By OPEN MINDS Circle
On December 29, 2021, the Centers for Medicare & Medicaid Services (CMS) approved the California Advancing and Innovating Medi-Cal (CalAIM) Medicaid waiver amendment and renewal for the stateās Medicaid 1115 demonstration and 1915(b) waiver, effective January 1, 2022, through December 31, 2026. The previous waiver expired December 31, 2021. The CalAIM provisions are intended to standardize Medicaid managed care plan benefits; to add institutional care and major organ transplants into managed care; to carve pharmacy out of Medi-Cal health plan managed care; and to implement Medicaid managed long-term services and supports (MLTSS) statewide.
The stateās Medicaid program serves 13.4 million people, with more than 11 million enrolled in a Medi-Cal managed care plan. The existing managed care plans cover physical health and non-specialty mental health services. Under the approved 1915(b) waiver, all of the stateās managed care delivery systemsā Medi-Cal managed care, dental managed care, specialty mental health services, and the DMC-ODSāwill be shifted to one coordinating authority.
Through the California Advancing and Innovating Medi-Cal (CalAIM), DHCS will implement the following initiatives:
- Population health management: Starting in 2023, managed care plans will be required to use population health management tools to implement a whole-system, person-centered strategy that includes assessments of each enrolleeās health risks and health-related social needs, focuses on wellness and prevention, and provides care management and care transitions across delivery systems and settings. By 2023, managed care plans are expected to be responsible for the care of more than 90% of Medi-Cal enrollees. All managed care plans will be required to meet the National Committee for Quality Assuranceās standards for Population Health Management as well as additional DHCS statewide Population Health Management standards. Also in 2023, DHCS will launch the Population Health Management Service, which will enable data sharing across multiple delivery systems and with enrollees, provider organizations, human services programs, and other partners.
- Enhanced care management (ECM): Starting January 1, 2022, this new service will provide person-centered care management for the highest-need Medi-Cal enrollees, primarily through in-person engagement where enrollees live, seek care, and choose to access services. In 2022, about 95,000 Medi-Cal enrollees will be able to use ECM, including those experiencing homelessness; those who have high utilization of avoidable emergency department, hospital, or short-term skilled nursing facility services; and adults with serious mental illness or addiction disorders.
- Community supports, also called āin-lieu of servicesā (ILOS): Starting January 1, 2022, managed care plans will begin offering community supports, such as housing supports and medically tailored meals, as cost-effective alternatives to traditional medical services or settings. Community supports are designed to help meet enrolleesā needs for heath and health-related services that reduce risks caused by their social determinants of health. Medicaid managed care plans can offer up to 14 community support services. Twelve of the community support services will be implemented under the managed care authority known as ILOS, and two moreārecuperative care and short-term post-hospitalization services ā are authorized through the new CalAIM Section 1115 waiver to assure consistent statewide implementation across the 1915(b) and 1115 waivers.
- Providing Access and Transforming Health (PATH) supports for provider organizations: The 1115 waiver provides funding for community-based organizations, counties, and other local provider organizations to expand capacity as some of the key CalAIM initiatives scale up statewide. PATH funding will help sustain critical services provided by the Whole Person Care Pilots until these services have fully moved to managed care. The funding will also support capacity building among provider organizations and county agencies as they begin to implement and scale up ECM and Community Support/ILOS. PATH will also sustain pre-release and post-release services for justice-involved adults and youth that are currently provided through the Whole Person Care Pilots, and the funding supports Medi-Cal pre-release application planning and information technology investments.
- New benefits added to the DMC-ODS for addiction treatment: DHCS will be able to cover contingency management, peer support specialists, and short-term residential treatment stays at facilities with more than 16 beds. Counties will have the option to implement peer support specialist services beginning in July 2022.
- Statewide dual eligible Medicare Special Needs Plans (D-SNPs) and MLTSS: DHCS intends to expand statewide a D-SNP to coordinate all Medicare and Medicaid benefits, which will include MLTSS to better coordinate care, simplify administration and provide a more integrated experience for enrollees.
- New statewide dental benefits: The benefits include dental services to identify risk factors for dental decay and regular application of silver diamine fluoride for children and certain high-risk populations. Additionally, dental provider organizations will be eligible to participate in statewide pay-for-performance initiatives to earn incentive payments for focusing on preventive dental services and continuity of care. These new benefits were added by a state plan amendment.
Additionally, DHCS intends to develop a long-term plan of action for foster youth. It intends to seek a federal waiver for short-term residential treatment for enrollees with a serious mental illness or serious emotional disturbance. DHCS also plans to pilot a managed care plan that fully integrates physical health, behavioral health, and dental health services. DHCS is working with CMS to cover pre-release reentry planning services for justice involved individuals who meet specific criteria (pregnant, chronic illness, behavioral health disorders). DHCS is also seeking approval of additional PATH funds to support planning and information technology investments to implement the provision of services in the period prior to release and to provide county behavioral health agencies with support to stand up in-reach programs. Michelle Baass, director of the California Department of Health Care Services (DHCS) said āCalAIM is our long-term commitment to transform and strengthen Medi-Cal, helping Californians get healthier, and stay healthy by using a more coordinated, person-centered approach to delivering the care they need.ā
For more information, contact: Michelle Baass, Director, California Department of Health Care Services, Post Office Box 997413, Sacramento, California 95899; Email: CalAIM@dhcs.ca.gov; Website: https://www.dhcs.ca.gov/CalAIM/Pages/calaim.aspx