California Advancing and Innovating Medi-Cal
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California Advancing and Innovating Medi-Cal (CalAIM) is a multi-year initiative by the Department of Health Care Services (DHCS) to implement overarching policy changes across all Medi-Cal delivery systems with the objective of: 1) Reducing variation and complexity across the delivery system; 2) Identifying and managing member risk and need through population health management strategies; and 3) Improving quality outcomes and drive delivery system transformation through value-based initiatives and payment reform.
Throughout 2019 and 2020, DHCS will conduct extensive stakeholder engagement for both CalAIM and the renewal of the 1115 waiver and transition of managed care authority from various waiver authorities to one consolidated 1915(b) CA Managed Care Waiver, comprised of Medi-Cal Managed Care Health Plans (MCP), Mental Health Plans (MHP), Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans and Dental Managed Care.
Below are the five stakeholder workgroups for which DHCS is soliciting members:
- Population Health Management and Annual Health Plan Open Enrollment: This workgroup will provide input on requiring MCPs to develop and maintain population health management strategies that address initial and ongoing assessment of risk and need, leverage risk stratification in care planning, consider social determinants of health, ensure smooth transitions of care, and focus on data collection and reporting. This workgroup will also provide input on a proposal to move to annual Medi-Cal health plan open enrollment.
- NCQA Accreditation: This workgroup will provide input on topics related to standards for and the process of requiring MCPs to obtain NCQA accreditation, including consideration of the proposed accreditation requirements. Workgroup members will be asked to provide feedback on the NCQA Medicaid module, the long-term services and supports distinction survey, and accreditation deeming policies.
- Enhanced Care Management (ECM) and In-Lieu-of Services (ILOS): This workgroup will discuss the possibility of implementing a policy to establish an enhanced care management (ECM) benefit. An ECM benefit would be designed to provide a whole-person approach to care that addresses the clinical and non-clinical needs of high-need Medi-Cal beneficiaries enrolled in MCPs. ECM is a collaborative and interdisciplinary approach to providing intensive and comprehensive care management services to individuals. Additionally, DHCS is seeking input regarding the possibility of including In-Lieu-of-Services (ILOS), which are flexible wrap-around services that the MCP will integrate into their PHMS. These services are provided as a substitute, or to avoid, other services, such as a hospital or SNF admission, discharge delay, or other. ILOS should be integrated with Case Management for members at medium to high levels of risk and may fill gaps in State Plan benefit service to address medical or social determinants of health needs. The workgroup will provide feedback on these concepts, including on topics such as target populations, beneficiary and provider eligibility criteria for the new benefit and payment structures.
- Behavioral Health: This workgroup will provide input on opportunities and challenges in integrating county-level mental health (MH) and substance use disorder (SUD) programs under a single contract; proposed changes to the reimbursement structure of county-level mental health and substance use disorder services; proposed revisions to the medical necessity criteria for behavioral health services; and, the possibility of pursuing the MH IMD waiver opportunity which would allow counties to receive federal reimbursement for services furnished to Medicaid eligible adults with serious mental illness (SMI) and children with serious emotional disturbance (SED) in an IMD.
- Full Integration Pilots: This work group will provide input on a pilot to test the effectiveness of full integration of physical health, behavioral health, and oral health under one entity. This component of CalAIM will be meeting later in the process, as it has a longer implementation timeline.
If you wish to be considered for participation in one or more of the five CalAIM stakeholder workgroups, please submit this request form to the DHCS CalAIM inbox at CalAIM@dhcs.ca.gov by September 27, 2019. DHCS will select and notify workgroup participants by October 18th. Group size will be limited to ensure a productive discussion environment, but there will be additional venues through which stakeholders will be able to provide feedback during this process.
For any other comments, questions, or concerns, please contact CalAIM@dhcs.ca.gov.