The 2021-22 Budget: CalAIM: New Directions for Services for Seniors and Persons With Disabilities

analysis full gutter The 2021-22 Budget: CalAIM: New Directions for Services for Seniors and Persons With Disabilities MARCH 2021 The California Advancing and Innovating and supports (LTSS) are administered. (LTSS Medi-Cal (CalAIM) proposal is a far-reaching set include, among other supports and services, of reforms to expand, transform, and streamline institutional care in nursing homes and home- and Medi-Cal service delivery and financing. This community-based services [HCBS] such as home post—the fourth in a series assessing different care and personal care services.) Previous posts aspects of the Governor’s proposal—analyzes in this series provided an overview of CalAIM, CalAIM proposals targeted at seniors and persons considered CalAIM financing issues, and examined with disabilities (SPDs), including new benefits equity considerations related to the CalAIM and structure changes to how long-term services proposal. Background THE GROWING POPULATION OF in average life expectancy, as seniors over the age of 85 are more likely to have developed disabilities SPDS late in life. Another driver of growth in the senior Senior Population Expected to Grow population with disabilities is the increasing racial Faster Than State’s Population as a Whole. diversity of the senior population, as seniors of The Department of Finance estimates that the color make up a disproportionate share of seniors state’s senior population (aged 65 and older) with disabilities. As the share of seniors of color will increase from 6 million in 2019 to 11 million increases, a higher proportion of the senior in 2060 (83 percent). The estimated growth population will likely have disabilities. rate of the senior population is higher than the estimated growth rate of the state’s total population PUBLIC SERVICES FOR SPDS ARE (13 percent) over the same period. HIGHLY FRAGMENTED, RAISING Senior Population With Disabilities Expected ACCESS AND OTHER ISSUES to Grow at a Higher Rate Than Overall Senior Population. In our 2016 report, A Long-Term Evidence of Fragmentation Outlook: Disability Among California’s Seniors, we projected that the number of seniors in California Large Share of SPD Population Must Access with disabilities (as defined by limitations in routine Two Different Insurance Programs. Among activities of daily living, such as dressing or bathing) the 2.1 million SPDs enrolled in Medi-Cal, about will increase by 135 percent, from 1.2 million 1.4 million are eligible for and enrolled in both in 2019 to 2.7 million in 2060, which is greater Medicare and Medi-Cal. For these dually eligible than the projected growth of the overall senior beneficiaries, Medicare is the primary payer for the population (83 percent) over the same period. services that it covers (such as hospitalization and The faster growth of the senior population with doctor visits), while Medi-Cal covers services that disabilities is partially driven by long-term increases are not covered by Medicare, including most LTSS. 2021-22 LAO Budget Series 1 analysis full gutter Figure 1 summarizes the services dual eligibles navigate both the Medicare and Medi-Cal delivery receive from Medi-Cal and Medicare. systems. Medi-Cal LTSS Infrastructure Encompasses Implications of Fragmentation Multiple Programs With Overlapping Beneficiaries. California’s Medi-Cal LTSS Fragmentation Creates Service Coordination infrastructure is made up of several programs— and Access Issues for SPD Beneficiaries. with different access points, delivery systems, and If individuals were able to access all Medi-Cal eligibility assessment processes—that may serve LTSS programs, they could be able to receive a the same or similar beneficiaries while operating comprehensive suite of LTSS benefits. However, independently. For example, a single Medi-Cal SPD individual programs’ services vary, as do their simultaneously may receive case management availability geographically. As a result, ensuring through the Multipurpose Senior Services Program that Medi-Cal beneficiaries are receiving all the (MSSP), personal and home care services through services they require, or that beneficiaries’ care is In-Home Supportive Services (IHSS), and care in being effectively coordinated between the various a congregate setting through Community-Based programs they have accessed, without duplication Adult Services (CBAS). This individual likely would or gaps in services is difficult. (Some beneficiaries receive these services through three different providers, after establishing eligibility separately Figure 1 for each program. Many LTSS programs—such Medi-Cal and Medicare Services for the as MSSP, Programs of All-Inclusive Care for the Dual-Eligible Population Elderly, Assisted Living Waiver, and CBAS—also have a limited number of slots or limited capacity, Medi-Cal Medicare such that many individuals who are eligible for • Long-term nursing facility • Hospital carea these programs may not be able to receive services stays from them due to supply constraints. Figure 2 • Home and community- • Short-term nursing facility stays shows the various aspects of this fragmentation based care • Pharmacy that make Medi-Cal LTSS challenging to navigate • Physician/clinic for SPDs. Additionally, dually eligible SPDs must a Medi-Cal provides “wrap-around” payments for these services. Figure 2 Various Aspects to Fragmentation of Medi-Cal LTSS Infrastructure Delivery System SPDs may access LTSS through a number of different delivery systems, including Medi-Cal managed care and Medi-Cal fee-for-service. Administrator Various state and local offices are responsible for administering LTSS programs, including the Department of Health Care Services, the Department of Social Services, the Department of Aging, and the Department of Developmental Services. Various LTSS programs provide different services and levels of care. In order to receive comprehensive care, many SPDs may need to utilize several LTSS programs simultaneously. Service Area Few LTSS services are accessible statewide. Some (such as the Program of All-Inclusive Care for the Elderly) are available only in a handful of counties. Service Provider LTSS is provided through thousands of private and nonprofit providers. These providers are of varying quality, capacity, and cost. Program Capacity Several LTSS programs (such as the Assisted Living Waiver and Multipurpose Senior Services Program) have a limited enrollment capacity due to facility constraints or state enrollment caps. Eligibility Criteria While many LTSS programs use similar eligibility criteria, some programs target individuals with higher levels of need. and Assessment Applicants generally go through a separate eligibility assessment for each LTSS program despite the overlap in eligibility criteria. SPDs = seniors and persons with disabilities and LTSS = long-term services and supports. 2021-22 LAO Budget Series 2 analysis full gutter may even receive case management services from to be in effect until the end of 2022, includes the multiple programs, with no guarantee their case following major components: managers are coordinating effectively with one • Cal MediConnect. In seven participating another.) For dual eligibles, similar coordination counties under CCI’s Cal MediConnect problems can exist between their Medi-Cal and program, dually eligible beneficiaries may Medicare plans. receive their Medicare benefits and Medi-Cal LTSS fragmentation also can create access benefits through the same managed care problems for many beneficiaries. Beneficiaries may plans known as Cal MediConnect managed have trouble navigating multiple access points and care plans. sets of eligibility requirements in order to receive • Mandatory Enrollment of Dual Eligibles in care from multiple programs. They also may find Medi-Cal Managed Care. CCI requires most that some LTSS programs they are attempting to dual eligibles in the seven demonstration access are not available in their regions, or have a counties to enroll in managed care plans to limited number of slots available. access their Medi-Cal benefits, including their Fragmentation Erodes Financial Incentives LTSS benefits. to Provide More Cost-Effective Care. In addition • Integration of LTSS Under Medi-Cal to contributing to a lack of service coordination Managed Care. CCI shifted funding for for SPDs, the current system can create an nursing home, IHSS, CBAS, and MSSP incentive for each program to “cost shift.” Cost benefits from Medi-Cal fee for service to shifting occurs when one entity or program takes Medi-Cal managed care for most SPDs in actions that have fiscal impacts on a separate the demonstration counties. Budget-related entity or program. Because the impacts are not legislation in 2017-18 later removed borne by the entity taking action, that entity has integration of managed care and IHSS. limited financial incentive to limit overall costs or maximize overall benefits for a particular total CCI Demonstration Has Shown Some level of expenditure. For example, under the Promise… Several evaluations of CCI have been current fragmented structure, while Medi-Cal pays carried out. These evaluations show promise for the majority of LTSS costs for dual eligibles, on the part of the demonstration project in the it pays for only a relatively small portion of the areas of improved care coordination between costs of hospitalizations, which are paid primarily Medi-Cal managed care plans and IHSS program by the federal government under Medicare. administrators (in a small subset of counties), high In such circumstances, the state has limited satisfaction among Cal MediConnect participants, financial incentive to provide additional LTSS that and potential reductions in hospital and nursing potentially would reduce hospital utilization for dual facility utilization. eligibles, since the savings resulting from avoided …But Has Experienced a Number of hospitalizations largely would accrue to the federal Challenges. At the same time, the CCI government instead of the state. demonstration experienced significant challenges. For example: RECENT AND ONGOING • CCI Was Not Able to Fully Address Fiscal STATE EFFORTS TO ADDRESS Misalignment. CCI did not fully align fiscal FRAGMENTATION incentives to provide more cost-effective care in at least two ways. First, for many SPDs, Coordinated Care Initiative (CCI) CCI maintained the state’s pre-CCI practice of directly paying managed care plans higher In 2012, the state undertook a major rates for plan enrollees residing in nursing demonstration project called CCI to improve care homes. Because this leads to higher managed coordination for individuals with both Medi-Cal care plan payments to cover the cost of and Medicare coverage. CCI, which is scheduled 2021-22 LAO Budget Series 3 analysis full gutter individuals’ placement in a nursing home, and Master Plan for Aging lower payments when such individuals leave a In June 2019, the Governor signed an executive nursing home, plans do not benefit financially order establishing a formal process for the creation when nursing facility care is avoided. As a of a Master Plan for Aging. The executive order result, they have limited fiscal incentive to required the creation of a stakeholder advisory avoid unnecessary and costly nursing home committee, publication of a stakeholder report placements. Second, CCI explicitly authorized on LTSS, and publication of the administration’s Cal MediConnect managed care plans to Master Plan for Aging. pay for nonmedical benefits (such as home Stakeholder’s Master Plan for Aging Has modifications or medically tailored meals), Components Related to Integration of Health but did not allow plans to be specifically and LTSS Programs Relevant to SPDs. The reimbursed for the costs of these nonmedical stakeholder report on LTSS was released in May benefits. This meant plans were not provided 2020 and made a number of recommendations with a fiscal incentive to arrange and pay for related to Medi-Cal and Medicare integration such benefits even when doing so would have efforts, including recommendations to: improved beneficiary outcomes and reduce the utilization of high-cost care. • Develop a Five-Year Plan for Integrating • Gaps in the Integration of LTSS and Services for SPDs Under Medi-Cal Managed Care. One of CCI’s primary Managed Care. Develop a five-year Medi-Cal/ goals was to better integrate some existing Medicare integration plan that commits LTSS programs and Medi-Cal managed the state to the highest level of integration care. Ultimately, only CBAS was integrated possible. At a high level, the plan should with managed care. CCI initially routed (1) ensure people have access to certain IHSS funding through managed care while highly integrated Medi-Cal/Medicare health leaving IHSS program and managed care plans, (2) incorporate best practices from administration relatively unintegrated. Then, past state integration efforts, (3) require in 2017-18, IHSS funding was removed strong consumer protections, (4) ensure from managed care. MSSP generally never dual eligibles are eligible for all CalAIM transitioned to becoming a managed care services, (5) implement a comprehensive benefit. set of Medi-Cal HCBS, (6) offer incentives to • Many Dually Eligible Beneficiaries Chose health plans to provide HCBS and contract Not to Participate in Cal MediConnect. with linguistically and culturally responsive In the years following initial implementation local organizations, and (7) establish a policy of CCI, many dually eligible beneficiaries and specific targets for reducing avoidable living in participating CCI counties chose institutionalization. (Additional detail on the not to participate in Cal MediConnect, recommended plan can be found in the leaving enrollment below initial expectations. stakeholder report.) This led to various challenges including • Improve Coordination Between IHSS, low participation on the part of health care Health, and Other LTSS Providers. Improve providers and also limited revenues to Cal care coordination between IHSS and other MediConnect plans to cover their costs of LTSS and health providers, including through participating in the demonstration. As of formal authorization for secure information September 2020, about 112,000 dually sharing with managed care providers of health eligible beneficiaries were enrolled in Cal and LTSS services. Additionally, require the MediConnect, which represented as little as state to collect data and report on beneficiary one-quarter of SPDs who were eligible to access to services, including data on referrals participate. and receipt of services, transitions, and care coordination. 2021-22 LAO Budget Series 4 analysis full gutter • Establish a Statewide Integration Oversight five goals and 23 strategies to help build what it Council. Establish a formal stakeholder describes as a “California for All Ages” by 2030. council comprised of health plans, consumers, The plan includes the implementation of certain advocates, and healthcare providers on CalAIM components to support specific initiatives, issues pertaining to integration of Medi-Cal/ which we discuss below. Medicare and Managed LTSS (MLTSS). The • Increase Access to LTSS. Expand access council should be charged with exploring and to HCBS for people receiving Medi-Cal via analyzing emerging implementation issues and CalAIM by implementing “in lieu of services” challenges, and provide recommendations for (ILOS) and enhanced case management systemwide improvements. (ECM). We define ECM and ILOS and describe • Create a Medi-Cal/Medicare Innovation them in detail later in the post. and Coordination Office. Establish an • Integrate Health Care for Dual-Eligible office to design and implement innovative Population. Plan and develop innovative strategies that are linguistically and culturally models to increase access to LTSS and responsive to serve dual eligibles from diverse integrated health care for dual eligibles by backgrounds, with a goal of improving how implementing statewide MLTSS and a Dual services are delivered at the local level across Eligible Special Needs Plan (D-SNP) structure, the health and LTSS systems. The office in partnership with stakeholders. We describe would explore (1) targeted demonstration MLTSS and define D-SNPs later in the report. programs intended to reach special • Consider Home and Community populations with complex care needs and Alternatives to Short-Term Nursing Home (2) new state and federal partnership models, Stays. Consider home and community while also overseeing implementation of alternatives to short-term nursing home stays related elements of CalAIM. for participants in Medi-Cal managed care Administration’s Master Plan for Aging through utilization of a combination of the Has Components Related to CalAIM. The home health benefit; ILOS; and proposed administration released its Master Plan for Aging in expanded telehealth benefit, including remote January 2021. The Master Plan for Aging identifies patient monitoring. CalAIM: SPD-Related Components CalAIM Includes Several Proposals With community-centered care coordination Significant Implications for SPDs. SPDs are a services than generally are available to key target population for CalAIM. Elements of the the targeted populations, which include, CalAIM proposal that would directly affect care for example, high utilizers of emergency for Medi-Cal SPDs through the provision of new departments and beneficiaries with unstable benefits and programmatic strategies include the housing. The intent is for ECM to connect following: high-risk, high-need beneficiaries to the appropriate preventive services (both • ECM. CalAIM proposes to create a new medical and non-medical) necessary for the statewide managed care benefit, ECM, to improvement of health outcomes. ECM target provide intensive case management and care populations include the following groups in coordination for Medi-Cal’s most high-risk which SPDs are heavily represented: high and high-need beneficiaries (provided they health care utilizers, individuals at risk of are enrolled in managed care). The intent is institutionalization in nursing homes, and for ECM to provide much more high-touch, 2021-22 LAO Budget Series 5 analysis full gutter individuals who are transitioning from a make several changes to how SPD care—and in nursing home to the community. particular, LTSS—is administered. Those proposed • New Population Health Management changes are as follows: Strategies. Population health management • Expanded Role of Managed Care in Nursing programs represent a bundle of administrative Home Care. Under CalAIM, institutional activities—typically performed by managed long-term care services (including in nursing care plans—that aim to (1) identify homes) would be shifted into managed care beneficiaries’ medical and nonmedical risks by January 2023. Currently, nursing home and needs and (2) facilitate care coordination care is a managed care benefit in more than and referrals. Managed care plans would be half of counties, but a fee-for-service benefit in required to collect and analyze information the remaining counties. on their members’ health status, service • Longer-Term Vision for MLTSS. The utilization history, and social needs. While administration proposes to transition from CCI existing data sources would form the basis of to standardized mandatory enrollment of dual some of this information, a new standardized, eligibles into managed care by January 2023. statewide Individual Risk Assessment tool By January 2027, the intention is to make would be developed by the Department of LTSS accessible directly through managed Health Care Services to ensure consistent care plans, rather than through the variety of information collection across managed care programs which currently comprise the state’s plans. With this information, managed care Medi-Cal LTSS infrastructure. LTSS provided plans would assign their members into one through managed care would be available of four risk categories, including “low risk,” statewide and not subject to a capped “medium and rising risk,” “high risk,” and number of slots for any service. (IHSS is not “unknown risk.” While plans would remain intended to be a part of the future statewide responsible for connecting low-risk members MLTSS at this time and would remain a to preventive and wellness services, they separate fee-for-service benefit.) would be responsible for providing increasing • D-SNPs. Under CalAIM, the state would levels of care coordination and service require all Medi Cal managed care plan linkages to their higher-risk members. contractors to establish specialized plans, • ILOS. The CalAIM proposal allows managed - known as D-SNPs, which are designed care plans to be reimbursed for ILOS, defined to provide managed Medicare benefits to as nonmedical services such as personal care individuals who also are eligible for Medi Cal. and housing navigation that managed care Under this framework, Medi Cal beneficiaries plans could provide (at their option) in place of - could, but would not necessarily be required more expensive standard Medicaid benefits. - to, receive their Medicare benefits through Today, managed care plans may offer such a D SNP that is operated by the same services but would not be reimbursed for the contracted managed care plan that provides associated costs. Many of the services that - their Medi Cal benefit. Qualifying D-SNP could be offered as ILOS benefits currently plans would not include so-called D-SNP are provided through existing LTSS programs, - “look-alikes,” which are Medicare plans that including personal care and home care are designed to attract dual eligibles but services, medically tailored meals, and home do not offer coordination with Medi-Cal or modifications such as wheelchair accessible other benefits targeted to the dual-eligible ramps. population, such as risk assessments or care CalAIM Also Would Make Several Structural plans. (The federal Centers for Medicare and Changes to SPD Care. In addition to creating Medicaid Services have proposed that it will new benefits for Medi-Cal SPDs, CalAIM would no longer enter into or renew contracts with 2021-22 LAO Budget Series 6 analysis full gutter such look-alikes beginning in 2022. In the are not affiliated with Medi-Cal managed care meantime, under CalAIM, the state would plans (“non-aligned” D-SNPs) would no longer permit plans in CCI counties to transition be able to accept new enrollees, although beneficiaries enrolled in D-SNP look-alikes to current enrollees could remain in those existing D-SNPs.) Additionally, D-SNPs that D-SNPs if they chose to do so. Assessment and Issues for Legislative Consideration Proposal Could Bring Benefits to SPDs. into nursing homes (or a lower rate when CalAIM has the potential to improve care for beneficiaries move out of such facilities). As Medi-Cal SPDs in the following ways: a result, plans might opt to provide care in less-costly settings where feasible. There is • ECM and ILOS Proposals Could Improve general agreement that some nursing home Incentives for Plans to Offer Supportive residents could be safely cared for in more Services and Coordinate Care for SPDs. community-based settings and would prefer Both the ECM and ILOS proposals would to do so if alternative services were available. expand the services potentially available to The process of providing alternative services Medi-Cal SPDs—ILOS by reimbursing plans would be facilitated by allowing ILOS benefits. for some nonmedical supportive services, • D-SNP Model Would Make Coordinated and ECM by providing care management Care More Broadly Available. The proposal that could connect high-risk beneficiaries to to require all Medi-Cal managed care plans to preventive services they might not otherwise offer a D-SNP for their Medi-Cal beneficiaries receive. In addition to providing a greater would expand opportunities for at least range of services for beneficiaries, these some level of integration and coordination proposals potentially could reduce costs for between Medi-Cal and Medicare more plans over the long run because high-risk widely than it is available today. However, beneficiaries who receive relatively low-cost the level of integration available through preventive supports and services may avoid D-SNPs potentially could vary between plans, the need for higher-cost interventions in since the CalAIM proposal does not specify the future. This could incentivize plans to a minimum standard of integration and provide high-risk beneficiaries with additional coordination for D-SNPs. preventive supports and services. As • Difficult to Evaluate Governor’s MLTSS mentioned above, this incentive does not Plan Due to Lack of Detail. As previously exist under CCI, because CCI maintained discussed, the Governor’s CalAIM proposal the state’s practice of directly paying includes a long-term goal of moving toward managed care plans higher rates for certain statewide MLTSS beginning in 2027 (the beneficiaries residing in nursing homes. year by which the state would reevaluate and • Institutional Long-Term Care Carve-In to potentially extend, sunset, or modify major Managed Care Could Create Incentive components of CalAIM generally). To lay the to Emphasize Less Costly Alternatives to groundwork for MLTSS, CalAIM would take Nursing Home Care. Moving institutional a number of incremental steps toward better long-term care into managed care statewide coordination and integration of managed care also could strengthen plan incentives to and LTSS, including through the carve in of provide effective, less-costly care for those long-term care facilities, the inclusion of LTSS potentially needing nursing home services. among optional ILOS, and the requirements Under CalAIM, plans would not immediately around greater alignment of Medicare and receive a higher rate when beneficiaries move 2021-22 LAO Budget Series 7 analysis full gutter Medi-Cal services. However, what exactly ISSUES FOR LEGISLATIVE the Governor’s vision is for MLTSS is unclear. CONSIDERATION Major outstanding questions on what this vision entails include which LTSS programs In its evaluation of CalAIM’s effect on SPDs, would be carved into managed care, how the Legislature may wish to consider the following services would be coordinated for any LTSS issues. not carved into managed care, and what Ensuring CalAIM Proposal Ultimately kind of fiscal resources would be needed to Achieves Legislature’s LTSS Objectives. The expand MLTSS statewide. CalAIM proposal is closely aligned with the LTSS objectives the administration laid out in its Major Other Questions Remain. Figure 3 lists Master Plan for Aging. The Legislature may wish our major outstanding questions about CalAIM as to consider whether the administration’s Master the proposal pertains to SPDs. As the Legislature Plan for Aging aligns with its own objectives. evaluates CalAIM’s impact on the SPD population, If the Legislature disagrees with some of the we suggest focusing on resolving these key administration’s LTSS objectives, the Legislature questions. could articulate its own set of objectives, and then monitor CalAIM to ensure that it aligns with Figure 3 SPD-Related CalAIM Questions for Legislative Focus Overall Strategy for LTSS • How will the administration include the Legislature in selecting and designing the LTSS benefits that will be provided statewide through MLTSS? • How will the state measure progress and assess whether it is on track to implement MLTSS by 2027? • What steps could the state take to strengthen coordination or integration between managed care and LTSS programs carved-out of MLTSS (IHSS and MSSP)? Changes to Medi-Cal Managed Care • How would the administration track the cost and utilization of ILOS and the services they replace to ensure cost-effectiveness and how would this information be made available to the Legislature? • What would be the fiscal impact of transitioning SNFs to managed care statewide, including both increased costs associated with newly paying for managed care plan overhead and earnings, as well as potential savings from reduced SNF utilization? • What steps would the state take to ensure a smooth transition of the SNF benefit into managed care statewide? • To what extent could the transition of the SNF benefit into managed care statewide be delayed if plan readiness is not achieved by the proposed transition date of January 2021? • Given the differences between ICFs and SNFs, how would the statewide transition of ICFs into managed care create benefits like those envisioned for SNFs? • To what extent will ILOS and ECM strengthen or duplicate existing LTSS programs? Discontinuing CMC in Favor of Statewide D-SNP Model • How would integration of Medi-Cal and Medicare benefits for dually eligible beneficiaries differ between the current CMC structure and the proposed new D-SNP structure? • What factors may contribute to, or hinder, the viability of D-SNPs in various parts of the state, particularly in instances where Medi-Cal managed care organizations have not offered them previously? What can the state do to address potential challenges? • What additional requirements should the state impose on D-SNPs to ensure they provide an adequate level of integration between Medi-Cal and Medicare? Evaluating CalAIM’s Impacts • What is the administration’s plan for ensuring that CalAIM proposals are evaluated robustly? SPD = seniors and persons with disabilities; CalAIM = California Advancing and Innovating Medi-Cal; LTSS = long-term services and supports; MLTSS = managed long-term services and supports; IHSS = In-Home Supportive Services; MSSP = Multipurpose Senior Services Program; ILOS = in lieu of services; SNFs = skilled nursing facilities; ICFs = intermediate care facilities; ECM = Enhanced Care Management; CMC = Cal MediConnect; and D-SNP = Dual Eligible Special Needs Plan. 2021-22 LAO Budget Series 8 analysis full gutter those objectives. For example, the Legislature features, such as consumers being responsible for may choose to consider whether the state should choosing their provider. prioritize expanding existing LTSS programs or Requiring an MLTSS Development Plan. The consolidating the state’s various LTSS services into administration has not yet articulated a specific a new statewide, comprehensive program. vision for how it would realize MLTSS. We suggest Considering Ways to Further Reduce LTSS the Legislature require more information from Fragmentation. Although CalAIM has the potential the administration on how it plans to implement to significantly improve LTSS coordination of MLTSS, and what components would be included care, there are additional steps the Legislature in the final MLTSS infrastructure. This information could consider toward creating an integrated could include what type of LTSS benefits would Medi-Cal LTSS system. For example, as previously be provided under MLTSS, what goals and mentioned, Medi-Cal SPDs currently are subject milestones the state would use to assess MLTSS to a different assessment and referral process for implementation progress, and how the state would each LTSS program they might utilize. This means, assess whether beneficiaries have equal access to for example, that an individual who requires both and receive the same quality of care under MLTSS. IHSS and MSSP services would need to go through Considering Putting a Process in Place for an entirely separate enrollment process for each Legislative Oversight of CalAIM Implementation. program. The Legislature could consider creating CalAIM would make many major changes to a standard assessment and referral process for Medi-Cal, with significant impacts on beneficiaries, Medi-Cal LTSS programs to streamline the process all over a relatively short period of time. If approved, of enrolling in multiple programs simultaneously. legislative oversight of CalAIM will be critical to Explore Opportunities to Further Strengthen ensuring smooth and successful implementation. Relationship Between Medi-Cal Managed Care Accordingly, prior to January 2022, the Legislature and IHSS Program. CalAIM allows for greater could consider requiring regular check-ins with, service coordination between Medi-Cal managed and reports from, the administration, managed care care and IHSS by allowing managed care plans to plans, and other partners to discuss readiness for provide eligible beneficiaries with personal care and implementation. After January 2022, the Legislature home care services while they await IHSS approval could expand the focus of the check-ins to include and, if needed, provide services above and beyond monitoring of the successes and challenges of authorized IHSS service levels. In deciding what CalAIM implementation. services will be provided through MLTSS by 2027, Requiring a Comprehensive and Independent the Legislature could consider the benefits and Evaluation of Any Major Reforms Ultimately trade-offs of pursuing a higher level of coordination Adopted. In order to understand the impacts or integration between Medi-Cal managed care of CalAIM, we recommend that the Legislature and IHSS. For example, the Legislature could establish a framework for an independent and replicate or scale up past coordination efforts, such robust evaluation of whichever major components as providing funding so that IHSS county social of the CalAIM proposal ultimately are adopted. workers could participate in interdisciplinary care Because ascertaining the true impacts of a reform teams and collaborate with other care providers to effort this large would be a significant challenge, address the social, medical, and behavioral needs we recommend that the Legislature consider of an IHSS recipient. Alternatively, the Legislature providing direction over the evaluation’s design and could consider testing a fuller integration of reporting. Reports of the evaluation should be clear IHSS within managed care plans, such as and accessible to policymakers and should focus allowing managed care to play some role in the on pre-identified measures of success. Ideally, administration of IHSS. Whatever the Legislature the evaluation should be available, at least in a chooses, it should carefully consider funding preliminary form, prior to any deadlines for deciding needs and the benefits and trade-offs to legislative on whether to reauthorize any major components of oversight; local control; and current IHSS program CalAIM. 2021-22 LAO Budget Series 9 analysis full gutter Adopting a D-SNP Model That Maximizes standard of integration and coordination for Integration Between Medi-Cal and Medicare. As D-SNPs themselves. The Legislature could consider previously mentioned, D-SNPs vary in the level of setting this minimum standard. Determining the coordination and integration they provide between appropriate minimum standard would require Medi-Cal and Medicare. Although the CalAIM further analysis, as there may be some trade-offs proposal makes clear that D-SNP look-alikes would between the level of integration a D-SNP model not meet the threshold that would be required of offers and the feasibility of implementing that model managed care plans, it does not specify a minimum statewide. LAO Publications This report was prepared by Ned Resnikoff, Ben Johnson, and Jackie Barocio, and reviewed by Mark C. Newton and Carolyn Chu. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. 2021-22 LAO Budget Series 10