California Advancing and Innovating Medi-Cal (CalAIM) is an ambitious effort to improve and reshape the Medi-Cal program. I believe these changes create an urgent opportunity for us at Archstone Foundation to partner with others to respond to the coming changes and ensure that older persons benefit from these improvement efforts.
Improving Medi-Cal is important to our work at the Foundation for three reasons:
- It is an opening to address equity in health by reducing health disparities.
- We have a critical opportunity to make sure these new systems will meet the needs of older adults and their caregivers.
- Our grantees and partners are in a unique position to offer social services in partnership with health providers to better care for people with complex health needs.
More than 1 million low-income older adults from marginalized communities are in both Medi-Cal and Medicare, and several hundred thousand more receive their only health care coverage from Medi-Cal. For all but the wealthiest, the costs of aging – especially long-term care – can exhaust resources and make one dependent on Medi-Cal to fill the gap. Having the program work well to address comprehensive needs, using whole person care approaches and social drivers of health, is closely aligned with our vision of what integrated, coordinated care should look like for all older people and their families.
A New and Improved Medi-Cal
Using a variety of waivers from the federal government and state authorities, CalAIM is an effort to reform the Medi-Cal program in ways that are intended to make it more effective, to solve some pernicious social problems (e.g., justice involved people leaving prison), and to control costs. By the time implementation ends in 2027, the program is intended to have strongly coordinated social services and health care that will allow it to address the complex needs of some of the populations who are the costliest and most difficult to care for – including people who are homeless, people with serious mental illnesses or substance use disorders, and people living in nursing homes.
As the Department of Health Care Services describes it, CalAIM “is a long-term commitment to transform and strengthen Medi-Cal, offering Californians a more equitable, coordinated, and person-centered approach to maximizing their health and life trajectory.”
Increased Emphasis on Managed Care Plans
Since the 1970s, California has experimented with managed care within its Medicaid program. And like many states, it has recently been making more and more use of managed care plans. In the last few years some populations long held aside from managed care have been added, with older adults and persons with disabilities most recently becoming mandatory managed care plan enrollees.
CalAIM doubles down on managed care plans, giving them more responsibility and authority while creating more consistency of benefits and processes across counties, ensuring that services that had previously been carved out of the contracts (e.g., institutional long-term care, substance use disorder treatment, and specialty mental health services) have been included. This will result in putting the plans at least partially at risk for these high-cost services and giving them the tools to coordinate among services.
Within CalAIM, the state will attempt to move further away from paying directly for services (Fee for Service) and to become a payer of per member/per month fees to contracted managed care plans. The plans will administer and pay for specified services from authorized providers in a framework of required and optional benefits as well as quality reporting. This is intended to enable plans to negotiate rates and contract with providers under a wide variety of terms and prices, and to use other techniques such as mandatory primary care physician assignment and gatekeeping. It is also intended to align the interests of the state, the plans, and the members.
Under the new model, plans contracting with the state to offer Medi-Cal will also be required to offer a coordinated Dual-Eligible Special Needs Plan (D-SNP) Medicare Advantage (MA) plan – termed an exclusively aligned enrollment (EAE D-SNP). Medi-Cal beneficiaries who are dually eligible for Medi-Cal and Medicare will be encouraged to enroll in these special plans.
In addition to putting more of existing benefits within managed care plans, the revision adds two main new benefits: Enhanced Care Management and Community Supports.
Enhanced Care Management
Enhanced Care Management is a required service under which plans must provide person centered high touch care coordination, navigation, education, and coaching to help meet the person’s health goals and the care plan created by the care team. It is intended to be offered to a small percentage of highest need Medi-Cal beneficiaries (about 5 percent) who meet specific requirements (e.g., at risk for multiple hospitalizations, homeless, or at risk for long-term care institutionalization).
There are 10 populations of focus. Categories 2, 5, and 6 (highlighted below) are the most likely to include large percentages of older adults and are where aging service organizations already have the most experience trying to address the underlying causes and risks.
Community Supports
Community Supports – also known as In Lieu of Services – are optional benefits that managed care plans are encouraged to offer to all who can benefit, both within and outside of Enhanced Care Management. Contracts between managed care plans and Community Supports providers will lead to additional payments for the services. Managed care plans are being strongly encouraged to offer as many Community Supports as possible and to contract with a variety of providers to meet the needs of diverse populations.
On the list of allowed Community Supports, the six in bold seem most likely to be within the competence of aging services organizations. We encourage aging service providers to consider how they can offer these services*:
- Housing Transition Navigation Services
- Housing Deposits
- Housing Tenancy and Sustaining Services
- Short-Term Post-Hospitalization Housing
- Recuperative Care (Medical Respite)
- Day Habilitation Programs
- Caregiver Respite Services
- Nursing Facility Transition/Diversion to Assisted Living Facilities
- Community Transition Services/Nursing Facility Transition to a Home
- Personal Care and Homemaker Services
- Environmental Accessibility Adaptations (Home Modifications)
- Medically Supportive Food/Meals/Medically Tailored Meals
- Sobering Centers
- Asthma Remediation
Payments for both Enhanced Care Management and Community Supports are set by contract between managed care plans and providers who can deliver services. The state has offered general guidance, but payments are considered private business agreements determined by negotiation and market forces.
Many people with dementia could benefit under this new arrangement. As an example, “adults living in the community at risk for LTC institutionalization” is defined in two ways:
- People who are living in the community and meet skilled nursing facility level of care criteria OR
- People who require lower-acuity skilled nursing AND have at least one complex social/environmental factor influencing health (e.g., Activities of Daily Living needs – assistance with personal care like eating, dressing, bathing, walking, and using the toilet – poor or inadequate caregiving, or communication difficulties) AND are able to reside in the community if wraparound supports are provided.
Opportunity for Partnership – A Dementia Care Collaborative
The situation creates an urgent opportunity for Archstone Foundation and other stakeholders to support the CalAIM effort, organize components of the new care continuum, and give early feedback and learning to maximize the chances of success.
One idea we are working on builds on these changes to specifically address the needs of people with dementia through a dementia care learning collaborative within CalAIM. This plan would assist two populations of focus – people at risk of institutionalization and high utilizers – recognizing that, while not specifically called out in CalAIM, many of the people who qualify will be older adults with dementia.
To bring this idea forward, we are working with the range of providers relevant to caring for people with dementia (this may include but is not limited to adult day health, respite, home modification), along with the managed care plans, advocates, and experts in the field. Together we can design template care plans, drawing on the Enhanced Care Management and Community Support services available to change placement and utilization.
We believe we can play a unique role. Where there are gaps in needed services, we can communicate them to the state and to advocates. And we can use our neutral position to help stakeholders understand their financial and regulatory constraints as part of an effort to ensure plan payments cover costs and reporting requirements are manageable – so that community-based organizations and other providers can deliver the best possible care for older Californians and their families.
If you are working to improve care for persons with dementia in California, we want to hear from you. If you are interested in joining the learning collaborative, please enter your contact information through this link and you’ll be added to our list to receive details about the upcoming kick-off meeting planned for Friday, October 27, 2023, at 11:00 am Pacific Time.
Or, please comment below or drop me a line to let us know how you are preparing for an improved Medi-Cal system that delivers coordinated, integrated care for low-income older adults.
*From the California Department of Health Care Services
