Greater than 13 million folks had been enrolled in Medi-Cal in California in September 2021, making it the biggest Medicaid program within the nation. In December 2021, the Facilities for Medicare & Medicaid Providers (CMS) accepted the California Division of Well being Care Providers’ (DHCS’) request for a five-year extension of its Medicaid part 1115 demonstration and a five-year extension of its Medicaid managed care part 1915(b) waiver. These Medicaid waivers are a part of the “California Advancing and Innovating Medi-Cal” (CalAIM) initiative which was launched in January 2022 to offer assist to California’s most susceptible residents and to offer extra equitable packages and entry statewide.
CalAIM seeks to construct upon the county-based Entire Individual Care (WPC) and plan-based Well being Properties Program (HHP) pilots to deal with social determinants of well being to handle the well being wants of people experiencing homelessness, behavioral well being care entry, youngsters with advanced medical situations, the rising variety of justice-involved populations who’ve important medical wants, and seniors and people dwelling with disabilities. It envisions enhanced coordination, integration, and knowledge alternate amongst managed care plans (MCPs); bodily, behavioral, community-based, and social service suppliers; and county businesses.
In 2015, DHCS launched the WPC Pilots as a part of its Medi-Cal 2020 Part 1115 Demonstration. It was a $3 billion Medicaid Part 1115(a) waiver demonstration venture that examined patient-centered interventions through which eligible beneficiaries obtained care coordination and different providers by partnerships of county well being businesses, Medicaid MCPs, community-based suppliers, and different public businesses. Pilots had the pliability to tailor their packages primarily based on regional wants and availability of assets and had been inspired to develop knowledge sharing infrastructure for efficient coordination and monitoring of progress.
In 2018, DHCS additionally launched the HHP pilot. The HHP served eligible Medi-Cal managed care plan Members with advanced medical wants and power situations who may benefit from intensive care administration and coordination. The HHP supplied six core providers: Complete care administration; Care coordination (bodily well being, behavioral well being, community-based long-term providers); Well being promotion; Complete transitional care; Particular person and household help; and Referral to group and social help providers, together with housing.
Each packages have seen early success: For WPC, in 2020, DHCS launched findings that the emergency division go to charge of enrollees had decreased from 214 to 181 visits per 1,000 members, inpatient utilization charge had decreased from 75 to 59 visits per 1,000 members, and justice-involved people skilled a 29% enhance in controlling of their blood stress. Equally, for HHP, the emergency division go to charge of enrollees decreased from 404 to 285 visits per 1,000 members, inpatient utilization charge had decreased from 134 to 91 visits per 1,000 members after a 12 months of this system, and the speed of initiation and engagement of substance abuse remedy elevated considerably for HHP enrollees from 45% to 55%. Consequently, these outcomes immediately influenced the design of CalAIM.
CalAIM has established an Enhanced Care Administration (ECM) profit, which offers intensive whole-person care administration and coordination to handle the medical and nonclinical wants of Medi-Cal members with advanced wants. ECM advantages are administered by MCPs: Plans establish members in every of the ECM goal populations and assign them to “ECM suppliers” accountable for conducting outreach and for coordinating and managing care throughout a broad spectrum of bodily, behavioral, and social service suppliers. ECM will probably be accounted for in MCP capitation charges, which means that when this system is totally carried out, MCPs should present the profit to Members in the event that they request it.
If efficiently carried out, ECM will be certain that enrollees with advanced wants are recognized and engaged by somebody who understands their objectives, develops a plan in partnership with them and their suppliers, and actively connects them with the medical and nonclinical providers and assets that assist them meet these objectives. DHCS has designated a dozen particular populations of focus (PDF) for the ECM profit, and managed care plans can add to that listing at their discretion.
CalAIM has additionally established an In Lieu of Providers (ILOS) group helps program, which offers cost-effective, health-supporting providers that could be substituted for present State Plan–lined providers to cut back hospitalization and institutionalization, cut back value, and deal with underlying drivers of poor well being. DHCS will permit 14 ILOS classes, together with housing transition and navigation providers, respite care, day habilitation packages, and nursing facility transition help to an assisted dwelling facility or a house. MCPs might select which ILOS to cowl, through which counties, and to which members the ILOS are supplied. These are providers that MCPs are strongly inspired, however not required, to offer as medically acceptable and cost-effective alternate options to utilization of different providers or settings equivalent to hospital or expert nursing facility admissions.
Financially, CalAIM is designed to enhance the State’s Dwelling-Based mostly Neighborhood Providers (HBCS) spending plan, which CMS conditionally accepted on January 4, and to help in drawing down extra federal funding through the American Rescue Plan Act Offering Entry and Reworking Well being (PATH) element. From a county perspective, it seeks to cut back the state and federal purple tape and bureaucratic delays imposed on counties by transitioning from a cost-based reimbursement mannequin to a rate-based intergovernmental switch mannequin. Thus, it’s anticipated to lower administrative burdens, pace up reimbursement processes, and streamline the auditing course of.
In gentle of CalAIM, well being plans are required to develop networks for ECM and Neighborhood Helps in ways in which protect important infrastructure developed underneath HHP and WPC. Since ECM and ILOS are community-based providers, Medi-Cal managed care members receiving these providers could have primarily in-person encounters with community-based suppliers slightly than telephonic encounters. Moreover, well being plans should set up contracts with suppliers and community-based organizations (CBOs) to offer each ECM and ILOS, beginning with serving transitioning populations in early 2022. Lastly, to keep up HHP and WPC infrastructure, well being plans are particularly required to work in the direction of contracts with WPC Lead Entities (counties) & Neighborhood Based mostly Care Administration Entities (CB-CMEs) as ECM & Neighborhood Helps Suppliers.
These packages additionally place sure necessities on suppliers. For instance, ECM suppliers should act as the first accountable entity for coordinating care throughout a number of well being techniques, designate a lead care supervisor for every member receiving the advantages, and contract with well being plans to fulfill particular contractual necessities and reveal sure capabilities associated to care fashions and knowledge sharing. Equally, ILOS suppliers should ship important medical and social providers, equivalent to housing navigation, recuperative care, medically-tailored meals, or group transitions, which aren’t usually funded by Medi-Cal, contract with well being plans as the first accountable entity for delivering choose medically acceptable alternate options to extra expensive state plan providers, and likewise meet sure contractual necessities and reveal sure capabilities associated to care fashions and knowledge sharing.
By specializing in inhabitants well being, implementing cost reforms, and making certain better accountability for MCPs, DHCS expects that CalAIM will lead to a greater high quality of life for Medi-Cal members in addition to long-term value financial savings. We are going to proceed to watch CalAIM’s progress to know how the coordination of care by packages like ECM and ILOS might enhance on value, high quality, and entry to healthcare.
