OCTOBER 2023 Fact Sheet CalAIM FAQ for Assisted Living Community Operators C alifornia's residential care facilities for the elderly Operators should conduct an internal operational and adult residential facilities are partnering capacity assessment to determine the most viable and with Medi-Cal managed care plans under sustainable path to working with MCPs before engaging CalAIM (California Advancing and Innovating Medi- in contractual discussions. The Medi-Cal Community Cal) to improve access to assisted living. The program Supports, or In Lieu of Services (ILOS), Policy Guide (PDF) lets operators access Medi-Cal reimbursement through of July 2023 details the requirements that Community an Enhanced Care Management benefit and optional Supports providers must meet and can be used as the Community Supports services. While these are exciting basis for the capacity assessment.1 opportunities, operators must navigate new requirements and challenges when contracting with managed care Is CalAIM part of the Assisted Living Waiver plans. CalAIM offers opportunities for increased access program? and financial stability but requires due diligence and No, they are separate programs. CalAIM is a statewide adaptation to new practices. reform of the Medi-Cal program and expands access to assisted living and adult residential care through This Frequently Asked Questions document is a compan- MCPs.2 The MCPs administer optional services known ion to CalAIM Explained for Assisted Living Community as Community Supports and a benefit called Enhanced Operators. It provides general information and resources Care Management. The Assisted Living Waiver is a for operators interested in learning more about CalAIM distinct waiver program with limited capacity and and how its Community Supports program may support geographic coverage and remains outside of managed the populations they serve. The questions were compiled care.3 Residents can be enrolled in either program, but through a survey sent to a diverse group of operators not in both. and the Q&A part of an educational webinar offered in June 2023. How does an assisted living or adult residential operator find MCPs operating in its service Does the assisted living or adult residential area? operator contract directly with the Managed Please see CHCF's short guide that includes both a list of Care Plan? current MCPs by county and the MCPs that will operate To bill for Community Supports, a licensed operator in each county starting January 1, 2024.4 Operators first needs to contract with a Medi-Cal managed care should note that the MCP changes by county starting plan (MCP). MCP administrative requirements include January 1 will be stable for several years. Operators contracting, data, and quality reporting. MCPs also should consider if an MCP will enter or leave a service require invoicing or billing processes, which may require area in 2024 when assessing the potential opportunities new workflows for operators. The operator may choose for partnerships and contracting. to negotiate a direct contract or work with a management services organization (MSO) that would contract with the Must operators have a National Provider MCP. An MSO would provide administrative support such Identifier and be enrolled as a Medi-Cal provider as financial management, coding and billing services, to contract with an MCP? and compliance oversight, among other services. Yes, operators will need a National Provider Identifier but they do not currently need to enroll as a Medi-Cal provider because there is not a pathway for enrollment through the Provider Application and Validation for If a resident receives Supplemental Security Enrollment (PAVE) portal. Instead, the MCP is responsible Income (SSI), is the licensed operator required for ensuring licensing and credentialing. MCPs may also to continue to provide all services for the SSI set up individual letters of agreement as a temporary rate if the resident is disenrolled in the plan? solution, but the goal is for MCPs to build contracted There are regulatory requirements and interpretations networks rather than one-off arrangements. for residential care facilities for the elderly specific to accepting and retaining residents receiving SSI that How does an assisted living or adult residential should be reviewed with regulatory counsel. The operator contracted with an MCP get paid? residency agreements and house rules that address the How long is the typical turnaround for payment? admission and retention criteria should clearly outline MCPs are required by state and federal law to meet financial responsibility if a resident is disenrolled for any certain claims payment requirements, including paying reason. 90% of clean claims (meaning those with no errors or omissions) within 30 days of receipt and 99% of all What happens if an MCP will leave the service clean claims within 90 days. Operators may also be able area in 2024? to negotiate for prospective per member per month A handful of MCPs are exiting current service areas at payment accompanied by retroactive submission of the end of 2023, as part of a recontracting between encounter data to show services rendered. California's Department of Health Care Services (DHCS) and Medi-Cal managed care plans. In these cases, Who signs the Residency Agreement? Who has there are specific transition requirements. DHCS has financial responsibility? developed the 2024 MCP Transition Policy Guide (PDF) The resident, or responsible person if the resident that outlines MCP requirements related to the transition lacks capacity, should sign the residency agreement of MCP members, including these:7 because it includes contractual agreements beyond financial responsibilities. Generally, the contract with the $ Member enrollment and noticing MCP outlines the financial obligations to the operator. $ Continuity of care requirements Operators should consult with their legal or regulatory counsel to determine what changes need to be made to $ Enhanced Care Management and Community the residency agreements, schedule of fees, and house Supports transition requirements rules if contemplating a Medi-Cal MCP contract. DHCS's companion All Plan Letter (APL) 23-018 (PDF) Since Community Supports are optional establishes the binding nature of the policy guide, which benefits, is there a risk that a resident or will be updated throughout calendar year 2023 with new managed care plan would opt out? and developing guidance.8 Per federal law Community Supports are optional for the MCP to offer and for the member to accept. So Do Medi-Cal MCPs have to conduct eligibility Community Supports are not available statewide, as assessments for enrollees to access Community MCPs have made different elections by county. These Supports? Will an MCP accept care levels and elections can change every six months; check the most assessments completed by an assisted living or recent list (PDF).5 If an MCP enrollee is receiving a adult residential operator for services? Community Support and switches to a new MCP that does MCPs are required to conduct initial health risk not offer that service, or if the MCP stops offering one of assessments to identify the needs of enrollees. the Community Supports, there are specific continuity of Additionally, each Community Support has specific care requirements that the MCP must adhere to. These individualized assessment requirements that are outlined requirements are outlined in the Community Supports in the Community Supports Policy Guide.9 Policy Guide.6 CalAIM FAQ for Assisted Living Community Operators www.chcf.org 2 Each MCP will have to work internally, and with its About the Authors providers, to complete these assessments for eligibility Paula Hertel, MSW, is founder of Senior Living Consult, to receive covered Community Supports. If an additional specializing in strategic, operational, and marketing assessment conducted by an operator points to the need services to senior living organizations. Additionally, she for additional or new services, the operator would have advises ancillary service providers, helping to identify to work with its contracted MCP to request authorization and address emerging needs and opportunities. Hertel and reimbursement for any additional Medi-Cal covered also serves as a board member and education cochair for services. The operator would want to review its contractual the California Assisted Living Association. arrangement with the MCP to determine how best to use its proprietary assessment as part of the overall care Athena Chapman, MPP, is president and Elizabeth management strategy for a Medi-Cal enrollee. Evenson is associate vice president at Chapman Consulting, which provides strategic planning, meeting Most MCPs allow for additional fees to be billed if the facilitation, organizational support, market research, and scope of additional services falls under acceptable regulatory and statutory analysis to organizations in the Medi-Cal reimbursable services and the fee schedule is health care field. negotiated and agreed upon. About the Foundation The California Health Care Foundation is an independent, nonprofit philanthropy that works to improve the health care system so that all Californians have the care they need. We focus especially on making sure the system works for Californians with low incomes and for communities who have traditionally faced the greatest barriers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improvement in a complex system. For more information, visit www.chcf.org. 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. CalAIM FAQ for Assisted Living Community Operators www.chcf.org 3 Endnotes 1. Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide (PDF), California Dept. of Health Care Services (DHCS), July 2023. 2. "Medi-Cal Transformation," DHCS, last modified August 10, 2023. 3. "Assisted Living Waiver," DHCS, August 14, 2023. 4. Ralph Silber, Medi-Cal Explained: 2024 Medi-Cal Managed Care Plans by County, California Health Care Foundation, June 2023. 5. CalAIM Community Supports - Managed Care Plan Elections (PDF), DHCS, updated June 2023. 6. Medi-Cal Community Supports, DHCS. 7. 2024 Medi-Cal Managed Care Plan Transition Policy Guide (PDF), DHCS, August 7, 2023 8. Dana Durham (chief, Managed Care Quality and Monitoring Div., DHCS) to all Medi-Cal managed care health plans, "Managed Care Health Plan Transition Policy Guide" (PDF), All Plan Letter 23-018, June 23, 2023. 9. Medi-Cal Community Supports, DHCS. CalAIM FAQ for Assisted Living Community Operators www.chcf.org 4