Besides the heavy loss of life and health and widespread financial impact, the COVID-19 pandemic is impacting state government healthcare plans. A revised May budget from California Gov. Gavin Newsom delays implementation of a sweeping Medicaid innovation program.
Noting that the state is not in a fiscal position to increase rates or expand programs given the drastic budget impacts of the COVID-19 recession, the California Department of Health Care Services said the May revision proposes to delay implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, resulting in a decrease of $695 million ($347.5 million General Fund) in 2020-21. In addition, the May Revision removes $45.1 million General Fund in 2020-21 and $42 million General Fund in 2021-22 in associated funding for the Behavioral Health Quality Improvement Program. “While the important goals and objectives we have outlined for CalAIM continue to be a high priority, DHCS is postponing CalAIM implementation timelines in order to allow all of us to effectively address COVID-19 in our communities,” DHCS said.
CalAIM proposed a series of reforms, including expanding whole-person care approach that targets social determinants.
Over the past several years, the California Department of Health Care Services (DHCS) has been aggressive in working to redefine its Medicaid program, Medi-Cal, by piloting care coordination and social service-related initiatives such as Whole Person Care. CALAIM followed an ambitious roadmap to expand those offerings and others to all Medi-Cal enrollees.
CalAIM sought to build on the successes of waiver demonstrations such as Whole Person Care, the Coordinated Care Initiative, and public hospital system delivery transformation. CalAIM would leverage Medicaid as a tool to help address many of the complex challenges facing California’s most vulnerable residents, such as homelessness, insufficient behavioral health care access, children with complex medical conditions, the growing number of justice-involved populations who have significant clinical needs, and the growing aging population.
Recognizing the social basis of many care needs, the proposal calls for non-clinical interventions focused on a whole-person care approach that target social determinants of health and reduce health disparities and inequities. The hypothesis is that taking a population health, person-centered approach to providing services will improve outcomes and ultimately reduce the per-capita cost over time.
CalAIM has three primary goals:
• Identify and manage member risk and need through Whole Person Care approaches and addressing social determinants of health;
• Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and
• Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems and payment reform.
DHCS says that Medicaid managed care plans should look at physical and behavioral as well as social determinants of health, with the overarching goals of improving quality of life and reducing the overall costs for the Medi-Cal population. CalAIM proposes to:
• Require plans to submit local population health management plans.
• Implement new statewide enhanced care management benefit.
• Implement in lieu of services (e.g. housing navigation/supporting services, recuperative care, respite, sobering center, etc.).
• Implement incentive payments to drive plans and providers to invest in the necessary infrastructure, build appropriate enhanced care management and in lieu of services capacity statewide.
California’s Whole Person Care project involves 25 county pilots implemented under the Section 1115 Medicaid Waiver that runs through 2020. They are designed to coordinate medical, behavioral and social services to improve the health and well-being of Medicaid beneficiaries with complex needs. To build upon and transition the work done under the Whole Person Care pilots, DHCS is proposing to implement in lieu of services, which are flexible wrap-around services that a managed care plan will integrate into its population health strategy. These services are provided as a substitute, or to avoid, other services such as a hospital or skilled nursing facility admission or a discharge delay.
In lieu of services would be integrated with case management or care management for members at high levels of risk and may fill gaps in state plan benefits to address medical or social determinants of health needs. Examples of in lieu of services include but are not limited to: housing transition and sustaining services, recuperative care, respite, home and community- based wrap-around services for beneficiaries to transition or reside safely in their home or community, and sobering centers.
The use of in lieu of services is voluntary, but the combination of enhanced care management and in lieu of services allows for a number of integration opportunities, including an incentive for building an integrated managed long-term services and supports (MLTSS) managed care program by 2026 and building the necessary clinically linked housing continuum for the state’s homeless population.
CalAIM also had planned to address transitions from incarceration. In an effort to ensure all county inmates receive timely access to Medi-Cal services upon release from incarceration, DHCS proposed that California mandate the county inmate pre-release Medi-Cal application process by January 2022. Additionally, DHCS proposed to mandate all counties implement warm-handoffs from county jail release to county behavioral health departments when the inmate was receiving behavioral health services while incarcerated to allow for continuation of behavioral health treatment in the community.
