medicare Beneficiary (120% FPL), Qualifying Individual (135% FPL) with low incomes and without disabilities OPTIONAL GROUPS – NOT REQUIRED BY FEDERAL LAW INCOME THRESHOLD NOTES or dependent children, and to parents and ACA "expansion" adults under age 65 138% FPL cap Coverage for group added when California opted to expand Medi-Cal as allowed by the ACA† caretaker relatives. Using state funds, California Parents and caretaker relatives 109%–138% FPL Coverage for group added when California opted to expand Medi-Cal as allowed by the ACA† also expanded Medi-Cal to cover three groups Qualifying state and county inmates 138% FPL cap Coverage for group added when California opted to expand in households with low income regardless of Medi-Cal as allowed by the ACA. Medi-Cal pays for inpatient hospital services immigration status: children, adults under 26, Children under age 19 134%–266% FPL Title XXI funded Optional Targeted Low-Income Children‡ Children under age 19 in specific counties§ 267%–322% FPL Title XXI (C-CHIP)‡ and in 2022, adults age 50 and over. Pregnant women, newborns and infants under age 2 213%–322% FPL Title XXI funded Optional Targeted Low-Income Children Children and youth under age 19 regardless of immigration status Below 266% FPL State-only funding Note: The 2021 federal poverty level (FPL) for a single Young adults age 19–25 regardless of immigration status 138% FPL cap State-only funding person is $12,760; 138% FPL is $17,609. People in long-term care regardless of immigration status 100% FPL cap* Subject to asset test* Sources: "California Medicaid Eligibility Groups by Medi-Cal Aid Code," California Health and Human Services Agency, Aged, blind, and people with disabilities - FPL program 138% FPL cap Subject to asset test* accessed October 22, 2020; All-County Letter Welfare Working disabled 250% FPL cap Subject to asset test* Letter 20-03 (PDF), California Dept. of Health Care Services (DHCS), February 5, 2020; List of Medicaid Eligibility Groups Adults age 50 and older regardless of immigration status** 138% FPL cap State-only funding (PDF), Centers for Medicare & Medicaid Services, accessed * People qualifying under specific aid categories must demonstrate that real and personal property do not exceed thresholds (e.g., countable property worth more than $3,300 for a family October 18, 2020; Medi-Cal Eligibility Division Informational of four). This is commonly referred to as the "asset test." Some real and personal properties are exempt (e.g., principal residence). This requirement applies only to specific aid categories Letter I 19–15 (PDF), DHCS, May 30, 2019; Tricia Brooks et al., such as the aged, blind, and disabled. Those in long-term care may also have to pay a share of cost. AB 133 (2021) directs the state to seek federal approval to eliminate the asset test as an "Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing eligibility requirement. Policies as of January 2020: Findings from a 50-State Survey," † While the Supreme Court made it the state's option to implement this expansion, states opting to do so must implement the expansion group as written in statute. KFF, March 26, 2020; Fact Sheet: Children's Health Insurance ‡ Title XXI of the Social Security Act passed in 1997, also known as the Children's Insurance Program, allows states the option to provide coverage to uninsured pregnant women, infants, Program (CHIP) (PDF), Medicaid and CHIP Payment and and children in families with household incomes higher than Medicaid thresholds and who cannot afford private insurance. States can create stand-alone programs, expand their Medicaid Access Commission, February 2018; Young Adult Full Scope programs, or create a hybrid program. Originally, California created the Healthy Families program but transitioned enrollees into Medi-Cal in 2012–13 and uses the Title XXI funds to expand Expansion: Eligibility and Enrollment Plan (PDF), DHCS, Medi-Cal eligibility thresholds. November 4, 2019; Program Eligibility by Federal Poverty Level § C-CHIP in San Mateo, Santa Clara, and San Francisco Counties only. for 2021 (PDF), Covered California, accessed October 18, 2020; and AB 133 (Cal. 2021-22). ** Effective in 2022 CALIFORNIA HEALTH CARE FOUNDATION 20 Medi-Cal Facts and Figures Medi-Cal Income Thresholds Eligibility and Enrollment ■ Mandatory ■ Optional ■ CHIP ■ Medi-Cal Medi-Cal income eligibility thresholds (Medicaid/federal) (Medicaid/federal) (optional Title XXI) (state only) Newborns vary. In 2021, a single, childless adult and Infants 213% 322% (under age 2)* with annual income below 138% Children 142% 266% (age 2 to 5) of the federal poverty level (FPL), or † Children (age 6 to 19)† 133% 266% $17,609, would be eligible for Medi- Children Regardless of Immigration Status (up to age 19) 266% Cal. A pregnant person would be Pregnant Women 213% 322% eligible if their annual income were Parents and below 322% of FPL, or $41,088. Caretaker Relatives 109% 138% Expansion Adults (with low income) 138% Young Adults Regardless of Immigration Status (age 19-25) 138% Adults Regardless of Immigration Status 138% (age 50+)‡ Seniors and People with Disabilities 100% 250% 0% 50% 100% 150% 200% 250% 300% 350% Federal Poverty Level Note: CHIP is Children's Health Insurance Program and is part of the Medi-Cal program. * Medicaid requires mandatory coverage of newborns and infants up to age 1 and up to 213% FPL. Title XXI allows states the option to cover newborns and infants under age 2 and up to 322% FPL. † 5% income disregard doesn't apply. ‡ Effective in 2022. Sources: "California Medicaid Eligibility Groups by Medi-Cal Aid Code," California Health and Human Services Agency, accessed October 22, 2020; All-County Letter Welfare Letter 20-03 (PDF), California Dept. of Health Care Services, February 5, 2020; Program Eligibility by Federal Poverty Level for 2021 (PDF), Covered California, accessed October 18, 2020; and "Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey," KFF, March 26, 2020. CALIFORNIA HEALTH CARE FOUNDATION 21 Medi-Cal Facts and Figures Immigration Status and Eligibility Eligibility and Enrollment Immigrants who are not citizens may be eligible for Medi-Cal if they meet categorical, financial, and residency Some immigrants who are not citizens requirements. Two main groups are eligible. are eligible for full-scope Medi-Cal, Qualified Immigrants while others may be eligible only • Legal permanent residents (LPRs), asylees, refugees, and other qualifying categories: Eligible for full-scope benefits and Federal Medical Assistance Percentage (FMAP) if they have resided in the US for more than five years (referred to for restricted-scope emergency and as the "five-year bar"). pregnancy-related services. Nonqualified Immigrants • Permanently Residing Under Color of Law (PRUCOL): Entitled to full-scope Medi-Cal with state-only funding and no FMAP. The ACA recognizes Deferred Action for Childhood Arrivals (DACA) status as "lawfully present" under PRUCOL. • Children who are undocumented: Entitled to full-scope benefits with state-only funding and no FMAP. • Young adults age 19–25 who are undocumented: Entitled to full-scope benefits with state-only funding and no FMAP. • Adults age 26–49 who are undocumented: Entitled only to restricted-scope (emergency and pregnancy-related) services. These services qualify for federal matching. • Adults age 50 and older who are undocumented: Entitled to full-scope benefits with state-only funding and no FMAP, effective in 2022. Notes: Other qualified groups include those (1) paroled into the US under specific conditions; (2) granted conditional entry pursuant to specific conditions; (3) Cuban or Haitian entrant; (4) battered spouses and children with a pending or approved: (a) self-petition for an immigrant visa or visa petition by a spouse or parent who is either a US citizen or LPR, or (b) application for cancellation of removal/suspension of deportation, where the need for the benefit has a substantial connection to the battery or cruelty (parent/child of such battered child/spouse are also "qualified"); (5) Victims of Severe Forms of Trafficking. The date someone receives their qualified status triggers the beginning of the "five-year bar." Some qualified immigrants are exempt from the five-year bar. Permanent Residence Under Color of Law (PRUCOL) is not an immigration status but a public benefits eligibility category; PRUCOL individuals are not US citizens but are considered to have the same rights as legal residents for welfare eligibility purposes. See 42 CFR § 435.408 for the federal definition and 22 CCR § 50301.3 for the state definition. Sources: Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates (PDF), Western Center on Law and Poverty, March 2016; Cal. Welf. and Inst. Code § 14007.8; "An Advocate's Guide to Medi-Cal Services," National Health Law Program, February 11, 2020; AB 133 (Cal. 2021-22); and Young Adult Full Scope Expansion: Eligibility and Enrollment Plan (PDF), California Dept. of Health Care Services, November 4, 2019. CALIFORNIA HEALTH CARE FOUNDATION 22 Medi-Cal Facts and Figures Medi-Cal Individual Application Process Eligibility and Enrollment In person. May apply for Medi-Cal at local county social services office or at hospitals and clinics where county To comply with the ACA, California eligibility workers and certified application assisters are located. Medi-Cal applications, paper or electronic, can be created a single streamlined submitted with the assistance of trained certified application assisters, many of whom work at community-based organizations. application for Medi-Cal and Covered Mail in. The paper version of the single streamlined application can be submitted to county offices or Covered California, the state's health care California. exchange. There are numerous Online. Medi-Cal applications can be initiated electronically using the Covered California portal and benefitscal.org website, which links applicants to county eligibility systems. Most applicants will be required to follow up in person pathways to submit an application. or by phone with county eligibility offices. By phone. Interested people can call the Covered California service center or county social services office to initiate an application with a customer service representative or county eligibility worker. These applications require in-person follow-up with the county eligibility worker. Presumptive eligibility. Participating providers in the Presumptive Eligibility Program for Pregnant Women, the Child Health and Disability Prevention Program, the Breast and Cervical Cancer Treatment and Prevention program, or the Hospital Presumptive Eligibility program can request immediate 60-day temporary, no-cost Medi- Cal coverage for qualified applicants. During the 60-day period, those receiving this temporary coverage apply for permanent Medi-Cal or other health coverage. During the COVID-19 public health emergency, the federal government expanded the use of presumptive eligibility. Applications during the COVID-19 pandemic. In April 2019, 37% of applications were online and 38% were in-person. In April 2020 at the start of the COVID-19 Public Health Emergency, online applications rose dramatically to 72% and in-person applications dropped to 5%. Notes: People eligible for temporary coverage through presumptive eligibility are pregnant women, foster youth age 18–26, children under 19, parent and caretaker relatives, and adults under 65 without dependent children. People must meet income and residency requirements and not have received presumptive eligibility benefits in the last 12 months. CalWORKs is a public assistance program that provides cash aid and services to eligible families that have children in the home. Sources: "Medi-Cal Eligibility and Covered California - Frequently Asked Questions," California Dept. of Health Care Services (DHCS), accessed October 18, 2020; Getting and Keeping Health Coverage for Low-Income Californians: A Guide for Advocates (PDF), Western Center on Law and Poverty, March 2016; and Medi-Cal Enrollment Update (PDF), DHCS, April 8, 2021. CALIFORNIA HEALTH CARE FOUNDATION 23 Medi-Cal Facts and Figures Medicaid Enrollment Eligibility and Enrollment Selected States, 2019 California has more Medicaid enrollees PERCENTAGE OF NONELDERLY STATE POPULATION in total (not shown), but New York New York 27% had a slightly higher percentage of the state's nonelderly population enrolled California 26% in Medicaid. Texas and Florida did Michigan 24% not expand their Medicaid programs Massachusetts 23% under the Affordable Care Act. Ohio 22% Pennsylvania 22% Illinois 20% Florida 18% New Jersey 17% Texas 16% NATIONAL AVERAGE 21% Notes: States with the 10 largest Medicaid expenditures in FY 2019, based on KFF's "Total Medicaid Spending (FY 2019)," are represented. Nonelderly is under age 65. Medicaid enrollment is self-reported and includes those covered by Medicaid, Medical Assistance, Children's Health Insurance Plan, or any kind of government-assistance plan for those with low incomes or a disability, as well as those who have both Medicaid and another type of coverage such as dually eligible enrollees also covered by Medicare. Source: "Health Insurance Coverage of Nonelderly 0-64" (2019), KFF. CALIFORNIA HEALTH CARE FOUNDATION 24 Medi-Cal Facts and Figures Enrollment, by Aid Category, 2021 Eligibility and Enrollment Other Nearly half of Medi-Cal enrollees were Undocumented 3% children and their parents/caretakers 7% and children in CHIP. Nearly one in six enrollees was a senior or person CHIP with a disability. The Affordable Care Parent/ 10% Caretaker Act (ACA) expansion group - adults Relative under 65 with low incomes and no and Child 38% dependent children - was the Seniors and TOTA L E N R O L L M E N T People with 13.6 million second-largest group of Medi-Cal Disabilities enrollees. 15% ACA Expansion Adult (age 19–64) 28% Notes: Enrollment month is January 2021. CHIP is Children's Health Insurance Program. Undocumented includes aid categories restricted to only pregnancy-related, long-term care, and emergency services for adults who do not have satisfactory immigration status, also known as restricted-scope benefits. Other includes long-term care and aid categories including Adoption/Foster Care, Refugee Medical Assistance / Entrant Medical Assistance, Breast and Cervical Cancer Treatment Program, Abandoned Baby Program, Minor Consent Program, Accelerated Enrollment in the Children Health and Disability Prevention Program (CHDP), Trafficking and Crime Victims Assistance Program, and state and county inmates. Segments may not total 100% due to rounding. Source: Medi-Cal Monthly Eligible Fast Facts (January 2021) (PDF), California Dept. of Health Care Services, April 2021. CALIFORNIA HEALTH CARE FOUNDATION 25 Medi-Cal Facts and Figures Medi-Cal Enrollment Eligibility and Enrollment 2010 to 2020 Medi-Cal enrollment has increased 15 IN MILLIONS significantly since 2013, largely 13.2 13.5 13.3 13.1 ■ ACA Expansion 13.0 12.7 due to the ACA expansion. In 2014, ■ Nonexpansion 12.0 3.3 3.8 3.9 4.0 nonexpansion enrollment increased 12 3.8 3.7 2.5 sharply when Healthy Families enrollees were moved to Medi-Cal. 9.9 Between 2016 and 2019 enrollment 9 9.5 9.7 9.5 9.2 8.9 9.1 declined. In 2020, enrollment 8.6 increased amid the COVID-19 7.5 7.6 7.6 6 pandemic, increased unemployment, and suspended eligibility redeterminations. 3 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Note: Enrollment month is November of each year. Sources: Month of Eligibility, Aid Category by County, Medi-Cal Certified Eligibility, California Dept. of Health Care Services (DHCS), November 25, 2020; and Medi-Cal Enrollment Update (PDF), DHCS, April 8, 2021. CALIFORNIA HEALTH CARE FOUNDATION 26 Medi-Cal Facts and Figures Medi-Cal Enrollee Profile Eligibility and Enrollment by Age and Gender, 2021 Half of Medi-Cal enrollees are adults; children and youth (age 0–20) Age Gender account for about 41% of enrollment. Medi-Cal enrollees are somewhat 65+ more likely to be female (54%) than 10% male (46%). 0 to 20 TOTAL ENROLLMENT 40% TOTAL ENR O L L MENT Male 13.6 million 13.6 million 46% 21 to 64 Female 50% 54% Note: Enrollment month is January 2021. Source: Medi-Cal Monthly Eligible Fast Facts (January 2021) (PDF), California Dept. of Health Care Services, April 2021. CALIFORNIA HEALTH CARE FOUNDATION 27 Medi-Cal Facts and Figures Medi-Cal Enrollee Profile Eligibility and Enrollment by Ethnicity and Primary Language, 2021 Medi-Cal serves a large and diverse population, with Latinx Californians Race/Ethnicity Primary Language accounting for 50% of all enrollment. Other (4%) American Indian / Alaskan Native (<1%) English is the most common language Vietnamese (2%) Unknown (<1%) All Chinese (2%) spoken (64% of enrollees). Spanish is Not the primary language spoken for 29% Reported 15% of enrollees. Black 7% TOTAL ENROLLEES Spanish TOTA L E NR O L L E E S Latinx 29% AANHPI 13.6 million 50% 13.6 million 10% English 64% White 18% Notes: AANHPI is Asian American / Native Hawaiian and Pacific Islander. Enrollment month is January 2021. Source uses Hispanic, African American, and Asian / Pacific Islander. All Chinese includes Mandarin, Cantonese, and Other Chinese. Other includes American Sign Language, Arabic, Armenian, Cambodian, Farsi, French, Hebrew, Hmong, Ilocano, Italian, Japanese, Korean, Lao, Mien, Other Non-English, Other Sign, Polish, Portuguese, Russian, Samoan, Tagalog, Thai, and Turkish. Segments may not total 100% due to rounding. Source: Medi-Cal Monthly Eligible Fast Facts (January 2021) (PDF), California Dept. of Health Care Services, April 2021. CALIFORNIA HEALTH CARE FOUNDATION 28 Medi-Cal Facts and Figures Medi-Cal Enrollment Eligibility and Enrollment by Family Work Status, Nonelderly Population, 2019 About three out of four nonelderly Medi-Cal enrollees are in households where they or another family member work part- or full-time. People Not Employed 22% Full-Time Part-Time Worker Worker 63% 15% Note: Source uses Non Workers. Source: "Distribution of the Nonelderly with Medicaid by Family Work Status" (2019), KFF, accessed October 9, 2020. CALIFORNIA HEALTH CARE FOUNDATION 29 Medi-Cal Facts and Figures Medi-Cal Benefits Benefits and Cost Sharing ESSENTIAL HEALTH BENEFITS OPTIONAL SERVICES The Affordable Care Act ensures that • Ambulatory services • Dental services for adults all Medi-Cal health plans offer 10 • Emergency services • Vision services for adults essential health benefits. In addition, • Prescription drugs • Nonemergency medical transportation services California provides other services not • Rehabilitative & habilitative services and devices • Long-term services and supports required by the federal government. • Maternity and newborn care • Hospitalization • Preventive & wellness services and chronic disease management • Mental health and substance use disorder services, including behavioral health treatment • Pediatric services, including oral and vision care • Laboratory services Sources: "State Plan Section 3 - Services," California Dept. of Health Care Services (DHCS), last modified March 23, 2021; "Essential Health Benefits," DHCS, accessed October 25, 2020; and Medi-Cal Provides a Comprehensive Set of Health Benefits That May Be Accessed as Medically Necessary (PDF), DHCS, January 2020. CALIFORNIA HEALTH CARE FOUNDATION 30 Medi-Cal Facts and Figures Medi-Cal Pharmacy Benefit Management Transition Benefits and Cost Sharing In January 2019, Governor Newsom directed the California Department of Health Care Services (DHCS) Starting in 2021, Medi-Cal will to transition the administration of pharmaceutical benefits from managed care plans to the state on standardize and centralize pharmacy January 1, 2022. The existing scope of Medi-Cal's pharmacy benefits does not change. benefits and services across the The new program, Medi-Cal Rx, aims to: state. Previously, managed care plans • Improve access to pharmacy services for Medi-Cal members were responsible for administering • Standardize the pharmacy benefit under one delivery system pharmacy benefits.1 • Apply statewide utilization protocols to all outpatient drugs • Strengthen the state's ability to negotiate drug rebates with drug manufacturers DHCS has contracted with Magellan Medicaid Administration, a national pharmacy benefit management firm, to administer Medi-Cal Rx. DHCS estimates the transition will reduce state general fund expenditures by $238 million in FY 2021–22. 1 Medi-Cal Rx will not apply to Programs of All-Inclusive Sources: Exec. Order N-01-19 (PDF), State of California, January 7, 2019; Medi-Cal November 2020 Local Assistance Estimate for Fiscal Years 2020-21 and 2021-22 (PDF), California Dept. of Care for the Elderly (PACE) plans, Senior Care Action Health Care Services (DHCS), accessed March 11, 2021; "Medi-Cal Rx: Transition," DHCS; Medi-Cal Rx Monthly Bulletin (PDF) DHCS, accessed August 16, 2021; and "Medi-Cal Rx Background," Network (SCAN) and Cal MediConnect health plans, or the DHCS, accessed October 25, 2020. Major Risk Medical Insurance Program (MRMIP). CALIFORNIA HEALTH CARE FOUNDATION 31 Medi-Cal Facts and Figures Premiums and Cost Sharing, by Eligible Group Benefits and Cost Sharing PREMIUM OR COST SHARING While most enrollees pay nothing for Children >160% FPL • Children age 1 to 19 in families with incomes between Medi-Cal, about 200,000 pay small 160% and 266% of the FPL have a monthly premium. premiums or are responsible for a • The premiums are $13 for each child but cannot exceed $39 per family per month. share of the cost.* 250% Working Disabled • People with a medical determination of physical or mental Program impairment lasting or proposed to last for one year whose countable monthly income is below 250% FPL. • Working people with disabilities and monthly income under 250% FPL. Disability income is excluded from income calculation. • Monthly premiums range from $20 to $250 for a single person depending on income. Aged, Blind, and Disabled - • People over age 65 or who have a disability, with income Medically Needy Program above $1,596 per month (after numerous deductions). Share of Cost* • People with a medical determination of a physical or mental impairment lasting or proposed to last for one year. * Share of cost is the amount of health care costs Notes: FPL is federal poverty level. American Indian / Alaskan Native children may be eligible to have the premiums waived. the enrollee must incur before Medi-Cal will pay for Sources: All-County Welfare Letter 20-03 (PDF), California Dept. of Health Care Services (DHCS), February 5, 2020; "Medi-Cal Premium Payments for the 'Medi-Cal for Families' Program - medically necessary goods and services. It is calculated Frequently Asked Questions," DHCS, accessed October 25, 2020; Fact Sheet: Aged & Disabled Medi-Cal Program (PDF), California Advocates for Nursing Home Reform, last updated July 30, as the monthly family income less a Maintenance Need 2019; and "Population Distribution for Medi-Cal Enrollees by Share of Cost (SOC)," California Health and Human Services Agency, accessed January 26, 2021. Allowance based on family size. CALIFORNIA HEALTH CARE FOUNDATION 32 Medi-Cal Facts and Figures Medi-Cal Waivers Benefits and Cost Sharing 1915(B) 1915(C) 1115(A) FREEDOM OF CHOICE HOME AND COMMUNITY-BASED SERVICES RESEARCH AND DEMONSTRATION PROJECTS States may use statutory authority PURPOSE PURPOSE PURPOSE to waive certain Medicaid rules, Permits states to implement Authorizes states to use home and Gives broad authority to waive certain provisions of service delivery models community-based services as an alternative the Medicaid statutes related to state program design subject to federal approval. As of that restrict choice of to placement in a nursing home, hospital, for "any experimental, pilot, or demonstration project providers, such as managed or other long-term care facility. likely to assist in promoting the objectives" of the January 2021, California has 12 care. States may also use programs. These waivers must be "budget neutral" these to waive statewide EXAMPLES (i.e., require no additional federal spending). requirements (e.g., limited HCBS for the Developmentally waiver programs. Due to the COVID- geographic area) and Disabled. For enrollees of any age with EXAMPLES comparability requirements. developmental and intellectual disabilities, Medi-Cal 2020. Composed of five main programs: 19 pandemic, Medi-Cal received an including autism, to assist with living in the • Public Hospital Redesign and Incentives in EXAMPLE community rather than in an institution. Medi-Cal. Changes care delivery to maximize extension to the end of 2021 for the Specialty Mental Health health care value and strengthens ability to Services. Waives freedom Nursing Facility / Acute Hospital Waiver. perform under risk-based alternative payment Medi-Cal 2020 demonstration waiver Provides case management, habilitation of choice and creates models. county mental health plans services, home health nursing, and • Global Payment Program. Establishes a statewide and the 1915(b) waiver. other services for medically fragile and to deliver specialty mental pool of funding for the remaining uninsured and technology-dependent people of any age. health services. provides an incentive for primary and preventive HIV/AIDS Waiver. Provides care care services. coordination, respite care, personal care, expressive therapies, family counseling and • Whole Person Care pilot program. Coordinates physical health, behavioral health, and social training, and other services for medically services for enrollees with poor health outcomes fragile and technology-dependent people who are high risk and have high costs. up to age 20. • Dental Transformation Initiative. Provides Other 1915(c) waivers. Include incentives to improve access to preventive services Multipurpose Senior Services Program, and continuity of care for dental services for Medi- Assisted Living, and In-Home Operations. Cal children. • Drug Medi-Cal Organized Delivery System. Aims to demonstrate how organizing substance use disorder services along a continuum of care increases enrollees' success while decreasing system health care costs. Sources: Jennifer Ryan and Julie Stone, Medi-Cal Explained Fact Sheet: Medicaid Waivers in California, California Health Care Foundation, October 2019; and "Medi-Cal Waivers," California Dept. of Health Care Services, accessed October 25, 2020. CALIFORNIA HEALTH CARE FOUNDATION 33 Medi-Cal Facts and Figures California Advancing and Innovating Medi-Cal (CalAIM) CalAIM Section 1115 and 1915(b) waivers, under which many Medi-Cal benefits and initiatives are delivered, are scheduled to The state has proposed innovations expire at the end of 2021. A new proposal, California Advancing and Innovating Medi-Cal (CalAIM), provides a framework and changes aimed at improving care for new waivers and future reforms. Importantly, CalAIM envisions moving away from demonstration waivers and making systemic programmatic changes focused on population health improvement. for Medi-Cal members. The CalAIM goals over six years are to: • Identify and manage member risk and need through whole-person care approaches and addressing social determinants of health. • Work toward a more consistent and seamless system by reducing complexity and increasing flexibility. • Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems, and payment reform. CalAIM proposes to: • Create new benefits - Enhanced Care Management and In Lieu of Services - which would be delivered by managed care plans. These benefits demonstrated their effectiveness in the Whole Person Care pilots and Health Homes Program. • Increase managed care plans' responsibility for care delivery and allow pilots wherein plans would manage and integrate services across multiple benefits (e.g., physical and behavioral health). • Streamline county behavioral health services reimbursement, contracting, and program administration. While the launch has been postponed to January 2022 due the COVID-19 pandemic, DHCS has affirmed its commitment to CalAIM. The FY 2021–22 budget includes $1.6 billion for implementation. Sources: California Advancing and Innovating Medi-Cal (CalAIM) (PDF), Insure the Uninsured Project, February 2020; California Advancing and Innovating Medi-Cal: Executive Summary and Summary of Changes (PDF), California Dept. of Health Care Services (DHCS), accessed January 26, 2021; and 2021-22 Governor's Budget: Department of Health Care Services Highlights (PDF), DHCS, January 8, 2021. CALIFORNIA HEALTH CARE FOUNDATION 34 Medi-Cal Facts and Figures Systems for Delivering Care Delivery Systems Medi-Cal services are financed and administered through an array of state departments and local intermediaries. Health Plans County Behavioral Health County County Social Services and Departments CCS Offices Public Authorities for IHSS Most Primary, Specialty Specialty Nursing Facility Personal Care Regional Center and Specialty, and Mental Health Pediatric Care Care Services Developmental Acute Care, Some Services and Center Services Long-Term Care Substance Use Disorder Services Notes: DHCS is the California Department of Health Care Services. CDSS is the California Department of Social Services. DDS is the California Department of Developmental Services. CCS is the California Children's Services program for children with special health care needs. IHSS is the In-Home Supportive Services program. Public authorities are the employers of record and maintain a provider registry for those eligible for personal care services through IHSS. Developmental centers (for facility-based care) and regional centers (for community-based care) serve people with developmental disabilities. This is not a complete list of services provided by Medi-Cal. The budgets of other departments (e.g., aging, corrections, public health) also include some general fund spending for Medi-Cal services. CALIFORNIA HEALTH CARE FOUNDATION 35 Medi-Cal Facts and Figures Medi-Cal and Telehealth Delivery Systems Many Medi-Cal enrollees report difficulty accessing specialty services, a problem exacerbated by The use of telehealth by Medi-Cal the COVID-19 pandemic. Telehealth can improve access to care by decreasing wait times between providers increased dramatically a referral and subsequent visit. during the COVID-19 pandemic. Telehealth is a collection of methods or means for enhancing health care, public health, and health education delivery and support using telecommunications technologies. Telehealth technologies can be used for diagnostic and monitoring activities as well as education across most health services disciplines, including medicine, dentistry, counseling, occupational and physical therapy, and chronic disease management. Telehealth is particularly valuable to deliver care to residents of rural areas. The COVID-19 public health emergency forced swift action by federal and state governments to support telehealth during the pandemic, including increased flexibility and enhanced payment to providers for telehealth visits. From March to September 2020 during the COVID-19 pandemic, the average monthly rate of outpatient telehealth visits per 100,000 Medi-Cal enrollees increased to 8,587 from 287 during the same period in 2019.* Nearly 7 in 10 Californians reported receiving care via telehealth in 2020. * Outpatient telehealth visits per 100,000 enrollees provided by both managed care and fee-for-service providers. Visits by phone or video. Does not include mental health visits. Sources: "What Is Telehealth," Center for Connected Health Policy, accessed October 24, 2020; The State of Telehealth in Medi-Cal Managed Care: Taking Stock in the Era of COVID-19, California Health Care Foundation (CHCF), April 2020; Shira H. Fischer et al., "Prevalence and Characteristics of Telehealth Utilization in the United States," JAMA Network Open 3, no. 10 (Oct. 26, 2020): e2022302; Rebecca Catterson, Lucy Rabinowitz, and Emily Alvarez, The 2021 CHCF California Health Policy Survey, CHCF, January 2021; and Stakeholder Advisory Committee Meeting (PDF), California Dept. of Health Care Services, February 11, 2021. CALIFORNIA HEALTH CARE FOUNDATION 36 Medi-Cal Facts and Figures Managed Care vs. Fee-for-Service, November 2020 Delivery Systems MANAGED CARE FEE-FOR-SERVICE Availability All 58 counties All 58 counties More than 8 in 10 Medi-Cal enrollees Market Share 85% of all enrollees 15% of all enrollees are enrolled in managed care plans, Enrollment Mandatory Voluntary • Dually eligible • Share of Cost (SOC) Medi-Cal and account for 50% of all Medi-Cal Categories • Children • Seniors and people with enrollees • Family PACT • Pregnant people disabilities (dually eligible • Foster children • Other enrollees without full- expenditures. The state determines • Parents / caretaker relatives for Medicare) • Long-term services scope Medi-Cal • Adults without dependents • Foster children and youth and supports • Enrollees who have received mandatory or voluntary managed • Seniors and people with disabilities • All enrollees in • Those with other a medical exemption (not also in Medicare) San Benito County health insurance • Those receiving restricted- care enrollment, subject to federal scope benefits Expenditures 50% 28%* approval. Covered All essential health benefits required by the ACA, including: • Most long-term • Dental services † Services • Ambulatory services • Hospitalization services and supports • California Children's Services • Emergency services • Pediatric services • Specialty mental for the seriously ill and health disabled children and youth • Mental health and substance use • Prescription drugs disorder services • Substance use in certain counties ‡ disorder services Payment The state pays plans a fixed monthly capitation rate for each member, The state pays providers according to a fee schedule. also known as a per-member per-month payment. Plans negotiate Notes: Family PACT is the Family Planning, Access, Care payment rates with most contracted network providers. and Treatment Program. Medi-Cal enrollees in San Benito County may elect not to enroll in the single managed care Carve-Outs • Pharmaceuticals § • Dental services † N/A plan and instead have all services provided to them by FFS • Specialty mental health • California Children's providers. Enrollees with restricted-scope benefits are all in • Substance use Services for the seriously ill FFS Medi-Cal. disorder services and disabled children and Sources: "Month of Eligibility, Delivery System and Health • Most long-term services and youth in certain counties‡ Plan, by County, Medi-Cal Certified Eligibility," California Health and Human Services Agency, accessed December supports 11, 2020; Medi-Cal May 2020 Local Assistance Estimate for * Fee-for-service expenditures include "carved-out" services received by managed care enrollees such as dental and specialty mental health. Fiscal Years 2019-20 and 2020-21 (PDF), California Dept. of Health Care Services (DHCS), accessed August 6, 2020; † Dental services are provided by Dental Managed Care (DMC) plans in Sacramento and Los Angeles Counties. In Sacramento County, enrollment is mandatory, with few exceptions. In Medi-Cal Managed Care Plans Mandatory or Voluntary Los Angeles County, an enrollee must opt in to participate in the DMC program. Enrollment by Medi-Cal Aid Codes (PDF), DHCS, December ‡ CCS children enroll in managed care plans that provide non-CCS services. For their CCS-related needs, they use fee-for-service CCS providers typically outside of the managed care 3, 2018; "California Children's Services Whole Child Model," plan. CCS services are delivered by the five County Organized Health Systems to CCS children in 21 counties under a model called "CCS Whole Child Model." DHCS; "Medi-Cal Dental Managed Care," DHCS, accessed December 19, 2020; and "Medi-Cal Rx: Medi-Cal Rx § Medi-Cal intends to transition the pharmaceutical benefit responsibility away from managed care plans in 2022 and centralize benefit administration within DHCS and a contracted Background," DHCS, accessed October 25, 2020. pharmacy benefit management vendor. CALIFORNIA HEALTH CARE FOUNDATION 37 Medi-Cal Facts and Figures Medi-Cal Managed Care and Fee-for-Service Enrollment Trends Delivery Systems 2010 to 2020, Selected Years The majority of Medi-Cal members are IN MILLIONS enrolled in managed care plans. The ■ Fee-for-Service share of members enrolled in fee-for- ■ Managed Care service Medi-Cal has decreased from 2.7 2.3 1.9 2010 to 2020. 3.1 10.8 10.7 11.2 8.9 3.4 2.7 4.9 4.1 2010 2012 2014 2016 2018 2020 PE RCENTAG E MANAG ED C ARE 55% 64% 74% 80% 82% 85% Note: Enrollment is from November of each year. Source: "Month of Eligibility, Delivery System and Health Plan, by County, Medi-Cal Certified Eligibility," California Dept. of Health Care Services, accessed December 11, 2020. CALIFORNIA HEALTH CARE FOUNDATION 38 Medi-Cal Facts and Figures Medi-Cal Managed Care Models by Model and County, November 2020 Delivery Systems ■ County Organized Health Systems (COHS) 2.2 million enrollees served by six health In California, there are six models of plans in 22 counties. ■Two-Plan managed care. 7.2 million enrollees in 14 counties. Nine local initiatives (county-organized) serve 5.3 million enrollees, and three commercial plans serve 1.8 million enrollees. ■ Geographic Managed Care (GMC) Eight commercial plans serve 1.1 million enrollees in 2 counties. ■Regional Two commercial plans serve 315,000 enrollees in 18 counties. ■Imperial Two commercial plans serve about 80,000 enrollees. ■ San Benito One commercial plan serves 8,800 enrollees. Notes: The figures above include Cal MediConnect enrollees but exclude SCAN, Primary Care Case Management, Special Project, and PACE plan enrollees. While Tulare is a Two-Plan Model county, there is no county-run local initiative and instead the county contracts with Anthem Blue Cross as the local initiative. Tulare's enrollment is included in commercial plans. Sources: Medi-Cal Managed Care Program Fact Sheet - Managed Care Models (PDF), California Dept. of Health Care Services, January 2, 2020; and "Medi-Cal Managed Care Enrollment Report," California Health and Human Services Agency, accessed December 15, 2020. CALIFORNIA HEALTH CARE FOUNDATION 39 Medi-Cal Facts and Figures Managed Care Enrollment, by Plan Type Delivery Systems November 2020 The Medi-Cal program uses a variety Regional (2%) Imperial, Cal MediConnect (1% each) of managed care models, including San Benito, Other (<1% each) county health plans and private health plans. The Two-Plan Model, in which Geographic a government-run local initiative Managed Care competes with a private health plan, 11% had the largest enrollment. County Organized TOTAL ENROLLMENT Health 11.2 million Systems Two-Plan 20% 64% Notes: Other includes Primary Case Management, PACE, and SCAN plans. Segments do not total 100% due to rounding. Source: "Medi-Cal Managed Care Enrollment Report," California Health and Human Services Agency, accessed December 15, 2020. CALIFORNIA HEALTH CARE FOUNDATION 40 Medi-Cal Facts and Figures Medi-Cal Managed Care Carve-Outs Delivery Systems Services offered under Medi-Cal but not provided by the managed care plan are referred to as "carve outs," and include the following services: Certain Medi-Cal services are • Specialty Mental Health Services (SMHS) are provided by county mental health plans to adults with a "carved out" of managed care plan serious mental illness and to children with a serious emotional disturbance. SMHS include targeted case contracts. Carved-out services management, partial hospitalization, and outpatient and inpatient mental health services. • Substance use disorder services are provided through the Drug Medi-Cal program, which provides have separate funding mechanisms on-demand treatments, including outpatient drug-free services, intensive outpatient services, detoxification services, medication-assisted treatment, and residential recovery services. and delivery systems. • Dental services are available on a fee-for-service basis through the Denti-Cal program. Denti-Cal provides preventive, diagnostic, restorative, and periodontal services. In Los Angeles and Sacramento Counties, dental services are provided through dental managed care plans. • Long-term services and supports (LTSS) include the use of home and community-based services intended to keep enrollees out of long-term care facilities. LTSS are carved out of managed care except for Community-Based Adult Services and the nursing home benefit in County Organized Health System (COHS) counties.* For the Coordinated Care Initiative, 11 Medi-Cal managed care plans refer and coordinate LTSS, but the services remain carved out except the nursing facility home benefit. • Institutional long-term care services are provided under most managed care contracts for only two months. A member requiring a longer stay in the long-term care facility is disenrolled from the plan and moved to fee-for-service, where DHCS is responsible for all covered services. DHCS has proposed a statewide carve-in of this benefit into managed care under its CalAIM initiative. • California Children's Services (CCS) provides diagnostic and treatment services, medical case management, and physical and occupational therapy services to children under age 21 with CCS-eligible medical conditions. Five COHS plans will manage these children's benefits in 21 counties in a program called the CCS Whole Child Model. • Prescription drug benefit in managed care plans will transition to Medi-Cal Rx in 2021. (See page 31 for details.) * Health Plan of San Mateo, a County-Organized Health System, has also fully integrated Multipurpose Senior Services Program benefits. Sources: 2019 Medi-Cal Dental Services Member Handbook (PDF), California Dept. of Health Care Services (DHCS), accessed October 26, 2020; "Medi-Cal Specialty Mental Health Services," DHCS, accessed October 26, 2020; "California Children's Services Whole Child Model," DHCS, accessed October 26, 2020; and Amber Christ and Georgia Burke, A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care, California Health Care Foundation, September 2020. CALIFORNIA HEALTH CARE FOUNDATION 41 Medi-Cal Facts and Figures Medi-Cal Long-Term Services and Supports Delivery Systems Medi-Cal enrollees who have a disability or chronic illnesses may need services to support their daily living. They Medi-Cal prioritizes keeping seniors may receive these services in an institutional setting, at home, or in the community. These services are referred to as long-term services and supports (LTSS). and people with disabilities living in The majority of California skilled nursing facility residents are Medi-Cal enrollees, and most using long-term the community with in-home and services and supports are dually eligible for Medicaid and Medicare. other services and supports. Medi-Cal There are nearly a dozen LTSS programs for which Medi-Cal coordinates benefits, financing, and oversight with spends three out of four long-term four other state agencies. This patchwork creates challenges for providers and Medi-Cal enrollees. services and supports dollars on home Qualifying enrollees are entitled to receive these LTSS benefits: • Skilled nursing facility services health and personal care. • Personal care services • Self-directed personal assistance services • Community first choice option (in-home supportive services) • Home and community-based services Eligibility requirements for Medi-Cal support of LTSS are based on income and having limited assets. Some enrollees with higher incomes may pay a share of the cost. Additional benefits may include case management, private duty nursing, home health aides, community transition services, and respite care for caregivers. However, these may not be available statewide. Medi-Cal spent $3.3 billion on skilled nursing facilities in FY 2019–20. Sources: Athena Chapman and Elizabeth Evenson, Long-Term Services and Supports in Medi-Cal (PDF), California Health Care Foundation, October 2020; If You Think You Need a Nursing Home: A Consumer's Guide to Financial Considerations and Medi-Cal Eligibility (PDF), California Advocates for Nursing Home Reform, revised January 2021; "Integrated Care: What Choices Exist for Californians with Medicare and Medi-Cal?," SCAN Foundation, last updated October 16, 2019; and Medi-Cal May 2020 Local Assistance Estimate for Fiscal Years 2019-20 and 2020-21 (PDF), California Dept. of Health of Health Care Services, accessed August 6, 2020. CALIFORNIA HEALTH CARE FOUNDATION 42 Medi-Cal Facts and Figures Medi-Cal Coordinated Care Initiative Delivery Systems The Coordinated Care Initiative (CCI) was enacted in 2012 and implemented in seven counties.* The The Coordinated Care Initiative is a goal is to better serve the state's seniors with low incomes, people with disabilities, and enrollees dually demonstration project to better serve eligible for Medi-Cal and Medicare. seniors with low incomes, people The first component of the CCI is a mandatory Managed Long-Term Services and Supports (MLTSS) with disabilities, and enrollees who program. Through MLTSS, Medi-Cal enrollees, including those who are dually eligible, must enroll in a Medi-Cal managed care plan to receive their benefits, including long-term care services and Medicare are dually eligible for Medi-Cal and wraparound benefits. Medicare. The demonstration has The second component, a demonstration project for dually eligible members called Cal MediConnect laid the groundwork for proposed (CMC), creates a single plan covering all Medi-Cal and Medicare benefits. Eleven managed care plans statewide changes. participate in CMC. Dually eligible enrollees voluntarily enroll in a CMC plan and receive coordinated medical, behavioral health, long-term institutional, and home- and community-based services. As of February 2021, 112,968 members were enrolled in CMC plans. The initial CMC demonstration has ended but California received extensions through December 31, 2022. * Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, Santa Clara Sources: "Coordinated Care Initiative Overview," California Dept. of Health Care Services (DHCS), accessed October 29, 2020; Cal MediConnect Performance Dashboard Metrics Summary (PDF), DHCS, September 2020; Amber Christ, Advocates Guide to California's Coordinated Care Initiative (PDF), Justice in Aging, December 2017; and "Medi-Cal Managed Care Enrollment Report," California Health and Human Services Agency, accessed March 16, 2021. CALIFORNIA HEALTH CARE FOUNDATION 43 Medi-Cal Facts and Figures Behavioral Health Services in Medi-Cal Delivery Systems Managed Care Plans Medi-Cal benefits include mental • Medi-Cal managed care plans are responsible for individual and group psychotherapy, psychological testing, health and substance use disorder psychiatric consultation, and medication management, as required by the ACA's essential health benefits. services. Service delivery is bifurcated • These outpatient services, which address lower-acuity behavioral health conditions, are also referred to as "mild-to- moderate" services. between managed care plans County Mental Health Plans and county mental health plans • County mental health plans are responsible for the assessment and treatment of enrollees with serious mental illness depending on an enrollee's needs. or substance use disorder needs. The CalAIM initiative proposes to • Adults with a serious mental illness and children with a serious emotional disturbance can receive specialty mental integrate speciality mental health and health services, which include crisis intervention, rehabilitation, targeted case management, partial hospitalization, and outpatient and inpatient mental health services. In FY 2017–18, about 4% of Medi-Cal enrollees (341,710 adults SUD services into one system, making and 267,991 children and youth) received specialty mental health services. access and use easier for enrollees. County Substance Use Disorder Programs • Substance use disorder (SUD) services are delivered by county mental health plans through the Drug Medi-Cal program. The Drug Medi-Cal Organized Delivery System (DMC-ODS) is a pilot program aimed at improving care, increasing efficiency, and reducing societal and health care costs associated with substance use.* Thirty-seven of California's 58 counties have implemented the DMC-ODS pilot. • The California Department of Health Care Services requires managed care plans and county mental health plans to have memorandums of understanding that specify policies and procedures for screening, referral, care coordination, information exchange, and dispute resolution in each county. * The Drug Medi-Cal Organized Delivery System pilot is part of the Medi-Cal 2020 Section 1115 waiver. Sources: "Behavioral Health Services," California Dept. of Health Care Services, accessed December 19, 2020; Don Kingdon, Molly Brassil, and Erynne Jones, The Circle Expands: Understanding Medi-Cal Coverage of Mild-to-Moderate Mental Health Conditions, California Health Care Foundation (CHCF), August 2016; Allison Valentine, Patricia Violett, and Molly Brassil, How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots, CHCF, August 2020; and "Performance Dashboard AB 470 Report Application," California Health and Human Services Agency, accessed January 26, 2021. CALIFORNIA HEALTH CARE FOUNDATION 44 Medi-Cal Facts and Figures Medi-Cal Expenditures Spending by Service Category, FY 2019–20 Managed care organizations were the Mental Health (3%) Dental (1%) largest category of service providers to Drug Medi-Cal (<1%) the Medi-Cal program, accounting for Medicare 6% Other half of all service payments. Hospital 10% inpatient services, paid on a fee-for- service basis, were the next largest Hospital Inpatient category, accounting for 14% of 14% Medi-Cal spending. TOTAL S P ENDI NG $94.7 billion FFS Professional Managed Care 7% 50% 3% Long-Term Care Pharmacy (2%) Other FFS (1%) Notes: Figures presented are estimates for FY 2019–20 calculated as of May 2020 and reflect annual spending. The Drug Medi-Cal program provides services to treat enrollees with substance use disorders. FFS is fee-for-service. Other FFS services includes medical transportation, home health, and other services. Other includes audits/lawsuits, state hospitals / developmental centers, recoveries, and miscellaneous services. Segments may not total 100% due to rounding. Hospital services are FFS. Source: Medi-Cal May 2020 Local Assistance Estimate for Fiscal Years 2019-20 and 2020-21 (PDF), California Dept. of Health Care Services, accessed August 6, 2020. CALIFORNIA HEALTH CARE FOUNDATION 45 Medi-Cal Facts and Figures Medi-Cal Annual Spending per Eligible Enrollee Spending FY 2019–20 Medi-Cal spending per enrollee varied by eligibility category. Medi-Cal spent $20,669 about $2,000 annually per child. The program spent over $20,000 annually per enrollee with disabilities. $14,134 OVERALL AVERAGE $5,873 $4,461 $5,040 $2,939 $1,944 Children Families Pregnant Women Adults Seniors People with Disabilities Notes: Figures presented are estimates for FY 2019–20 calculated as of May 2020 and reflect annual spending. Reported values exclude Hospital Presumptive Eligibility and other aid codes totaling 0.3% of enrollees. For additional information about Medi-Cal spending on maternity care, please see CHCF's report Maternity Care and Paying for Maternity Services. Source: "Fiscal Year 2019-20 Cost per Eligible Based on May 2020 Estimate," in Medi-Cal May 2020 Local Assistance Estimate for Fiscal Years 2019–20 and 2020–21 (PDF), California Dept. of Health Care Services. CALIFORNIA HEALTH CARE FOUNDATION 46 Medi-Cal Facts and Figures Medi-Cal Enrollees and Spending Spending by Eligibility Category, FY 2019–20 People with disabilities represented 9% of Medi-Cal enrollees, but <1% <1% accounted for 31% of spending. 17% 3% 6% 2% ■ Other Children accounted for 17% of ■ Pregnant Women 17% ■ Children enrollee, but just 6% of spending. ■ Families 35% ■ Seniors 19% ■ Adults ■ People with Disabilities 24% 8% 29% 31% 9% Enrollees Spending Notes: Figures presented are estimates for FY 2019–20 calculated as of May 2020. Other includes Hospital Presumptive Eligibility and other aid codes. For additional information about Medi-Cal spending on maternity care, please see CHCF's report Maternity Care and Paying for Maternity Services. Source: "Fiscal Year 2019-20 Cost per Eligible Based on May 2020 Estimate," in Medi-Cal May 2020 Local Assistance Estimate for Fiscal Years 2019–20 and 2020–21 (PDF), California Dept. of Health Care Services. CALIFORNIA HEALTH CARE FOUNDATION 47 Medi-Cal Facts and Figures Medicaid Spending per Full-Year Equivalent Enrollees Spending California vs. United States, FY 2018 Across all enrollee groups, California's Seniors per enrollee spending is lower than $13,767 the national average. $23,089 People with Disabilities $22,311 $22,634 Other Adult $4,538 $5,684 ■ California New Adult Group ■ United States $5,811 $6,474 Children $2,566 $3,146 All Full-Benefit Enrollees $7,037 $8,346 Notes: Full-year equivalent (FYE) may also be referred to as average monthly enrollment. Data are for full-benefit enrollees and exclude those receiving coverage of only family planning services, assistance with Medicare premiums and cost sharing, or emergency services. Other adult includes adults under age 65 who qualify through a pathway other than disability or Section 1902(a)(10)(A)(i)(VIII) of the Act (e.g., parents and caretakers, pregnant people). New adult group is the ACA "expansion" population. Source: "Exhibit 22. Medicaid Benefit Spending per Full-Year Equivalent (FYE) Enrollee by State and Eligibility Group, FY 2018," in MACStats: Medicaid and CHIP Data Book, Medicaid and CHIP Payment and Access Commission. CALIFORNIA HEALTH CARE FOUNDATION 48 Medi-Cal Facts and Figures Medicaid Spending per Resident Spending Selected States, FY 2019 While California's Medicaid program has the largest enrollment in the New York $3,099 nation, spending per resident ($2,246) Massachusetts $2,557 was lower than in New York ($3,099), Massachusetts ($2,557), and Pennsylvania $2,518 Pennsylvania ($2,518). The national California $2,246 average Medicaid spending per resident was $1,839 in 2019. Ohio $2,023 Michigan $1,838 New Jersey $1,812 Texas $1,467 Illinois $1,407 Florida $1,141 NATIONAL AVERAGE $1,839 Note: The 10 states chosen for comparison had the largest Medicaid expenditures in FY 2019. Sources: "Total Medicaid Spending" (FY2019), KFF, accessed October 24, 2020; and Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2019 (NST-EST2019-01), US Census Bureau, accessed October 30, 2020. CALIFORNIA HEALTH CARE FOUNDATION 49 Medi-Cal Facts and Figures Net Patient Revenues Role in the System by Hospital Ownership Type and Payer, California, 2019 Medi-Cal is a key source of funding for IN BILLIONS hospitals. Medi-Cal provided nearly $9.4 $82.8 $12.6 $4.7 two-thirds (65%) of the net patient - 1% - 2% - 1% - 2% ■ Other Payers revenue for city/county hospitals and 16% 45% 32% 37% ■ Private Insurance nearly a third (32%) for investor- - 2% ■ County Indigent Program ■ Medicare owned hospitals. 16% ■ Medi-Cal - <1% - <1% 65% 35% - <1% 34% 28% 32% 25% 27% City/County District Investor Nonprofit Notes: Data are only for hospitals classified as comparable by the Office of Statewide Health Planning and Development and thus do not include state-run and Kaiser hospitals or facilities classified as psychiatric or long-term care. Segments may not total 100% due to rounding. Source: 2019 Pivot Table - Hospital Annual Selected File (November 2020 Extract), California Health and Human Services Agency, December 10, 2020. CALIFORNIA HEALTH CARE FOUNDATION 50 Medi-Cal Facts and Figures Change in Medi-Cal Net Patient Revenue Role in the System by Hospital Ownership Type, 2013 to 2019 All hospital types experienced a growth in Medi-Cal net patient 95% revenue between 2013 and 2019, likely as a result of the ACA expansion in 2014. Net patient revenue from 70% 72% Medi-Cal grew by 95% at city/county hospitals. 48% City/County District Investor Nonprofit Note: Data are only for hospitals classified as comparable and thus do not include state-run and Kaiser hospitals or facilities classified as psychiatric or long-term care. Source: 2019 Pivot Table - Hospital Annual Selected File (November 2020 Extract), California Health and Human Services Agency, December 10, 2020. CALIFORNIA HEALTH CARE FOUNDATION 51 Medi-Cal Facts and Figures Primary Care Clinic Visits and Net Patient Revenue Role in the System by Payer, 2013 and 2019 Primary care clinics experienced PERCENTAGE OF VISITS 17.2 MILLION / 23.3 MILLION PERCENTAGE OF NET PATIENT REVENUE $2.1 BILLION / $4.3 BILLION significant growth in Medi-Cal visits Medi-Cal Medi-Cal and net patient revenue since the 43% 57% implementation of the Affordable Care 63% 73% Act. Medi-Cal visits increased from Medicare Medicare 7% 8% ■ 2013 43% of visits in 2013 to 63% of visits ■ 2019 9% 9% in 2019. Both visits and revenue from Uninsured or Indigent Programs Uninsured or Indigent Programs uninsured patients declined as more 24% 14% patients were enrolled in Medi-Cal 11% 4% and private insurance. Private Insurance Private Insurance 6% 6% 8% 6% Other Public Other Public 19% 15% 9% 8% Notes: Includes Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes, and other clinic types. Uninsured and indigent coverage are combined due to data-reporting inconsistencies, and include self-pay/sliding scale, free, and county indigent program patients. Other public includes Alameda Alliance for Health, Family PACT, and all other payers, except for the PACE program, which is excluded from all categories. Excludes county-run clinics. Segments may not total 100% due to rounding. S ource: Blue Sky Consulting Group analysis of 2019 Pivot Table - Primary Care Clinic Utilization Data, California Health and Human Services Agency (CHHS), last updated December 4, 2020, and 2013 Pivot Table - Primary Care Utilization Data, CHHS, last updated May 8, 2018. CALIFORNIA HEALTH CARE FOUNDATION 52 Medi-Cal Facts and Figures Net Patient Revenues, Long-Term Care Facilities Role in the System by Payer, 2013 and 2019 Medi-Cal provided an important IN BILLIONS $9.8 $12.1 source of net patient revenue for long- 4% 5% ■ Other Payers term care facilities. Even though the 6% 4% ■ Self-Pay share of revenues from Medi-Cal was 10% ■ Managed Care down from 2013, Medi-Cal accounted 20% ■ Medicare ■ Medi-Cal for 39% of all long-term care facilities' 34% net patient revenues in 2019. 32% 46% 39% 2013 2019 Notes: Long-term care facilities includes those facilities providing sub acute and intermediate care, skilled nursing, and facilities for the developmentally disabled. Managed care patients are those enrolled in a managed care health plan who receive all or part of their health care from providers on a prenegotiated or per diem basis, usually involving utilization review. This includes health maintenance organizations (HMOs), HMOs with point-of-service option, preferred provider organizations, exclusive provider organizations (EPOs), EPOs with point-of- service option, etc. Also includes patients enrolled in Medicare and Medi-Cal managed care health plans. Segments may not total 100% due to rounding. Sources: 2019 - Pivot Profile - Long-Term Care Annual Financial Data (December 2020), California Health and Human Services Agency (CHHS), last updated December 14, 2020; and 2013 - Pivot Profile - Long-Term Care Annual Financial Data, CHHS, last updated May 3, 2018. CALIFORNIA HEALTH CARE FOUNDATION 53 Medi-Cal Facts and Figures Insurance Not Accepted by Provider Access and Utilization by Source of Coverage, Adults, California, 2019 Adults enrolled in Medi-Cal were more SHARE OF ADULTS WHOSE INSURANCE WAS NOT ACCEPTED BY THEIR PROVIDER than twice as likely to report difficulty ■ Medi-Cal 24% finding a provider that accepted their ■ Medicare insurance when compared to those ■ Medicare and Medi-Cal ■ Employment-Based 20% with employer-based insurance or ■ Privately Purchased Medicare. This pattern held for both primary and specialty care. 11% 11% 9% 9% 7% 5% 4% 3% Primary Care Specialty Care Note: Insurance status is self-reported. Medicare includes people who have only Medicare, and Medicare and other. Source: 2019 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 54 Medi-Cal Facts and Figures Difficulty Finding Primary and Specialty Care Access and Utilization by Source of Coverage, 2013 and 2019 Of all adults enrolled in Medi-Cal, the PERCENTAGE OF ADULTS WHO HAD DIFFICULTY FINDING PRIMARY AND SPECIALTY CARE percentage reporting difficulty finding primary care increased slightly, while ■ Medi-Cal ■ Medicare the percentage reporting difficulty 27% ■ Medicare and Medi-Cal 26% finding specialty care increased from ■ Employment-Based ■ Privately Purchased 21% in 2013 to 26% in 2019. 21% 15% 15% 13% 12% 11% 10% 10% 10% 9% 7% 7% 7% 4% 4% 4% 2% 2% 2013 2019 2013 2019 Primary Care Specialty Care Note: Insurance status is self-reported. Medicare includes people who have only Medicare, and Medicare and other. Source: 2013 and 2019 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 55 Medi-Cal Facts and Figures Preventive Care Visits Access and Utilization by Source of Coverage, California, 2019 Medi-Cal enrollees reported having PERCENTAGE WHO HAD THE FOLLOWING PREVENTIVE CARE WITHIN THE PAST YEAR a routine checkup at the same rates Dental Visit (children) as people with employer-based or 82% private insurance. Adult enrollees were 84% 72% less likely to have visited a dentist Dental Visit (adults) during the past 12 months, compared 57% ■ Medi-Cal to those with employer-based or 79% ■ Medicare private insurance. 52% ■ Medicare and Medi-Cal 78% ■ Employment-Based 68% ■ Privately Purchased Routine Checkup (adults)* 71% 88% 85% 70% 67% * With a doctor or medical provider. Note: Insurance status is self-reported. Medicare includes people who have only Medicare, and Medicare and other. Source: 2019 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 56 Medi-Cal Facts and Figures Delay of Care Access and Utilization by Source of Coverage, California, 2019 One in seven Medi-Cal enrollees SHARE OF POPULATION THAT DELAYED CARE DUE TO COST OR LACK OF INSURANCE, BY INSURANCE TYPE reported delaying care, roughly the same percentage as Californians 91% DELAYED CARE FOR ANY REASON Medi-Cal overall (not shown). Among those 15% Medicare who delayed care, Medi-Cal enrollees 7% Medicare and Medi-Cal 14% were much less likely to report cost Employment-Based 14% or lack of insurance as reasons for Privately Purchased 59% Uninsured 20% delaying care, compared with the 25% those that were uninsured or those 48% with privately purchased insurance. 42% 33% 35% Medi-Cal Medicare Medicare Employment- Privately Uninsured and Based Purchased Medi-Cal Note: Insurance status is self-reported. Medicare includes people who have only Medicare, and Medicare and other. Source: 2019 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 57 Medi-Cal Facts and Figures Diabetes Care Access and Utilization by Source of Coverage, California, 2018 Medi-Cal enrollees were less likely ADULTS EVER DIAGNOSED WITH DIABETES WHO REPORTED THEY WERE VERY CONFIDENT IN THEIR ABILITY TO CONTROL/MANAGE IT than those with other types of 91% EVER DIAGNOSED WITH DIABETES insurance to report that they were Medi-Cal 10% confident that their diabetes was Medicare 19% under control. Medicare and Medi-Cal 74% Employment-Based 30% 6% 65% Privately Purchased 60% 6% Uninsured 54% 57% 6% 25% 50% Medi-Cal Medicare Medicare Employment- Privately Uninsured and Based Purchased* Medi-Cal * Statistically unstable. Note: Insurance status is self-reported. Medicare includes people who have only Medicare, and Medicare and other. Source: 2018 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 58 Medi-Cal Facts and Figures Asthma Care Access and Utilization by Source of Coverage, California, 2019 One in four Medi-Cal enrollees ■ Medi-Cal diagnosed with asthma reported they ■ Medicare EVER DIAGNOSED WITH ASTHMA had an asthma attack in the past 12 ■ Medicare and Medi-Cal Medi-Cal 13% ■ Employment-Based Medicare months, and one in two took daily ■ Privately Purchased 14% Medicare and Medi-Cal medication to control their asthma. ■ Uninsured 17% Employment-Based 67% 16% Privately Purchased 17% 60% Uninsured 13% 54% 37% 38% 34% 33% 32% 25% 26% 15% 11% * Population with Asthma Who Population Ever Diagnosed with Asthma Take Daily Medication to Control It Who Had an Attack in the Past 12 Months * Statistically unstable Note: Insurance status is self-reported. Medicare includes people who have only Medicare, and Medicare and other. Source: 2019 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 59 Medi-Cal Facts and Figures Heart Disease Care Access and Utilization by Source of Coverage, 2018 Slightly more than 6 in 10 Medi- SHARE OF ADULTS DIAGNOSED WITH HEART DISEASE WITH A MANAGEMENT PLAN Cal enrollees diagnosed with heart 91% EVER DIAGNOSED WITH HEART DISEASE disease were provided a heart disease 88% Medi-Cal 85% 4% Medicare management plan by their provider. 22% 75% Medicare and Medi-Cal 19% 70% Employment-Based 3% 64% Privately Purchased 4% Uninsured 55% 3% Medi-Cal Medicare Medicare Employment- Privately Uninsured and Based Purchased Medi-Cal Note: Insurance status is self-reported. Medicare includes people who have only Medicare, and Medicare and other. Source: 2018 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 60 Medi-Cal Facts and Figures Preventable Hospitalizations Quality by Source of Coverage, California, 2018 Rates of avoidable hospitalizations for PER 100,000 POPULATION ambulatory care–sensitive conditions 3200 (including diabetes complications, 2800 adult asthma or other lung diseases, hypertension, heart failure, and 2400 2,574 other conditions) are widely used 2000 as a marker of access to primary care. Those with public coverage 1600 experienced higher rates of avoidable 1200 OVERALL hospitalizations when compared to 1,155 AVERAGE 897 those without insurance or those 800 with private or employment-based 400 660 coverage. 154 222 0 Employment-Based / Other Public Uninsured Medi-Cal Medicare Privately Purchased Notes: PQI 90 (Prevention Quality Indicator 90) is an overall composite measure of avoidable hospitalizations. The rate of avoidable hospitalizations was calculated as the number of hospitalizations for a particular payer category divided by the corresponding adult population according to the California Health Interview Survey. Rates presented are overall rates, not adjusted for age, gender, or other demographic characteristics. For additional information about this measure, see www.oshpd.ca.gov. Sources: Blue Sky Consulting Group analysis of Agency for Healthcare Research and Quality PQI applied to custom data request, Office of Statewide Health Planning and Development Hospital Inpatient Discharge data; and the 2018 California Health Interview Survey, UCLA Center for Health Policy Research. CALIFORNIA HEALTH CARE FOUNDATION 61 Medi-Cal Facts and Figures Antidepressant Medication Management Quality Among Medi-Cal Managed Care Enrollees, by Race/Ethnicity, California, 2019 Medi-Cal managed care enrollees EFFECTIVE ACUTE PHASE TREATMENT reporting their race/ethnicity as American Indian / Alaska Native Latinx, Black, American Indian / 53% Alaska Native or Native Hawaiian / Asian American Other Pacific Islander had slightly 60% lower rates of remaining on Black antidepressant medication for at least 52% 84 days than other races/ethnicities. Latinx 54% Effective medication treatment of Native Hawaiian / Other Pacific Islander major depression can improve a 53% person's daily functioning and well- Other being and can reduce the risk of 61% suicide.* White 62% MINIMUM PERFORMANCE LEVEL Notes: Based on measures reported by 25 full-scope Medi-Cal managed care health plans. Effective acute phase treatment measures the percentage of members age 18 and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication for at least 84 days. Minimum performance level represents the national Medicaid 50th percentile for the indicator and is used as a proxy display to provide information about overall performance and is not a statistical benchmark. The rate for unknown/missing race/ethnicity was 60%. Source uses Asian, Black or African American, and Hispanic or Latino. * "Antidepressant Medication Management (AMM)," Source: 2019 Health Disparities Report, California Dept. of Health Care Services, December 2020. National Committee for Quality Assurance. CALIFORNIA HEALTH CARE FOUNDATION 62 Medi-Cal Facts and Figures Antidepressant Medication Management Quality Among Medi-Cal Managed Care Enrollees, by Race/Ethnicity, California, 2019 Medi-Cal managed care enrollees EFFECTIVE CONTINUATION PHASE TREATMENT reporting their race/ethnicity as American Indian / Alaska Native Latinx, Black, or Native Hawaiian / 37% Other Pacific Islander had lower Asian American rates of continuing antidepressant 44% medication for at least 180 days Black than other races/ethnicities. Effective 34% Latinx medication treatment of major 35% depression can improve a person's Native Hawaiian / Other Pacific Islander daily functioning and well-being and 34% can reduce the risk of suicide.* Other 44% White 46% MINIMUM PERFORMANCE LEVEL Notes: Based on measures reported by 25 full-scope Medi-Cal managed care health plans. Effective continuation phase treatment measures the percentage of members age 18 and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication for at least 180 days. Minimum performance level represents the national Medicaid 50th percentile for the indicator and is used as a proxy display to provide information about overall performance and is not a statistical benchmark. The rate for unknown/missing race/ethnicity was 43%. Source uses Asian, Black or African American, and Hispanic or Latino. * "Antidepressant Medication Management (AMM)," Source: 2019 Health Disparities Report, California Dept. of Health Care Services, December 2020. National Committee for Quality Assurance. CALIFORNIA HEALTH CARE FOUNDATION 63 Medi-Cal Facts and Figures Asthma Medication Ratios Quality Among Medi-Cal Managed Care Enrollees, by Race/Ethnicity, California, 2019 Black and American Indian / Alaska Native managed care enrollees with American Indian / Alaska Native persistent asthma had the lowest 55% rates for receiving medications to Asian American control their condition. Appropriate 68% medication management for patients Black with asthma could reduce the need 56% Latinx for rescue medication as well as the 63% costs associated with emergency Native Hawaiian / Other Pacific Islander room visits, inpatient admissions, and 63% missed days of school and work.* Other 64% White 59% MINIMUM PERFORMANCE LEVEL Notes: Based on measures reported by 25 full-scope Medi-Cal managed care health plans. Asthma medication ratio measures the percentage of members age 5 to 64 who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater. Minimum performance level represents the national Medicaid 50th percentile for the indicator and is used as a proxy display to provide information about overall performance and is not a statistical benchmark. The rate for unknown/ * "Medication Management for People with Asthma missing race/ethnicity was 69%. Source uses Asian, Black or African American, and Hispanic or Latino. and Asthma Medication Ratio (MMA, AMR)," National Source: 2019 Health Disparities Report, California Dept. of Health Care Services, December 2020. Committee for Quality Assurance. CALIFORNIA HEALTH CARE FOUNDATION 64 Medi-Cal Facts and Figures Breast Cancer Screening Quality Among Medi-Cal Managed Care Enrollees, by Race/Ethnicity, California, 2019 While Latinx and Asian American women enrolled in Medi-Cal managed American Indian / Alaska Native care plans had the highest rates of 46% breast cancer screening, American Asian American Indian / Alaska Native enrollees had 66% the lowest rates. Early detection can Black reduce the risk of dying from breast 56% cancer and can lead to a greater range Latinx of treatment options.* 69% Native Hawaiian / Other Pacific Islander 55% Other 62% White 54% MINIMUM PERFORMANCE LEVEL Notes: Based on measures reported by 25 full-scope Medi-Cal managed care health plans. Breast cancer screening measures the percentage of women age 50 to 74 who had a mammogram to screen for breast cancer. Minimum performance level represents the national Medicaid 50th percentile for the indicator and is used as a proxy display to provide information about overall performance and is not a statistical benchmark. The rate for unknown/missing race/ethnicity was 57%. Source uses Asian, Black or African American, and Hispanic or Latino. * "Breast Cancer Screening (BCS)," National Committee for Source: 2019 Health Disparities Report, California Dept. of Health Care Services, December 2020. Quality Assurance. CALIFORNIA HEALTH CARE FOUNDATION 65 Medi-Cal Facts and Figures Plan All-Cause Readmissions Quality Among Medi-Cal Managed Care Enrollees, by Race/Ethnicity, California, 2019 Native Hawaiian / Other Pacific Islanders had a slightly higher rate American Indian / Alaska Native of readmission to the hospital than 10% Medi-Cal managed care enrollees of Asian American other races/ethnicities. Unplanned 8% readmissions can be prevented Black by standardizing and improving 9% Latinx coordination of care after discharge 8% and increasing support for patient Native Hawaiian / Other Pacific Islander self-management.* 11% Other 9% White 10% Notes: Based on measures reported by 25 full-scope Medi-Cal managed care health plans. Plan all-cause readmissions-observed readmission rate-total measures the percentage of members age 18 and older who had an acute inpatient and observation stay during the measurement year that was followed by an unplanned acute readmission for any diagnosis within 30 of discharge. The rate for unknown/missing race/ethnicity was 9%. Source uses Asian, Black or African American, and Hispanic or Latino. * "Plan All-Cause Readmissions (PCR)," National Committee Source: 2019 Health Disparities Report, California Dept. of Health Care Services, December 2020. for Quality Assurance. CALIFORNIA HEALTH CARE FOUNDATION 66 Medi-Cal Facts and Figures Medi-Cal Managed Care Quality, Childhood Measures Quality 2009 to 2018 From 2009 to 2018, quality of care in Medi-Cal managed care was stagnant PERCENTAGE POINT CHANGE 32.1 on over half of 41 measures (not shown). Among the nine quality measures currently in use for children, six declined or stayed the same. 18.1 11.2 -0.2 -3.3 0.8 -2.1 -1.9 -1.3 Well-Child Access to Primary Care Immunization Status* Counseling* Visits 12–24 25 Months 7–11 12–19 Combi- Combi- Nutrition Physical 3rd–6th Months to 6 Years* Years Years nation nation Activity Years of Life 2 3 * Change is statistically significant. Notes: Not every measure was reported every year. Change over time represents percentage points. Source: Andrew Bindman et al., A Close Look at Medi-Cal Managed Care: Statewide Quality Trends from the Last Decade, California Health Care Foundation, September 2019. CALIFORNIA HEALTH CARE FOUNDATION 67 Medi-Cal Facts and Figures Looking Ahead Looking Ahead The Medi-Cal program faces numerous changes in the • Assess the outcome of a planned transition to The Medi-Cal program faces coming years. Some of this change is driven by leadership carved-out pharmacy benefits with the Medi-Cal Rx decisions from the executive branch and also from the program. numerous changes and challenges California legislature. DHCS will: • Possible expansion of full-scope coverage of adults in the coming years as it evolves • Continue to support Medi-Cal enrollees, providers, with low incomes regardless of immigration status if in response to new policies and and Californians who are undocumented during the the legislature continues to pursue this goal. COVID-19 public health emergency, working with In addition, DHCS will have to address: unprecedented funding approved by waivers provided by the federal government. • An aging enrollee population as California's the governor and legislature, to health • Accommodate increased enrollment in 2021 due in over-60 population increases at a rate three care inequities laid bare by the COVID- part to the COVID-19 pandemic. times faster than overall population growth. This will likely increase Medi-Cal's spending on long- 19 pandemic, and to a growing desire • Seek CalAIM approval from the federal government and then prepare for implementation of several term services and supports. for the program to contribute more initiatives in January 2022. See page 34 for more • Disparities in access, quality of care, and health outcomes for enrollees of color. to addressing longstanding health information on CalAIM. • Begin the process to procure contracts for all disparities and social determinants of commercial health plans providing services and to health. recontract with local plans. Starting in 2024, this may bring a change of health plans to some portion of the 11 million Medi-Cal enrollees in managed care in 58 counties. Sources: Medi-Cal Managed Care Request for Proposal (RFP) Schedule by Model Type (PDF), California Dept. of Health Care Services, last updated February 27, 2020; and "Facts About California's Elderly," California Dept. of Aging, accessed March 18, 2021. CALIFORNIA HEALTH CARE FOUNDATION 68 Medi-Cal Facts and Figures About the Data The survey data used in this publication rely on self-reported insurance status. When asked by survey researchers about health coverage, some immigrants ABOUT THIS SERIES who are undocumented and who have used restricted-scope Medi-Cal may The California Health Care Almanac is an online respond that they have Medi-Cal coverage. Restricted-scope Medi-Cal, which clearinghouse for data and analysis examining covers only emergency and pregnancy-related services, is not comprehensive the state's health care system. It focuses on issues of quality, affordability, insurance coverage and coverage. If these adults who are undocumented and reporting Medi-Cal were the uninsured, and the financial health of the instead considered uninsured, the number of Californians without insurance system with the goal of supporting thoughtful would be higher. Furthermore, some respondents with Medi-Cal may mistakenly planning and effective decisionmaking. Learn report having private coverage. more at www.chcf.org/almanac. AU T H O R S Len Finocchio, James Paci, Matthew Newman Blue Sky Consulting Group DESIGNERS D. Johnson, J. Black, A.B. Goldin, K. Costantinidis Dennis Johnson Design F O R M O R E I N F O R M AT I O N California Health Care Foundation 1438 Webster Street, Suite 400 Oakland, CA 94612 510.238.1040 www.chcf.org CALIFORNIA HEALTH CARE FOUNDATION 69