Yesterday the Department of Health Care Services (DHCS) held its first Stakeholder Advisory Committee of 2015, which coincided with new DHCS Director Jennifer Kent’s third day on the job. Ms. Kent, who has held other roles at DHCS, said this new role will be “the greatest job” and “the hardest job” she’ll have in her career. Kent committed to working with stakeholders and improving the department’s stakeholder engagement process, including overhauling the website and posting meeting materials ahead of time. Ms. Kent also expressed a desire to continue the Stakeholder Advisory Group beyond this year.
Highlights of the Meeting
President’s Executive Order on Immigration: Medi-Cal Director Mari Cantwell stated the Administration is still assessing the impact of the President’s Executive Order on Medi-Cal and reminded folks that DHCS is not proposing changes to existing eligibility processes. Anthony Wright, Executive Director of Health Access California and a member of the Stakeholder Advisory Committee, emphasized that having clarity around what California will or will not do with respect to Medi-Cal coverage for the immigrant families that are touched by the Executive Action would be helpful.
Update on California’s Section 1115 Waiver Renewal: This discussion began with a look back to California’s “Bridge to Reform” (2010-2015) Waiver, which was critical to our successful implementation of the Affordable Care Act. California’s uninsured rate was cut by 50%, and the Medi-Cal expansion led to a 29% increase in Medi-Cal enrollment. The state also was first in the nation in implementation of the DSRIP (Delivery System Reform Incentive Payment) program, with 21 public safety net systems taking part in this comprehensive effort to improve health care delivery and realign incentives for providers.
Cantwell then shared the Department’s current thinking about the proposed waiver renewal. The waiver will build on the state’s efforts in transforming care delivery; integrating physical and behavioral health; and improving people’s health and quality of life. The next waiver should also make the program more sustainable in the long run without the continued use of 1115 waivers. DHCS hopes the waiver renewal will include a $15-$20 billion investment from the federal government—considerably more than the $10 billion investment from the Bridge to Reform waiver. Consumer advocates, including Health Access, CPEHN, and SEIU urged DHCS to make health equity a more explicit goal of the waiver. In addition to offering incentives to improve quality of care, we should be focusing on addressing health disparities amongst low-income communities and communities of color in California.
Health Access has developed recommendations for a waiver which supports our safety net; improves care and provides a medical home for Medi-Cal enrollees and the remaining uninsured; and moves California toward the “quadruple aim” of better care, better health, lower cost, and reduced disparities. (See our issue brief on Health Access Priorities for California’s Next Medicaid Waiver here.) Some advocates’ input on the waiver was incorporated in Ms. Cantwell’s presentation—for example, core strategy 3 transforms California’s public safety net for the remaining uninsured [our emphasis] by unifying DSH and Safety Net Care Pool funding streams into a county-specific global payment system”–a proposal advanced by public hospitals that we support. However, we and other advocates were not seeing the detail on disparities we should expect at this stage of the process.
Next steps: DHCS is still working through all the input it received through its stakeholder workgroup process. The department is working on a draft proposal that will be available for public review before it submits the final proposal to CMS in March. Cantwell emphasized that much of the proposal will change substantially between now and when the feds approve it.
Details about the waiver update can be found here: 1115 Waiver Renewal Update
DHCS also gave updates on the following efforts:
- Medi-Cal Enrollment and Renewals: DHCS has seen a significant increase in Medi-Cal enrollees during Covered CA’s open enrollment period. As of early February, a total of 881,937 Medi-Cal eligible individuals have signed up. DHCS says of these, 83% are being determined eligible in real-time, though advocates questioned the accuracy of this figure. DHCS says return rate on 2014 renewals are lower than 2013. They are doing additional outreach to increase the return date. We expect a formal report on 2014 renewals to be available in March. DHCS is working on improving renewals for 2015, including the use of ex-parte reviews and pre-populated forms with MAGI (Modified Adjusted Gross Income, the new formula used to determine eligibility for lower costs in the marketplace and for Medicaid and CHIP) Medi-Cal populations. DHCS’s temporary policy for Covered CA enrollees transitioning to Medi-Cal will remain in effect until system changes are implemented to allow folks to keep their Covered CA coverage until final Medi-Cal eligibility is confirmed. This will hopefully allow people to avoid gaps in coverage.DHCS is also working on implementation of the expansion of full-scope Medi-Cal for pregnant women with incomes between 60 and 138% of the FPL. They will be enrolled in a Medi-Cal managed care plan unless an exemption applies. Advocates requested that women in their second and third trimesters not be defaulted into a plan in order to avoid affecting continued access to a provider for the remainder of their pregnancy. DHCS expects federal approval of the relevant state plan and 1115 waiver amendments this month.
- Coordinated Care Initiative: DHCS gave an update on enrollment numbers in the counties that are participating in CCI. 122,908 individuals were enrolled as of January 15, with an additional 31,000 projected enrollees by the end of March. DHCS also shared data showing many people are opting-out of CCI before actually enrolling. DHCS believes an integrated delivery system is better than a fractured one and is working on better education and outreach to beneficiaries, plans, and providers. This will be a subject of significant discussion in the budget hearings, given concerns with the program and the opt-out rate. DHCS stands by its commitment to CCI and will work to improve enrollment and retention and attain cost-effective changes.
- AB 361 Health Homes: DHCS provided an update on implementation of Senator Mitchell’s AB 361 (2013), which authorizes the Department of Health Care Services to apply for the Section 2703 Health Homes option under the Affordable Care Act to create health homes for Medi-Cal enrollees with chronic conditions, in addition to developing a model that targets the homeless population who use the emergency room as their primary source of care. DHCS is in the midst of program design and has been soliciting stakeholder feedback. They plan to hold a stakeholder event in March and share a draft concept paper for review and feedback. DHCS expects to submit the State Plan Amendment to CMS in August.
- Behavioral Health Treatment Benefit. – California is implementing a federal directive requiring Medi-Cal to include behavioral health therapy (BHT) as a covered Medi-Cal benefit for people under the age of 21. DHCS has directed all Medi-Cal Managed Care Plans to include medically necessary BHT services such as Applied Behavior Analysis (ABA) and other evidence-based behavioral intervention services that develop or restore, to the maximum extent practicable, the functioning of a beneficiary with Autism Spectrum Disorder. The BHT State Plan amendment was submitted to CMS in September, and DHCS is working with stakeholders on transition and implementation issues.