Medi-Cal Managed Care and Long-Term Services and Supports: Opportunities and Considerations Under CalAIM MARCH 2023 AUTHORS Athena Chapman, MPP, and Elizabeth Evenson, Chapman Consulting Contents About the Authors 3Introduction Athena Chapman, MPP, is president and 5 Characteristics and Challenges of Elizabeth Evenson is senior policy director the Current Medi-Cal LTSS System at Chapman Consulting, which provides strategic planning, meeting facilitation, 6 Moving from LTSS to MLTSS: Federal organizational support, market research, and State Roles and regulatory and statutory analysis to 6 Preparing for MLTSS: Integrating organizations in the health care field. Lessons Learned from Past Efforts About the Foundation 8 Potential Benefits of Expanding MLTSS The California Health Care Foundation Increased Accountability and Oversight (CHCF) is an independent, nonprofit phil­ Reduced Disparities in Access to Services anthropy that works to improve the health Streamlined Enrollment and Assessment Processes care system so that all Californians have the Improved System Navigation and Care Transitions care they need. We focus especially on mak­ Strengthened Data Exchange ing sure the system works for Californians with low incomes and for communities who 13 Scenarios for Designing the MLTSS have traditionally faced the greatest barri­ Program ers to care. We partner with leaders across the health care safety net to ensure they 16 Conclusion have the data and resources to make care 17 Appendices more just and to drive improvement in a complex system. 21 Endnotes CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. Introduction care programs."1 DHCS has not yet defined its vision for the full scope of LTSS services that would M illions of Californians live with disabling be the direct responsibility of Medi-Cal MCPs under conditions or chronic illnesses that require statewide MLTSS, but has stated its intent to keep them to seek assistance with common the In-Home Supportive Services (IHSS) program - activities of daily living, such as bathing, dressing, the largest LTSS program - outside of managed and eating. Others need help with services such as care for the foreseeable future. It is likely that other transportation, housekeeping, meal preparation, or LTSS benefits also would remain outside the man­ other assistance to live safely and independently at aged care benefit, so Medi-Cal enrollees would home. Some need these types of supportive ser­ receive some LTSS benefits through managed care vices to thrive in a nursing home, assisted living and some outside the managed care system, with community, or other facility setting. MCPs serving as the single point of accountability for referral, coordination, and delivery of services. To address these needs, a patchwork of programs across the state provides what are collectively Through various reforms and programs, CalAIM known as long-term services and supports (LTSS); increases the responsibility of MCPs for addi­ for many Californians with low incomes, some tional benefits, services, and populations that may LTSS are provided through Medi-Cal, the state's increase the role of managed care in delivery of Medicaid program. LTSS. Because of the sheer amount of activity under CalAIM, this report does not examine every CalAIM California's Medicaid agency, the Department of initiative that will impact MLTSS. However, it is Health Care Services (DHCS), seeks to improve the important to understand that many components state's current approach to providing LTSS as part of CalAIM are interdependent, and many of these of its ambitious, multiyear set of reforms known as components increase the types of LTSS that MCPs the CalAIM (California Advancing and Innovating can provide to enrollees. (See box titled "CalAIM Medi-Cal) initiative. The broad goals of CalAIM are Reforms Building Toward Managed Long-Term to implement whole-person care approaches that Services and Supports.") address social drivers of health, improve quality out­ comes, reduce health disparities, and create more This report explores some design options for imple­ consistent and seamless statewide Medi-Cal ben­ menting MLTSS that policymakers, agency leaders, efits that are easier for enrollees to navigate. One advocates, and other stakeholders can consider of the strategies that the state is using to achieve as planning for this work unfolds. The information these goals is putting more responsibility for pro­ provided is based on research of existing LTSS in vision or coordination of services on its contracted California and other states, more than 20 stake­ Medi-Cal managed care plans (MCPs). holder interviews, and input from an advisory committee composed of regulators and subject While a variety of approaches could help California matter experts (see Appendix A). achieve more standardized LTSS benefits and improve the enrollee experience, DHCS has stated The report provides an overview of the challenges its intent to move toward a delivery system referred of the current system of supports and describes the to as statewide Managed Long-Term Services and potential benefits of statewide MLTSS. It also offers Supports (MLTSS) by 2027. The CalAIM proposal perspectives and lessons learned that can inform defines MLTSS as "the delivery of long-term services how the system could be developed, an overview of and supports through capitated Medi-Cal managed the improvements that a new system could provide, Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 3 as well as different scenarios for implementation. hope is to help ensure a smooth transition to this The analysis should help highlight viable options new approach to LTSS, and to advance and align for the further development and implementation of with the larger goals of CalAIM. statewide MLTSS in Medi-Cal managed care. The CalAIM Reforms Building Toward Managed Long-Term Services and Supports Following is a brief introduction to some of the related CalAIM components that impact MLTSS, which are in varying phases of implementation. Additional information can be found at the Department of Health Care Services' CalAIM web page. $ Institutional Long-Term Care Carve-In. Medi-Cal managed care plans (MCPs) statewide are responsible for institutional long-term care, starting with nursing facilities in January 2023, and other types of facilities in January 2024. $ Enhanced Care Management (ECM). ECM is a new Medi-Cal managed care benefit that is designed to address the clinical and nonclinical needs of specific populations of focus (e.g., high-risk, high-needs enrollees), who may require MCPs to deliver or coordinate additional LTSS to meet their needs. $ Community Supports (CS). Formerly known as "In Lieu of Services," CS include 14 medically appropri­ ate and cost-effective alternatives to traditional Medi-Cal services that are optional for MCPs to offer and optional for enrollees to accept. Some CS are very similar to existing LTSS. $ Exclusively Aligned Enrollment (EAE) Dual-Eligible Special Needs Plans (D-SNPs). Beginning in 2023 in select counties and phasing in statewide by 2026, enrollees eligible for both Medicare and Medi-Cal will have the option to receive both program benefits from health plans from the same parent company. The goal of this model is to provide care coordination and wraparound services, including LTSS, through aligned Medi-Cal MCPs and Medicare Advantage plans known as Medicare Medi-Cal Plans. $ Population Health Management (PHM) Program. The PHM Program includes a road map that outlines the goals and requirements for MCPs to implement population health management strategies. A com­ ponent of the PHM Program is the establishment of a PHM Service to provide access to comprehensive, timely, and accurate data to MCPs, providers, counties, and Medi-Cal members. MCPs will be required to use data from the PHM Service to identify gaps in care, focus on approaches that link members to social services and supports, utilize a standard member risk-stratification process, and improve care transitions across the delivery system for all Medi-Cal covered services. $ Standard Mandatory MCP Enrollment Policy. Nearly all Medi-Cal enrollees in the Seniors and Persons with Disabilities eligibility category are now required to enroll in an MCP for their Medi-Cal benefits statewide. This includes both those covered by Medi-Cal only and those enrolled in both Medicare and Medi-Cal (dually eligible enrollees). These MCP enrollment policies are intended to ensure that Medi-Cal enrollees have more consistent benefits and to reduce fragmentation of all Medi-Cal services, funding, and accountability through a single delivery system. California Health Care Foundation www.chcf.org 4 Characteristics and depend on waiver availability and/or capacity, the scope of services, and where enrollees live. This Challenges of the Current patchwork of program types and authorities means Medi-Cal LTSS System that California's current LTSS delivery system is frag­ mented, and services are not available consistently Detailed information about the current system across the state. Medi-Cal enrollees who need of Medi-Cal LTSS can be found in the CHCF fact services in the community or in a facility must navi­ sheet, "Long-Term Services and Supports in Medi- gate a complicated system, without a coordinated Cal."2 In addition, below are a few key points about approach to support. Inefficiencies and inconsis­ the existing delivery system that are important tency in the system can result in enrollees either to understand at a high level as California moves not receiving care or accessing it in more costly toward statewide MLTSS. settings, such as a hospital. Some of the program design issues that impact access to LTSS include: California has flexibility in designing its approach to LTSS. Medicaid programs across the country $ Fragmented accountability, oversight, and are jointly financed by states and the federal gov­ financial responsibility among the state, coun­ ernment. The Centers for Medicare & Medicaid ties, and MCPs Services (CMS) sets broad requirements for each $ Regional differences in networks state to develop its own Medicaid program through a Medicaid State Plan, which CMS both approves $ Varying waiver availability and eligibility criteria and monitors.3 $ Long wait-lists, resulting in disparities in access States may request additional flexibility in design­ $ Multiple intake/screening processes, making ing their Medicaid programs through the formal it difficult to determine the most appropriate approval of federal waivers.4 Under the waivers, program/waiver states can receive approval to deliver an alternative $ Program enrollment processes that can be benefit plan, such as offering certain benefits to difficult for people needing care (or their care­ only a subset of Medicaid beneficiaries, implement­ givers) to navigate ing Medicaid managed care programs or restricted networks, and extending coverage to enrollees $ Difficultyidentifying available LTSS providers, beyond those defined under Medicaid rules. This especially providers willing to serve the Medi- structure makes each state's Medicaid program Cal population unique and provides flexibility for California in its $ Lack of robust data sharing across the LTSS current approach to LTSS and how it could design system, impeding the delivery of person-cen­ its statewide MLTSS program. tered care Today's complicated system can make it difficult More LTSS are moving under managed care for people to get the care they need. Currently, through CalAIM. MCPs have responsibility for pro­ California delivers most Medi-Cal LTSS through a viding a subset of LTSS, including care delivered in complex patchwork of programs authorized through long-term care facilities (expanded statewide under its Medicaid State Plan and several home and com­ CalAIM), Community-Based Adult Services (or munity-based services (HCBS) waivers. The ability CBAS, an adult day health program that operates of Medi-Cal enrollees to access these services can Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 5 in 28 counties),5 and Enhanced Care Management 7. A comprehensive, integrated service package benefits. Additionally, MCPs have the option to 8. A network of qualified providers offer various Community Supports services. (See Appendix B for more details on the LTSS provided 9. Participant protections through MCPs.) 10. Quality assurances The remaining Medi-Cal LTSS are "carved out" of Additionally, the state legislature will play a role the MCP benefit. A carved-out benefit means that in allocating funds from the state budget for the the MCP does not pay for or administer the services, MLTSS program. Depending on the program's which are accessed through a complicated system scope, statutory authority may be needed to imple­ of waivers and other programs. (See Appendix C for ment the benefits statewide. Once CMS gives its more detail on current LTSS provided outside of the approval and the state completes its legislative MCP benefit.) deliberations, states must adequately document - through managed care contracts, for example - the Moving from LTSS to requirements and expectations of MCPs in provid­ ing and coordinating MLTSS. MLTSS: Federal and State Roles Preparing for MLTSS: No single path or prescribed format exists for a state Integrating Lessons to create an MLTSS program. CMS will consider a Learned from Past state's existing LTSS benefits and program structure as it evaluates and negotiates each MLTSS program Efforts one by one for compliance with Medicaid require­ ments. Once a state creates its MLTSS design, CMS California is not entirely new to MLTSS. Through a and the state can identify the appropriate combina­ demonstration project known as the Coordinated tion of waiver and State Plan authority necessary to Care Initiative (CCI), California attempted to move meet the program's goals, given the requirements more LTSS under the responsibility of MCPs in seven and limitations for each waiver and State Plan option. counties. These experiments with MLTSS were met with considerable challenges. Specifically, two pro­ CMS has broadly outlined the following key compo­ grams - In-Home Supportive Services (IHSS) and nents that the department expects states to include the Multipurpose Senior Services Program (MSSP) in an MLTSS program design:6 - were "carved in" to managed care for a few years, but were carved back out due to implemen­ 1. Adequate planning tation challenges, unmet cost savings expectations, and significant opposition from key stakeholders. 2. Robust stakeholder engagement 3. Enhanced provision of home and community- As the state embarks on a pathway to defining and based services operationalizing statewide MLTSS, experiences 4. Alignment of payment structures and goals from past efforts such as CCI can inform the work. 5. Support for beneficiaries 6. Person-centered processes California Health Care Foundation www.chcf.org 6 Making clear and consistent policy decisions. enrollees. Based on past efforts to improve LTSS For the statewide MLTSS initiative to be success­ networks and workforce retention, California stake­ ful, stakeholders need clear expectations and policy holders could consider the following approaches: decisions to support their planning and implemen­ tation processes. During CCI, shifting policies $ Standardize and increase the use of telehealth (such as the carve-in and subsequent carve-out of and other virtual platforms to provide some IHSS and MSSP) created challenges for MCPs and LTSS virtually, which would help reach more their partners; these changes led to uncertainty people with the current workforce, especially and confusion about the benefit structure and the in rural parts of the state. role of MCPs, which resulted in frustration and dis­ $ Create career pathways for LTSS providers. trust among stakeholders and made it difficult for For example, one organization noted that it MCPs to provide the integrated and coordinated trains interested janitorial staff and others in care envisioned in the initiative. For MLTSS, early, entry-level positions so that they can move clear, and consistent articulation of expectations into direct care roles, and increases reimburse­ and policy decisions can help prevent this type of ment when providers complete a certificate or confusion. training or when they otherwise demonstrate increased capabilities. Engaging providers. Communicating with im­ pacted providers about the benefit and policy $ Consider the value of creating different reim­ changes can help alleviate some of the confusion bursement structures and tiers based on and opposition to enrollee transitions and the role enrollee needs, so that providers are paid of managed care. DHCS could work with plans adequately for the required workload. and providers that have had success under previ­ $ Provide a stipend to enrollees so that they ous pilots and existing MLTSS programs to create could pay their LTSS provider directly, and at resources and trainings about developing relation­ a consistent amount each month, rather than ships between MCPs and LTSS providers and how having provider incomes fluctuate based on to build up expertise for statewide MLTSS imple­ hours worked. mentation. These supports could address provider capacity for the reporting, invoicing, and data shar­ Focusing on person-centered, sustainable ser- ing necessary to support an effective network, and vices. Another key lesson is to center the design ability to coordinate excluded services. Proactive and implementation of MLTSS on providing person- engagement and collaboration between DHCS, centered care that enables Medi-Cal enrollees to MCPs, and LTSS providers leading up to expanded receive high-quality care in the setting most appro­ MLTSS could help identify and reduce some bar­ priate for them, rather than focusing primarily on riers and integrate solutions that would support a cost savings. While LTSS can be less expensive than broad network of LTSS providers. Those steps, in higher-intensity care alternatives, person-centered turn, could help improve coordination across the LTSS provided in the community may not result in continuum of care. significant or immediate cost savings to the system and may result in an appropriate increase in the use Supporting the LTSS workforce. DHCS could use of other services, such as primary care and prescrip­ statewide MLTSS as a mechanism to implement tion drugs. But the potential positive outcomes policies that lead to a more robust LTSS pro­ include improved health and a better enrollee vider network and increased options for Medi-Cal Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 7 experience, especially when the enrollee is actively involved in their health care decisions. Under the Gap Analysis and Road Map CCI, the requirement to achieve cost savings to In July 2021, the Department of Health Care continue the program was one of the major road­ Services (DHCS) received approval from the blocks to the sustainability of those MLTSS.7 Centers for Medicare & Medicaid Services for $5 million in supplemental funding to engage Exploring next steps. As the state moves into plan­ in a statewide Home and Community-Based ning for MLTSS, stakeholders can consider models Services (HCBS)/MLTSS Gap Analysis and that other states already use to inform program Multi-Year Roadmap for its HCBS and MLTSS design. The CHCF series titled "CalAIM for Seniors programs and networks. The gap analysis is and People with Disabilities" includes examinations intended to highlight how the road map can of efforts to integrate care in other states.8 be designed to reduce inequities in access and services, meet enrollee needs, increase program integration and coordination, improve Beyond information from past efforts, stakehold­ quality, and streamline access. The results of ers will need to engage in constructive dialogue this gap analysis will inform the development about program design options. One venue could of MLTSS in Medi-Cal and impact the scope be DHCS's CalAIM MLTSS and Duals Integration of federal authority needed to implement this Workgroup,9 where the state engages a broad program. DHCS is holding quarterly stake­ group of stakeholders in planning for current holder meetings to provide updates and will and upcoming reforms. To date, this group has be completing semiannual reports on activities primarily focused on more immediate CalAIM imple­ and milestones.10 mentation issues, and discussions of MLTSS have focused mainly on the carve-in of institutional long- term care and implementation of Enhanced Care Management and Community Supports. Focused Potential Benefits of discussions on achieving statewide MLTSS through­ out the Medi-Cal landscape will be essential to Expanding MLTSS creating stakeholder support and identifying best Given the complexity and inconsistency of the cur­ practices. Lessons from past experiences with MLTSS rent LTSS system, the intention to expand MLTSS should be evaluated and integrated into these is an important part of making Medi-Cal benefits discussions and into the future program design. more consistent statewide under CalAIM. MLTSS is Another venue for learning and planning is DHCS's just one program design option for creating a more Home and Community-Based Services (HCBS)/ standardized system and is not a panacea for all of MLTSS Gap Analysis and Multi-Year Roadmap the system's current challenges. But since California process. (See box titled "Gap Analysis and Road has chosen this pathway, stakeholders should con­ Map.") sider and seek to realize the potential benefits of this approach. A statewide MLTSS program is expected to result in more uniform benefits and more consistent pro­ gram requirements. While the state still needs to define which specific LTSS will be paid for and cov­ ered by the MCPs under statewide MLTSS, MCPs California Health Care Foundation www.chcf.org 8 are positioned to play a vital role as the single identify gaps and bright spots in key areas, such entity responsible for providing and/or coordinat­ as access, outcomes, quality, and equity across ing all covered LTSS for Medi-Cal enrollees. This the LTSS delivery system. This could help ensure approach will require close collaboration between that resources are not simply transferred from one MCPs and LTSS providers, which is essential to inte­ delivery system to another with no change in the grate and coordinate these services and reduce experience and outcomes for enrollees. confusion for Medi-Cal enrollees. Implementing a statewide system could also provide an opportunity to evaluate where requirements for reporting and LTSS Data Dashboard other administrative burdens can be streamlined or One component of California's Home and reduced and could help plans and providers work Community-Based Services Spending Plan more effectively and efficiently to serve Medi-Cal includes Department of Health Care Services enrollees. Additional potential benefits of state­ (DHCS) implementation of an LTSS Data Dash­ wide MLTSS are explored below. board to improve the transparency of LTSS data on service use, quality, and cost. The dash­ board also should be able to inform statewide Increased Accountability and MLTSS accountability and oversight. DHCS Oversight and its dashboard development partners have been examining which demographic, utiliza­ Under a statewide MLTSS program, MCPs would tion, access, quality, and equity metrics should be the entities singly responsible for the referral to, be included in the dashboard and working delivery of, and coordination of services. Having with stakeholders to identify data priorities and MCPs in this role would allow the state to estab­ how data will be used to monitor and improve lish a standard monitoring and oversight role, rather care. The first iteration of the dashboard was than overseeing a variety of waiver programs with released in late 2022, and it will be periodically different requirements. This consistent approach updated with more comprehensive data. This should help streamline monitoring and improve public reporting tool provides some transpar­ transparency. ency on program use and could inform DHCS's development of key metrics and goals for state­ As part of its monitoring and oversight, DHCS wide MLTSS.11 could begin to collect both qualitative and quan­ titative quality metrics to evaluate health outcomes and enrollee satisfaction with Medi-Cal LTSS. The data could be made publicly available and shared Reduced Disparities in Access to with enrollees, their trusted messengers (includ­ Services ing providers, local community organizations, and social service agencies), and other stakeholders, to California currently provides limited public data on create a feedback process that iterates on program who receives LTSS, the specific benefits provided, design to improve outcomes. (See box titled "LTSS where enrollees access services, and inequities in Data Dashboard.") access to services based on race, age, geography, and other factors. Over time, this should improve DHCS could use this information to strengthen through the LTSS Data Dashboard. (See box above.) oversight in collaboration with MCPs and other Establishing MLTSS across the state provides an stakeholders, to assess changes over time, and to opportunity to aggregate data on the delivery and Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 9 coordination of services at the plan level, which has By consolidating responsibility for LTSS under the potential to improve data collection and bet­ MCPs, California has an opportunity to centralize ter inform strategies to reduce known disparities data collection and reporting and use these data in access. (See box titled "Importance of Culturally to better identify and address these types of dis­ Appropriate Care" for more information on the parities. For more information about data gaps and importance of culturally appropriate LTSS.) opportunities specific to HCBS in California, see CHCF's report Using Data for Good: Toward More Examples of disparities in access have been well- Equitable Home and Community-Based Services in documented. For example, a national study of Medi-Cal.14 dually eligible enrollees found that HCBS spend­ ing for Black enrollees was lower than spending for The CalAIM waiver approval includes a requirement White HCBS recipients. Meanwhile, Black enrollees for DHCS to ensure that contracted MCPs submit had the highest rates of avoidable hospitaliza­ encounter data and supplemental reporting on tions, and this greater spending on hospital care health outcomes and quality metrics at both a local did not correlate with better outcomes.12 A study and aggregate level to assess equity of care. Where of staffing levels in nursing facilities showed that possible, the data must be stratified by age, gen­ facilities with a population of majority-White resi­ der, race, ethnicity, and language spoken. Under dents had registered nurse staffing levels that were statewide MLTSS, additional standardized data 34% and 60% higher, respectively, than majority- should be available to plans as a result of increased Black and majority-Latino/x facilities. Furthermore, requirements to coordinate across the delivery sys­ these disparities were not entirely accounted for tem, even if particular services are not specifically by variables including the residents' medical condi­ included under the MCP benefit. tions, the facility's percentage of Medicaid-eligible residents, and whether the facility was in an urban Some key informants suggested this equity-focused or rural environment.13 analysis could begin prior to the implementation of statewide MLTSS, and that both qualitative and quantitative data could inform pre-implementation Importance of Culturally Appropriate policy decisions. The state could explore several Care key questions to assess and address disparities in Person-centered LTSS should be delivered in the delivery of LTSS as it pursues a more standard­ a way that respects and reflects the cultural ized, coordinated, and accountable system that differences among the Medi-Cal population. As better serves Medi-Cal enrollees. (See box titled eligibility is expanded to cover additional pop­ "Key Questions to Assess and Address Inequities ulations, such as undocumented Californians in LTSS.") age 50 or older, it is increasingly important to ensure care is delivered in a culturally appropri­ ate manner and in the preferred language of Streamlined Enrollment and the enrollee. Existing disparities could be exac­ Assessment Processes erbated if enrollees are unaware of the benefits Statewide MLTSS could create a standardized struc­ for which they are eligible due to cultural or language barriers, and unable to access LTSS ture for LTSS eligibility and benefits, which would that meet their cultural and linguistic needs. make it easier for MCPs to refer and coordinate LTSS, even if a particular service is not part of their contracted benefits. The structure could improve a California Health Care Foundation www.chcf.org 10 Key Questions to Assess and Address Inequities in LTSS $ Who receives a service and how do they access the service? $ How are enrollees educated and/or contacted regarding benefits that they are eligible to receive? $ Which Medi-Cal populations are underrepresented in the current use of LTSS or HCBS? $ What impact do eligibility processes and criteria have on who receives LTSS? $ How does the assessment process track enrollees' need for access or referrals to services? $ How does the state document enrollees' preferences for services and settings for receiving care? $ Which metrics demonstrate that enrollees are getting services in their preferred setting? $ Isa mechanism in place to identify Medi-Cal enrollees who need LTSS but may not be receiving care because of barriers to access or other reasons? $ What kinds of data are available to help providers more effectively identify and work with local popula­ tions in need of services? $ How can data be used to ensure that LTSS is offered through contracts with providers that can deliver culturally appropriate services and services in the language of the population they serve? $ How can the state take advantage of the DHCS Comprehensive Quality Strategy to ensure adequate attention to equity in LTSS? $ How will DHCS study subgroups of the population to monitor changes in equity and access during implementation of MLTSS? plan's ability to help enrollees access a consistent The ability to develop standard workflows could and coordinated set of services. This standardized increase referrals to LTSS both within and outside structure also could eliminate or greatly reduce of the MCP benefit, which would help support the the number of individual waiver assessments that financial sustainability of LTSS providers by pro­ enrollees must undergo to qualify for services. viding a steady pipeline of referrals. Additionally, DHCS also could integrate stronger requirements streamlined assessments and standard criteria and oversight through MCPs as the single account­ should address gaps in care for enrollees with tem­ able organization to ensure that referrals to LTSS porary disabilities, who often struggle to navigate are occurring across the continuum of care. the eligibility criteria for different waiver programs. Designating MCPs as the single accountable orga­ nization could lead to the development of standard Improved System Navigation and workflows related to LTSS delivery and referrals. Care Transitions Because current LTSS benefits and waiver programs Under MLTSS, MCPs would be expected to help are administered by various state departments, their members transition between care settings enrollment and reporting processes are not stan­ (e.g., skilled nursing facility to home) or between dardized. This patchwork system leads to manual LTSS programs, and to navigate the entire LTSS sys­ processes that rely on individual expertise and tem. CalAIM reforms more broadly require MCPs to knowledge of available programs. coordinate and contract with community-based orga­ nizations (CBOs) and other social service providers Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 11 to meet members' needs. Through the combina­ barriers will require significant stakeholder engage­ tion of these programs and MLTSS, plans will have ment and agreement about which data should be the opportunity to implement whole-person care shared and how to share data consistently across approaches and demonstrate improved outcomes the Medi-Cal program. Improved data flow and related to access to and delivery of these services. information sharing would allow MCPs to engage Having a single point of contact and continuous in appropriate care coordination, identify duplica­ support for all LTSS, regardless of whether a particu­ tion of services, create more robust care teams, lar service is included under managed care or not, ensure adequate referrals and access to services, should make it easier for the enrollee to navigate the and better transition enrollees to more appropriate system and any transitions between care settings. levels of care. If MCPs have greater insight into all enrollee needs under statewide MLTSS, they could Stakeholders, however, may want to consider realis­ better identify and address gaps in LTSS, such as tic expectations of what MCPs can achieve as they food insecurity, loneliness, and other social deter­ support enrollees who continue to receive some minants of health. LTSS outside of the managed care benefit. To suc­ cessfully support transitions and system navigation, However, MCPs will not be able to coordinate MCPs would need the cooperation of contracted services in isolation. Coordination will require and non-contracted LTSS providers for coordination engagement and formal relationships among and access to information on their members. Since MCPs, counties, and LTSS providers. These rela­ MCPs do not have the authority to compel non- tionships will be key to statewide goals for MLTSS contracted providers or social services to share data integration and coordination and can assist with the or to engage in care coordination activities, clear transition to MLTSS even in the absence of robust expectations or requirements may need to be estab­ statewide data exchanges, which may take years lished by the state. DHCS can consider how MLTSS to establish. DHCS could consider CalAIM and could serve as a mechanism to engage MCPs, coun­ statewide MLTSS to be important opportunities ties, LTSS providers, and CBOs to ensure effective to create stronger requirements not just for MCPs coordination across the continuum of care. but also for providers and counties to share data and information about enrollees. More robust data sharing could promote a more integrated system Strengthened Data Exchange and hold all LTSS providers accountable for helping Plans and LTSS providers require robust infrastruc­ coordinate care. ture, training, and resources to receive and digest data in ways that meaningfully impact care delivery. An immediate challenge to sharing LTSS data across Because the LTSS system is not integrated and sig­ the continuum of care is the lack of a consistent nificant barriers exist for sharing data among LTSS approach to data exchange throughout the system. providers, counties, and MCPs, the move to a stan­ As a result, plans and providers have been hesi­ dardized MLTSS benefit presents an opportunity to tant to invest in significant information technology improve data exchange and ensure that plans and improvements. Interviewees suggested that DHCS providers have access to the information needed to could identify a common data exchange platform best support Medi-Cal enrollees. and require entities to use it, as well as provide funding or grants to those organizations required Because some LTSS benefits will remain outside of to make significant investments to comply with the MCP responsibility, addressing current data sharing California Health Care Foundation www.chcf.org 12 chosen platform. Greater resources would make it feasible for more organizations to participate. IHSS Contract Mode Currently, no more than 5% of the total In- Additionally, DHCS could assess whether LTSS Home Supportive Services (IHSS) recipients in a providers have the capacity for the data exchange county may receive their IHSS services and pro­ needed for MLTSS, and then identify the resources viders through a qualified agency that employs it would take to coordinate the entire LTSS system. IHSS caregivers, rather than directly hiring their MLTSS could help foster this work through a coor­ own provider. Known as IHSS Contract Mode, dinated statewide approach and strategy for LTSS this model can be especially useful for IHSS data exchange. recipients who need assistance identifying and securing a provider, those who have too few IHSS hours approved to recruit a provider on Scenarios for Designing their own, or those who are between provid­ ers or are hiring one for the first time and need the MLTSS Program temporary assistance. While MLTSS is not the only way to improve out­ IHSS Contract Mode has been implemented comes throughout the LTSS system, since it is the in several counties in the past, but it is cur­ path that the state is exploring, it could be helpful to rently only available in San Francisco. As DHCS consider different scenarios about how the program moves to statewide MLTSS, it could explore an could work. DHCS has several years to develop and expanded pilot of the IHSS Contract Mode to implement the program, which provides an oppor­ gain insights into how coordination with IHSS tunity to be thoughtful about exploring the impacts could be enhanced under MLTSS even if not of different policy and design options. Table 1 on integrated under the MCP. (IHSS and MLTSS page 14 outlines some potential options for MLTSS will be the topic of a future paper in this series.) program design and the impact that each approach could have on the delivery system. These scenar­ ios could inform stakeholders considering these and other options. (See box titled "IHSS Contract Mode" for unique considerations specific to the IHSS program.) Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 13 Table 1. Potential Options for and Impacts of MLTSS Program Design OPTIONS: Limited Maintain the status quo: Continue a limited MLTSS program that includes institutional LTC, CBAS, ECM, and MLTSS optional Community Supports, and the renewal of the current LTSS waivers as carved-out benefits that are not available statewide. Make LTSS consistent statewide: Continue with the status quo but move HCBS waivers into a statewide structure in which benefits and services are available to all eligible Medi-Cal enrollees but remain excluded from the MCP benefit. Pilot a greater inclusion of LTSS in managed care: Explore new opportunities to test additional LTSS offer­ ings through MCPs in certain geographic locations. Integrate additional services (except IHSS) into statewide managed care benefits: Continue to include statewide institutional LTC, CBAS, ECM, and optional Community Supports under MCPs. Move HCBS waivers into a statewide structure in which the benefits and services are available to all eligible Medi-Cal enrollees and include all LTSS benefits, except for IHSS, under the MCP benefit. Integrate services into a statewide MCP benefit, including IHSS: MCPs would offer statewide MLTSS ben­ Full efits for all services, including IHSS. (This option is not currently under consideration by DHCS but is included MLTSS for illustrative purposes.) IMPACTS: Integrate additional services (except IHSS) Integrate services Make LTSS Pilot a greater into statewide into a statewide Maintain the consistent inclusion of LTSS managed care MCP benefit, status quo statewide in managed care benefits including IHSS† Increases in- X* X X X tegration of May only increase integration in pilot LTSS geographies Creates a X X X X consistent Would not address current patchwork of and state- waivers wide benefit Shifts the X X X X focus from cost savings to person- centered care Expands ac- X X X cess to new Does not guarantee that current IHSS pro- enrollees in viders would contract current ser- with MCPs vice areas continued next page * X indicates that the policy option has the potential to influence the delivery of MLTSS. † This option is not currently under consideration by DHCS but is included for illustrative purposes. Notes: CBAS is Community-Based Adult Services; DHCS is Department of Health Care Services; ECM is Enhanced Care Management; HCBS is home and community-based services; IHSS is In-Home Supportive Services; LTC is long-term care; LTSS is long-term services and supports; MCP is managed care plan; and MLTSS is managed long-term services and supports. Source: Developed by authors based on stakeholder interviews, literature review, and consideration of potential scenarios/approaches. California Health Care Foundation www.chcf.org 14 Table 1. Potential Options for and Impacts of MLTSS Program Design (continued) Integrate additional services (except IHSS) Integrate services Make LTSS Pilot a greater into statewide into a statewide Maintain the consistent inclusion of LTSS managed care MCP benefit, status quo statewide in managed care benefits including IHSS† Includes new X X X or expanded Workforce capacity Workforce capacity Does not guarantee may be a limiting may be a limiting that current IHSS pro- service areas factor factor viders would contract with MCPs Requires X X X X current LTSS MCPs' requirements for data sharing, re- providers to porting, and billing make signifi- may be burdensome cant changes for some providers Requires X X X X new federal waivers and approvals Has signifi- X X X X cant impacts to the state budget Disrupts X X the lives of Potential disrup- Enrollees may be re- tion from providers quired to change pro- enrollees not contracting with viders and processes currently re- MCPs/benefits not for receiving services ceiving LTSS matching current waiver services * X indicates that the policy option has the potential to influence the delivery of MLTSS. † This option is not currently under consideration by DHCS but is included for illustrative purposes. Notes: CBAS is Community-Based Adult Services; DHCS is Department of Health Care Services; ECM is Enhanced Care Management; HCBS is home and community-based services; IHSS is In-Home Supportive Services; LTC is long-term care; LTSS is long-term services and supports; MCP is managed care plan; and MLTSS is managed long-term services and supports. Source: Developed by authors based on stakeholder interviews, literature review, and consideration of potential scenarios/approaches. Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 15 Conclusion The pathway to statewide MLTSS will be complex, as it requires building on a fragmented patchwork of programs while aligning the overall policy and financing goals of CalAIM and other related state health care initiatives. Stakeholders can leverage the lessons learned from pilots and the current LTSS delivery system to create a thoughtful and strategic implementation plan to increase coordination and improve the enrollee experience through more per­ son-centered and equitable care delivery. With robust stakeholder engagement and the development of standard data sharing and care coordination expectations along the continuum of care, statewide MLTSS has the potential to improve the enrollee experience and increase access to ser­ vices through a more coordinated and consistent statewide benefit. However, large-scale system changes take time. DHCS, state policymakers, and LTSS advocates could take advantage of the years leading up to MLTSS implementation by 2027 to begin addressing existing barriers and identifying innovative solutions that will lay the groundwork for more effective and sustainable statewide MLTSS. California Health Care Foundation www.chcf.org 16 Appendix A. Advisory Committee Members Organization Representative Anthem Blue Cross Beau Hennemann California Association for Adult Day Services Lydia Missaelides California Department of Health Care Services Anastasia Dodson Justice in Aging Tiffany Huyenh-Cho Partners in Care Foundation Anwar Zoueihid Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 17 Appendix B. Medi-Cal Long-Term Services and Supports Provided Through Managed Care Plans Institutional Long-Term Inpatient stays in an institutional setting, such as a skilled nursing facility, intermediate care Care Services - state­ facility, or subacute facility wide for nursing facilities Source: CalAIM Long-Term Care Carve-In Transition, California Department of Health Care Services (DHCS), accessed by January 1, 2023, and October 12, 2022. other facilities by January 2024. Community-Based Adult $ Individual assessments Services (CBAS) - 28 $ Professional nursing services counties $ Physical, occupational, and speech therapies $ Mental health services $ Therapeutic activities $ Social services $ Personal care $ Meals $ Nutritional counseling $ Transportation between a participant's residence and a CBAS center $ Emergency response services Because CBAS is only available in 28 counties, the Department of Health Care Services (DHCS) requires managed care plans (MCPs) to "arrange for the provision of unbundled services based on the assessed needs of the Member eligible for CBAS if a certified CBAS Provider is not available or not contracted, or there is insufficient CBAS Provider capacity in the area." Source: Community-Based Adult Services, DHCS, last modified September 8, 2022. Enhanced Care Populations of Focus include: Management $ Individuals and families experiencing homelessness A statewide benefit avail­ $ Adults, youth, and children who are high utilizers of avoidable emergency department, able to select "Populations hospital, or short-term skilled nursing facility services of Focus," ECM is de­ signed to address clinical $ Adults with serious mental illness or substance use disorder and nonclinical needs $ Children and youth with serious emotional disturbance, identified to be at clinical high of the highest-need en­ risk for psychosis or experiencing a first episode of psychosis rollees through intensive $ Adults and youth who are incarcerated and transitioning to the community coordination of health and health-related services. $ Adults at risk of institutionalization and eligible for long-term care $ Adult nursing facility residents transitioning to the community $ Children and youth enrolled in California Children's Services (CCS) with additional needs beyond CCS $ Children and youth involved in child welfare (including those with a history of involvement in welfare and foster care up to age 26) $ Individuals with intellectual/developmental disabilities (I/DD) $ Pregnant and postpartum individuals; birth equity population of focus Source: California Advancing and Innovating Medi-Cal (CalAIM) Enhanced Care Management Fact Sheet, DHCS, last modified January 18, 2023; and CalAIM Enhanced Care Management Policy Guide, DHCS, last modified December 2022. continued next page California Health Care Foundation www.chcf.org 18 Appendix B. Medi-Cal Long-Term Services and Supports Provided Through Managed Care Plans (continued) Community Supports Community Supports include: Community Supports can $ Housing transition navigation services be provided by MCPs as $ Housing deposits cost-effective alternatives $ Housing tenancy and sustaining services to traditional medical $ Short-term post-hospitalization housing services or settings and $ Recuperative care (medical respite) are designed to address $ Habilitation programs social drivers of health. Community Supports are $ Caregiver respite services optional for both MCPs to $ Nursing facility transition/Diversion to assisted living facilities provide and for enrollees $ Community transition services/Nursing facility transition to a home to accept, and availabil­ $ Personal care and homemaker services ity varies by plan and by $ Environmental accessibility adaptations (home modifications) county. $ Medically supportive food/Meals/Medically tailored meals $ Sobering centers $ Asthma remediation Source: CalAIM Community Supports - Managed Care Plan Elections, DHCS, accessed November 28, 2022. Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 19 Appendix C. Medi-Cal Long-Term Services and Supports Provided Outside of Managed Care Benefit In-Home Supportive $ Housecleaning Services (IHSS) - Benefit $ Meal preparation Under California's $ Laundry Medicaid State Plan $ Grocery shopping $ Personal care services, such as bathing and grooming $ Accompaniment to medical appointments $ Protective supervision for the mentally impaired $ Paramedical services Source: In-Home Supportive Services, California Welfare and Institutions Code, § 12300 (2021); and Overview of the IHSS Program, California Department of Social Services, November 2020. Services Provided Services may include: Through Home and $ Case management - services that help people gain access to needed medical, social, Community-Based educational, and other services 1915(c) Waivers $ Community transition services - services that help people locate, secure, and coordinate The following list repre­ affordable housing, adaptive equipment, or a care provider, and create a plan to return to sents an inclusive set of community living services offered through $ Private-duty nursing - one-on-one nursing care various 1915(c) waiv­ $ Family training - education, support, and resources for family members and other care­ ers, including the Home givers about how to provide care and Community-Based $ Home health aides - health care workers who provide personal care and light household Alternatives (HCBA) waiv­ support to people in their homes er, Multipurpose Senior $ Life-sustaining utility reimbursement - help paying utility bills to ensure enrollees main­ Services Program (MSSP), and the Assisted Living tain water or power service Waiver (ALW). Availability $ Habilitation services - services and devices that assist people in regaining full or partial of each service depends skills and functioning to the maximum extent practical on the specific waiver $ Respite care (in-home and out-of-home) - short-term care for patients as a relief to the or program, and access primary caregiver may be limited based on $ Personal care services - care provided by an unlicensed individual who is employed by unique waiver/program a Home Health, Employment, or Personal Care Agency that meets the HCBS waiver pro­ criteria and geographic vider requirements limitations. $ Environmental accessibility adaptations - home modifications, such as ramps, grab bars, doorway widening, stair lifts, specialized electric and plumbing systems, and wheelchair- accessible bathrooms and showers that reduce the risk of accidents $ Minor home repair(s) $ Personal emergency response system (PERS) or communication device $ Protective supervision - supervision in the absence of the usual care provider to people in their own homes who are very frail or otherwise may suffer a medical emergency, to prevent immediate placement in an acute care hospital, nursing facility, or other 24-hour care facility $ Meal services - congregate living facility or home-delivered $ Social reassurance/therapeutic counseling - periodic telephone contact, visiting, or other social and reassurance services, to verify that the individual is not in medical, psychologi­ cal, or social crisis; or to offset isolation $ Money management - activities related to managing money and the effective handling of personal finances $ Communication services - includes translation and interpretation Source: Medi-Cal Waivers, California Department of Health Care Services, last modified January 6, 2023. California Health Care Foundation www.chcf.org 20 Endnotes 1. California Advancing and Innovating Medi-Cal (CalAIM) Proposal (PDF), California Department of Health Care Services (DHCS), March 23, 2021. 2. A thena Chapman and Elizabeth Evenson, "Long-Term Services and Supports in Medi-Cal," California Health Care Foundation (CHCF), October 13, 2020. 3. "State Plan," Medicaid and CHIP Payment and Access Commission (MACPAC), accessed September 1, 2022. 4. "Waivers," MACPAC, accessed September 1, 2022. 5. "List of Community-Based Adult Services Providers," California Department of Aging, accessed October 12, 2022; "1915(c) Home and Community Based Services Waivers," DHCS, accessed July 21, 2022; and "Community-Based Adult Services," DHCS, accessed July 20, 2022. 6. Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports Programs (PDF), Centers for Medicare & Medicaid Services, May 20, 2013. 7. Senate Bill 1036 (Chapter 45, Statutes of 2012) and Senate Bill 1008 (Chapter 33, Statutes of 2012); and The Coordinated Care Initiative: A Critical Juncture, Legislative Analyst's Office, February 27, 2017. 8. "CalAIM for Seniors and People with Disabilities," CHCF, accessed July 25, 2022. 9. "CalAIM Managed Long-Term Services and Supports and Duals Integration Workgroup," DHCS, accessed July 22, 2022. 10. "Gap Analysis and Multi-Year Roadmap of Medi-Cal Home and Community-Based Services and Managed Long-Term Services and Supports," DHCS, accessed October 11, 2022. 11. "Home and Community-Based Services Spending Plan," DHCS, accessed October 11, 2022; and "California Long- Term Services and Supports Dashboard," DHCS, accessed December 13, 2022. 12. Rebecca J. Gorges, Prachi Sanghavi, and R. Tamara Konetzka, "A National Examination of Long-Term Care Setting, Outcomes, and Disparities Among Elderly Dual Eligibles," Health Affairs 38, no. 7 (2019): 1110-1118. 13. Eric Carlson and Gelila Selassie, Racial Disparities in Nursing Facilities and How to Address Them (PDF), Justice in Aging, September 2022. 14. Amber Christ and Tiffany Huyenh-Cho, Using Data for Good: Toward More Equitable Home and Community-Based Services in Medi-Cal, CHCF, December 3, 2021. Medi-Cal Managed Care and Long-Term Services and Supports www.chcf.org 21