SB 256

Bill Subjects

Abstract

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed by, and funded pursuant to, federal Medicaid program provisions. Under existing law, health care services are provided under the Medi-Cal program pursuant to a schedule of benefits, and those benefits are provided to beneficiaries through various health care delivery systems, including fee-for-service and managed care. Existing law authorizes the department to enter into various types of contracts for the provision of services to beneficiaries, including contracts with a Medi-Cal managed care plan. Existing law imposes various requirements on Medi-Cal managed care plan contractors, and requires the department to pay capitations rates to health plans participating in the Medi-Cal managed care program using actuarial methods. Existing law authorizes the department to establish, and requires the department to utilize, health-plan- and county-specific rates for specified Medi-Cal managed care plan contracts, and requires those developed rates to include identified information, such as health-plan-specific encounter and claims data. Existing law, the Medi-Cal 2020 Demonstration Project Act, requires the department to implement specified components of a Medi-Cal demonstration project, including the Global Payment Program, the Whole Person Care pilot program, and the Dental Transformation Initiative, consistent with the Special Terms and Conditions approved by the federal Centers for Medicare and Medicaid Services. Pursuant to existing law, the department has created a multiyear initiative, the California Advancing and Innovating Medi-Cal (CalAIM) initiative, for purposes of building upon the outcomes of various Medi-Cal pilots and demonstration projects, including the Medi-Cal 2020 demonstration project. Existing federal law authorizes specified managed care entities that participate in a state's Medicaid program to cover, for enrollees, services or settings that are in lieu of services and settings otherwise covered under a state plan. This bill would establish the CalAIM initiative, and would require the implementation of CalAIM to support stated goals of identifying and managing the risk and needs of Medi-Cal beneficiaries, transitioning and transforming the Medi-Cal program to a more consistent and seamless system, and improving quality outcomes. The bill would require the department to seek federal approval for the CalAIM initiative, and would condition its implementation on receipt of any necessary federal approvals and availability of federal financial participation. To implement the CalAIM initiative, the bill would authorize the department to enter into exclusive or nonexclusive contracts, or amend existing contracts, and to implement these provisions by various means, including provider bulletins. For purposes of the CalAIM initiative, this bill would additionally authorize the department to standardize those populations that are subject to mandatory enrollment in a Medi-Cal managed care plan across aid code groups and Medi-Cal managed care models. Commencing January 1, 2023, the bill would require the department to implement the Population Health Management Program under the Medi-Cal managed care delivery system to improve health outcomes, care coordination, and efficiency through application of standardized health management requirements. The bill would require the department to require each Medi-Cal managed care plan to develop and maintain a beneficiary-centered population health management program that meets specified standards, including identifying and mitigating social determinants of health and reducing health disparities or inequities. The bill would require the department to consult with specified stakeholders, including the State Department of Public Health, to establish requirements for the population health management program, as specified, and, beginning January 1, 2024, would require the department to annually develop and issue a public report, which includes prescribed information, on this program. Under the CalAIM initiative, this bill would require the department to implement an enhanced care management (ECM) benefit designed to address the clinical and nonclinical needs on a whole-person-care basis for certain target populations of Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans, as specified. The bill would require Medi-Cal managed care plans to consult and collaborate with county mental health plans for the delivery of ECM services for beneficiaries with certain health conditions, including serious mental illness, to maximize federal reimbursement and minimize duplication of services. The bill would require the department to require those plans to report specified information related to the ECM benefit and would require the department to annually publicly report on the utilization of ECM in a manner that allows for an analysis of demographic populations, as specified. As part of the CalAIM initiative, and commencing January 1, 2022, this bill would require the department to authorize Medi-Cal managed care plans to elect to cover those services or settings approved by the department as cost effective and medically appropriate in the comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services. The bill would provide that in lieu of services include specified services, such as housing transition navigation services, recuperative care, and asthma remediation. The bill would require the department to establish metrics for, and conduct an annual evaluation of, the utilization and effectiveness of in lieu of services, and to publicly report, as prescribed, the evaluation and conduct the evaluation in a specified manner. Commencing January 1, 2022, this bill would require the department, subject to appropriation, to make incentive payments available to qualifying Medi-Cal managed care plans that meet predefined milestones and metrics associated with implementation of applicable components of the CalAIM initiative, and to consult with specified entities, including Medi-Cal managed care plans, to establish the methodology pursuant to prescribed standards. This bill would authorize the department to establish capitation rates to contracted health plans on a regional basis in lieu of health plan and county-specific rates, and would require the department to consult with affected entities and individuals, including consumer representatives. Before the implementation of a regional-based capitation rate, the bill would require the department to report to the Legislature on specified matters, including how these rates are to be established. This bill would make its provisions severable and would make other legislative findings and declarations.