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Senate Select Committee on Aging and Long-Term Care Recommends Long-Term Care System Overhaul

The State Senate Select Committee on Aging and Long-Term Care released a December 2014 report identifying major deficiencies in the state’s programs and services for older adults and individuals with disabilities and recommending extensive changes to the state’s long-term care system to correct these deficiencies.  The report describes the current long-term care system as fragmented, inefficient, and lacking accountability.  The changes outlined in the report include 30 legislative recommendations and a detailed strategy to establish a more efficient and integrated system of care for the state’s aging and disabled population.  (Source:  Senator Carol Liu website)  
Senate Select Committee on Aging and LTC Final Report (12/2014)

Managed LTSS Program

Under Medicaid §1915(a) authority, SCAN Connections at Home provides LTSS to Medicare-Medicaid enrollees age 65 and older at a capitated rate. Services include nursing facility and HCBS waiver-like services, including homemaker, home delivered meals, personal care, transportation escort, custodial care, in-home respite, and adult day.  The program operates in a limited geographic area under voluntary enrollment.  (Source: CMS and Truven Health Analytics, The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update, 7/2012)

On September 29, 2014, Governor Jerry Brown vetoed Assembly Bill 1552 to codify Community-Based Adult Services (CBAS) as a Medi-Cal benefit.  The CBAS program provided adult day health for many of the oldest and most frail Medi-Cal beneficiaries as a result of a 2011 settlement agreement that expired in August 2014.  Although a proposed Medicaid waiver amendment that will include CBAS as a Medi-Cal benefit is expected to be approved by the end of October, the governor’s veto leaves an uncertain future for the CBAS program.  (Source:  CaliforniaHealthline.org /Capitol Desk, 10/1/2014)
Veto of Assembly Bill 1552 (9/29/2014)

On December 1, 2014, the state will shift Medi-Cal seniors and persons with disabilities in 28 rural counties into Medi-Cal managed care plans, as a continuation of an extended effort by the state to expand Medi-Cal managed care to rural areas.  (Source:  CaliforniaHealthline.org/Capitol Desk, 10/28/2014)

On May 11, 2015, California Healthline reported that California is negotiating with CMS regarding the state’s 1115 Medicaid Waiver renewal; the current waiver expires October 1, 2015.  The state’s proposed changes include expanding the current DSRIP program, as well as making significant payment reforms to its managed care plans.  Under the proposed waiver, managed care plans and providers would be able to form partnerships similar to accountable care organizations (ACOs) and receive shared savings incentives by meeting quality and cost thresholds.  Additionally, managed care plans could participate in a pay-for-performance program.  Finally, the proposal encourages managed care plans to engage in regional and local partnerships to assist the state’s highest needs patients.  (Source:  California HealthLine.org/Capitol Desk, 5/11/2015)

The California State Auditor released a report examining Medicaid managed care in California, also known as Medi-Cal. Roughly 9.3 million of the state’s 12.2 million Medicaid population are enrolled in managed care plans. The report identified network adequacy and inaccurate information on providers as the challenges in the Medi-Cal managed care program. (Source: Modern Healthcare, 6/17/2015; Kaiser Health News, 6/22/2015)

California state health officials operating the state’s Medicaid program, Medi-Cal, are facing pushback over plans to transition individuals in the California Children’s Services program into managed care by 2017—a year later than initially planned. The program provides fee-for-service Medicaid services to an estimated 180,000 children under age 21. Parents and advocates, citing a recently published report outlining network adequacy challenges with Medi-Cal, are stating that the transition timeline is too short and does not allow for proper preparation by families and providers. The California Children’s Services program also has responsibility for operating LTSS services for enrollees. The decision to officially delay implementation until 2017 was made when the governor signed bill AB 187 into law. (Source Link No Longer Available)

The California Department of Health Care Services (DHCS) released a proposed request for proposal (RFP) and request for application (RFA) reprocurement schedule for the Medi-Cal managed care program, which is broken down by model type and county. DHCS intends to issue RFPs/RFAs between 2019 and 2021, with potential implementation dates ranging from 2021 to 2024. Implementation dates may also fluctuate based upon health plan readiness. (Source: RFP/RFA Schedule 5/16/2017)

State Demonstration to Integrate Care for Dual Eligible Individuals

In May 2012, California submitted to CMS a capitated payment model demonstration proposal to integrate care for dual eligible beneficiaries known as the Coordinated Care Initiative (CCI). The CCI mandates managed care enrollment for dual eligibles and makes changes to LTSS. The target population includes full benefit Medicare-Medicaid enrollees age 21 and over in 8 counties. Full benefit duals are Medicare beneficiaries with Parts A, B, and D coverage and full Medi-Cal coverage. (Medi-Cal covers: Medicare premiums; co-insurance; copayments; deductibles; and services not covered by Medicare such as LTSS). Beneficiaries enrolled in §1915(c) HCBS waiver programs and beneficiaries with DD receiving DDS services are excluded from the demonstration. Beneficiaries with DD receiving IHSS or CBAS services are included in the demonstration. Covered benefits include Medicare Parts A, B, and D; and Medicaid covered services. (Source: Demonstration Proposal; NASDDDS Managed Care Tracking ReportDemonstration ProposalState Website on Coordinated Care Initiative

In March 2013, California and CMS entered into a Memorandum of Understanding (MOU) to integrate care for dual eligibles as a component of the state’s Coordinate Care Initiative (CCI) through a project referred to as Cal MediConnect.   Through Cal MediConnect, eligible beneficiaries can combine their Medicare and Medi-Cal benefits into one health plan and receive more coordinated and accountable care.  The state initially proposed an enrollment start date of October 2013, but later changed the enrollment start date to January 2014.  (Source: CalDuals, accessed 5/13/2013) 
Memorandum of Understanding
Three-Way Contract for Demonstration

On February 4, 2014, the state announced a Coordinated Care Initiative Update and LA Enrollment Strategy. Cal MediConnect enrollment will begin in April 2014, with passive enrollment in San Mateo and opt in enrollment in Riverside, San Bernardino, San Diego, and Los Angeles counties. The update included a Revised Enrollment Chart outlining the CCI enrollment timeline by population and county. (Source: CalDuals, accessed 2/27/14) 

Revised Enrollment Chart
Coordinated Care Initiative Update on CalDuals.org

In March 2014, the state announced the following changes to its CCI timeline: Cal MediConnect and Managed Medi-Cal Long-Term Services and Supports (MLTSS) enrollment will be aligned so that beneficiaries will not transition to MLTSS ahead of passive enrollment into Cal MediConnect; the Medi-Cal fee-for-service population will transition to MLTSS starting in August 2014 rather than July 2014; and enrollment in Alameda and Orange counties will start no sooner than January 2015. (Source: HMA Weekly Roundup, 3/26/2014; CalDuals website) CCI Timeline (3/25/2014)

In March 2014, CMS approved California’s §1115 Bridge to Reform waiver amendment, authorizing the state to implement its Coordinated Care Initiative (CCI) on April 1, 2014. (Source: CalDuals website)

On April 1, 2014, the state launched its duals demonstration, beginning passive enrollment in five counties. Passive enrollment for three additional counties will begin in May 2014. (Source: HMA Weekly Roundup, 4/9/14)

San Diego County, one of the five counties that began passive enrollment in the demonstration on April 1, 2014, is developing a unique managed care initiative. The county’s Aging and Independence Services (AIS), acting as the local AAA, is planning to collaborate with the Care1st managed care health plan to provide case management and other social services for dual eligible older adults. (Source Link No Longer Available)

On June 4, 2014, the state released an updated enrollment timeline for the demonstration. (Source: HMA Weekly Roundup, 6/11/2014) CCI Revised Timeline (6/4/2014) 

On July 1, 2014, the California duals demonstration began passive enrollment in Los Angeles County. (Source: HMA Weekly Roundup, 7/9/2014)

On July 2, 2014, stakeholders filed a lawsuit in Superior Court against Cal MediConnect, claiming the duals demonstration enrollment process is misleading and confusing. Stakeholders asked the court for a preliminary injunction to halt the demonstration. (Source: California Healthline/Capitol Desk, 7/7/2014)

On July 14, 2014, in response to stakeholder comments that the state’s duals demonstration enrollment notices were unclear, the state revised its Cal MediConnect enrollment notices and will begin mailing the new notices to beneficiaries in July and August 2014. (Source: CalDuals website; HMA Weekly Roundup, 7/16/2014)
Revised Enrollment Materials (July 2014)

On July 18, 2014, the state released a set of initial concepts for the Medi-Cal §1115 Bridge to Reform waiver renewal. The state aims to submit the waiver renewal in early 2015 and is seeking stakeholder input. Waiver renewal concepts include a successor DSRIP program and Medicaid-funded shelter for vulnerable populations. Source: HMA Weekly Roundup, 7/23/2014) §1115 Waiver Renewal Concepts (July 2014)

On August 1, 2014, a California Superior Court judge ruled the state may continue its duals demonstration project to more duals into Medi-Cal managed care plans. The Medicaid Defense Fund intends to appeal the ruling as soon as possible. (Source: California Healthline/Capitol Desk, 8/4/2014)

On August 1, 2014, the state announced a change to the Coordinated Care Initiative enrollment timeline for its dual eligible demonstration and mandatory enrollment in MMLTSS. Enrollment in Alameda and Orange Counties will now begin in July 2015 to allow more time to achieve plan readiness. (Source: CalDuals website)
CCI Revised Timeline (7/31/2014)

On August 29, 2014, a group of advocates for seniors filed a lawsuit in the U.S. District Court in Los Angeles seeking an injunction to halt the Coordinated Care Initiative’s duals demonstration project, known as Cal MediConnect.  The lawsuit claimed passive enrollment into managed care puts frail and elderly duals at risk of a gap in care during the transition period.  A previous lawsuit was judged in favor of continuing the duals project implementation.  (Source:  CaliforniaHealthline.org/Capitol Desk, 9/4/2014)

On September 30, 2014, L.A. Care Health Plan, the nation’s largest publicly operated health plan, announced it received an improved Medicare Part D Star Rating from CMS; with its new rating, L.A. Care will begin accepting passive enrollment into the Cal MediConnect duals demonstration project in January 2015.  (Source:  L.A. Care News, 9/30/2014)

On October 3, 2014, California Healthline reported that advocates have dropped their efforts to seek a preliminary injunction against Cal MediConnect.  (Source:  CaliforniaHealthline.org/Capitol Desk, 10/3/2014)

As of October 3, 2014, the state has sent Cal MediConnect enrollment notices to almost half of the 456,000 people eligible for California’s duals demonstration project; and about 36% have opted out of the program.  (Source:  CaliforniaHealthline.org/Capitol Desk, 10/3/2014)

On November 1, 2014, federal regulators will lift an enrollment freeze on CalOptima, Orange County’s only health plan participating in the Cal MediConnect duals demonstration project.  The freeze was enacted earlier this year when auditors from CMS found serious threats to patient health and safety at CalOptima.  Regulators will reassess the plan’s progress in January 2015.  (Source:  Orange County Register, 10/27/2014)

On November 14, 2014, the Department of Health Care Services announced:  Cal MediConnect will no longer move forward in Alameda County; passive enrollment in Orange County will now begin no sooner than August 2015; and opt-in enrollment in Orange County will now begin no sooner than July 2015.  (Source:  Calduals.org, 11/14/2014)

On November 18, 2014, California Healthline reported Cal MediConnect has enrolled about 50,000 individuals to date.  Across seven counties, 33% of eligible individuals have chosen to opt-out of the program; however, this number is skewed by the 40% opt-out rate in Los Angeles county.  (California Healthline.org/Capitol Desk, 11/18/2014)

On November 20, 2014, the state released an updated enrollment timeline for the demonstration.  (Source:  Calduals.org)
CCI Revised Timeline (11/20/2014)

On November 21, 2014, the Department of Health Care Services (DHCS) published an updated list of Expert Stakeholder Workgroup Dates and Locations in connection with the Medi-Cal Bridge to Reform §1115 waiver renewal.  The state also recently published an updated list of Expert Stakeholder Workgroup Participants and a Stakeholder Input Summary Log.  The Bridge to Reform §1115 Waiver expires October 31, 2015; DHCS intends to submit a waiver renewal to CMS in early 2015.  The expert stakeholder workgroups will provide feedback on the following waiver renewal concepts:   Housing/Shelter Resources; MCO/Provider Incentives Resources; DSRIP 2.0 Resources; Workforce Resources; and Safety Net Financing Resources. 
Expert Stakeholder Workgroup Dates and Locations (Updated 11/21/2014) 
Stakeholder Input Summary Log (11/17/2014) 

On December 4, 2014, California Healthline reported the Cal MediConnect opt-out rate continues to be significantly higher in Los Angeles County than the other six counties in the state’s seven-county duals demonstration pilot project.  State and federal health officials are analyzing data to understand why so many more people in Los Angeles County have been rejecting enrollment; although they didn’t release an official time frame for completing this analysis, officials hope to make preliminary results available in the coming months.  (Source:  California Healthline.org, 12/4/2014)

In December 2014, the Department of Health Care Services released Cal MediConnecToons, a series of four animated informational videos to explain Cal MediConnect.  (Source:  Calduals.org)
Cal MediConnecToons (12/2014)

On January 1, 2015, the state began passive enrollment in Santa Clara County.  (Source:  Calduals.org)

On January 15, 2015, California released enrollment information detailing the current participation across the demonstration counties.  The statistics show that 40% of potential enrollees are participating in the program; 48% of individuals opted out of the demonstration; and 12% were involuntarily disenrolled.  Los Angeles county has the highest opt-out rate in the state.  (Source:  Calduals.org)

On February 20, 2015, California Healthline reported that the state is weeks away from completing the first draft of its Bridge to Reform §1115 waiver renewal proposal.  According to the director of California’s Department of Health Care Services, the proposed waiver will center on payment reforms; and a final draft form should be available in the next few weeks for distribution to stakeholders and the public for discussion.  (Source:  California Healthline.org/Capitol Desk, 2/20/2015)

On March 27, 2015, the California Department of Health Care Services (DHCS) submitted to CMS a request for renewal of the state’s Bridge to Reform §1115 Waiver.  The new waiver, known as “Medi-Cal 2020”, seeks $17 billion from the federal government for health care reform projects over a new five-year term; these projects will build on the first five-year Medi-Cal Bridge to Reform waiver that was approved in 2010.  (Source:  California Healthline.org/Capitol Desk, 3/31/2015; California DHCS website; HMA Weekly Roundup, 4/1/2015)
§1115 Waiver Renewal Concept Paper and Attachments (3/27/2015)

On July 10, 2015, the California Department of Health Care Services (DHCS) announced that passive enrollment in the dual eligible demonstration in Orange County, which aims to coordinate care for those jointly enrolled in Medicare and the state’s Medicaid program, Medi-Cal, will not begin before November 1, 2015 for those in Long Term Care facilities (LTC). For Medi-Cal beneficiaries not residing in an LTC, passive enrollment began August 1, 2015. (Source: CalDuals, 7/10/2015) 

On August 10, 2015, CaliforniaHealthline reported that dual eligible individuals in California may now designate someone whom they trust as an enrollment assistant to aid them in making choices regarding Medi-Cal and enrollment in managed care plans (Source: CaliforniaHealthline, 8/10/2015) 

The head of California’s Medicaid program has written a letter to CMS expressing interest in potentially extending the state’s dual eligible demonstration—Cal MediConnect—albeit with some significant refinements. With the Coordinated Care Initiative set to end in the coming year, CMS reached out to the 12 participating states to explore possibilities for program extension. (Source: Calduals.org 8/2015)

The California Department of Health Care Services (DHCS) released the Cal MediConnect Performance Dashboard, which looks at data for LTSS, health risk assessments (HRAs), case management, hospital use, and appeals among enrollees in California’s dual eligible demonstration. Currently, Cal MediConnect has enrolled approximately 124,000 dual eligibles. Of these, in the third quarter of 2015 33,743 members were receiving LTSS. The vast majority of enrollees received LTSS in the community through In-home Supportive Services (IHSS), Community-based Adult Services (CBAS), and Multipurpose Senior Services Program (MSSP), while over 4,000 received services in a nursing facility. (Source: Performance Dashboard 3/2016;  HMA Roundup 3/23/2016) 

On May 9, 2016, FierceHealthPayer reported that California will cease passive enrollment of enrollees in the state’s Coordinated Care Initiative, which aims to better coordinate care and services for those jointly eligible for both Medicare and Medicaid. A number of states, including California, have faced challenges with enrollment in their dual eligible demonstrations. State officials did add, however, that they will consider returning to automatic enrollment if voluntary enrollment numbers are unsatisfactory. (Source: FierceHealthPayer 5/9/2016)

On December 7, 2016, the Field Research Corporation on behalf of, and in collaboration with, the SCAN Foundation and the California Department of Health Care Services, released Wave 4 of the Rapid Cycle Polling Project, which is a tracking survey for the state’s dual eligible population enrolled in Cal MediConnect (CMC), the state’s financial alignment demonstration. The survey notes a number of positive trends for CMC enrollees, including: 83 percent express they are confident in handling their health conditions; 83 percent say they can get their health questions answered, and; 84 percent are able to identify who they need to call if they have a health-related question.

Significant majorities of CMC beneficiaries also report high levels of satisfaction with the health services they consume as a part of the program. Also of note, CMC enrollees report fewer hospitalizations in the previous 12 months than individuals that have opted out of the program, 24 percent compared to 30 percent, respectively. This is particularly notable since there are no major differences in reported health status of enrollees versus those opting out of the program, and this may reflect the effectiveness of the integrated and coordinated care provided by the CMC program. 

Approximately a third of CMC enrollees are under 65, another third are between 65 and 74, and a final third are 75 and older. (Source: Survey Report 12/7/2016)

On January 10, 2017, California’s governor Jerry Brown released his proposed 2017-2018 budget for the state. Included in the budget proposal is the elimination of the Coordinated Care Initiative (CCI), which is required if the initiative does not reach cost-effectiveness targets. CCI includes the state’s dual eligible demonstration, Cal MediConnect, which operates in seven California counties. Although the budget would wind down the CCI broadly, it also proposes extending Cal MediConnect through December 31, 2019, due to an estimated General Fund savings of $20 million, as well as improving health outcomes for beneficiaries. (Source: Budget 1/10/2017)       

On May 11, 2017, Governor Brown released his revised budget for 2017-18. The budget proposal includes $158.7 billion for all health and human services, which includes $33.7 billion in state General Funds, and $125.1 billion in other funds. Altogether, this is a decrease of $324.8 million in General Funds from the governor’s original budget.

In accordance with California law, the budget revision ends the Coordinated Care Initiative (CCI) that includes the states’ dual eligible demonstration, Cal MediConnect. However, the budget includes language that would:

  • Extend the Cal Mediconnect program;
  • Require mandatory enrollment of dual eligible beneficiaries; and
  • Continues the integration of long-term services and supports (LTSS) into managed care except for the In-Home Supportive Services (IHSS) program.

The state anticipates it will save $8 million over the course of the first year of the extension of Cal Mediconnect. (Source: Revised Budget Document 5/11/2017)

Section 1915(i) HCBS State Plan Option

As of May 2014, CMS has approved the state’s §1915(i) HCBS State Plan Amendment; and the state is currently participating in the HCBS State Plan Option.  (Source:  Kaiser HCBS State Plan Option website, 5/2014)

Section 1915(k) Community First Choice Option

In September 2012, CMS approved the state’s first CFCO SPA, making California the first state to receive CMS approval to enact the Community First Choice Option.  The CFCO would provide the state an estimated $573 million in additional federal funds during the first two years of implementation; and the funding is retroactive for most in-home supportive services provided since December 2011.  (Source: Press Release, 9/4/2012) CFCO SPA (8/31/2012)

In May 2013, the state submitted its second CFCO SPA to update the eligibility language related to Medi-Cal's CFCO.  In July 2013, CMS approved the state’s second CFCO SPA.  (Source:  CFCO SPA 7/31/2013)

Health Homes

As of March 2014, CMS has approved the state’s Health Home Planning Request.  (Source:  CMS State Health Home Proposal Status, 3/2014)

On April 10, 2015, the state published a Health Homes Version 2.0 Concept Paper.  The state plans to implement Health Homes for individuals with two or more chronic conditions; individuals with one chronic condition and at risk for another; and individuals with serious and persistent mental illness.  California DHCS will host a webinar on April 15, 2015, to review the concept paper and share updates on the Health Homes Program concept.  (Source:  State DHCS website)  
Draft Health Homes Concept Paper Version 2.0 (4/10/2015)