DHCS Stakeholder Advisory Committee Digs Deeper into Medi-Cal 2020 Waiver, SB 75 Implementation (Health4Kids), and Other Care Transformation Initiatives

This blog was written by Tam M. Ma (Policy Counsel) and Judi Hilman (Director of Special Projects)

DHCS held its quarterly Stakeholder Advisory Committee today, the first time since California’s Medi-Cal 2020 waiver was approved at the end of December, covering a range of topics, including the waiver renewal, SB 75 implementation of Health for Kids, and other Medi-Cal care transformation initiatives.

Medi-Cal 2020 Waiver Details from the Special Terms and Conditions

Medi-Cal Director Mari Cantwell provided an overview of the new waiver (See our earlier blog overview of the new waiver) and an update on implementation efforts. The Medi-Cal 2020 waiver provides more than $6.2 billion in new federal funding through programs that shift the focus away from hospital-based and inpatient care and towards outpatient, primary, and preventative care while supporting the public health care systems’ essential safety net mission and mandate to provide care to everyone. Public health care systems cover 40% of the remaining uninsured and a quarter of the Medi-Cal population.

Medi-Cal 2020 includes four major programs as well as a variety of reporting and assessment requirements:

  1. Public Hospital Incentives and Redesign in Medi-Cal (PRIME)

PRIME builds on the state’s DSRIP (Delivery System Reform Incentive Program) that was initiated in the 2010 Bridge to Reform Waiver, providing public hospitals with federal incentive payments using evidence-based quality improvement methods for improving care delivery. PRIME takes a more focused approach to incentivizing high-quality and efficient, patient-centered care in outpatient settings, targeting high-risk or high-cost populations (foster youth, post-incarceration populations; chronic pain management and advanced illness care). It also promotes more efficient use of resources by avoiding overuse and misuse of diagnostic tests and imaging and treatments and eliminates the use of ineffective or harmful clinical services.

DHCS is currently finalizing the PRIME Attachments on Metrics and Mechanics/Funding (Attachments Q and II) and seeks approval by February 29. The proposed project plans from the Designated Public Hospitals and municipal hospitals will be due 30 days later. From there, DHCS will have 60 days to review and approve Project Plans, during which it will hold two public meetings (at least one in-person, perhaps the other by webinar).

  1. Global Payment Program (GPP)

The Global Payment Program (GPP) is a first-in-the-nation payment reform program that seeks to change the way county-owned and operated public health systems are compensated for providing care to the remaining uninsured. GPP encourages shifting away from cost-based, hospital-based care by providing financial incentives for providing cost-effective primary, specialty, and preventative care.

The shift from volume to value is done through a value-based point methodology that accounts for both the value of the care to the patient and the costs to the health system. Participating public health systems can earn a global budget to provide care for the remaining uninsured and must meet service thresholds to receive full funding.

DHCS is finalizing GPP Attachments Mechanics/Funding and Valuation (Attachments EE and FF) by February 29. Thresholds will be established in Attachment FF, and future thresholds will only adjust based on overall GPP funding levels and will adjust proportionately to the funding levels.

  1. Dental Transformation Initiative

The goal of this initiative is to give patients consistent and easy access to high quality dental care, focusing on increasing preventative dental care for kids under age 20. It includes a pilot program to give providers incentive payments if they maintain continuity of care to their patients.

  1. Whole Person Care (WPC) Pilots

The WPC pilot targets care for highest-risk and most vulnerable patients by allowing counties to better coordinate physical health, behavioral health, and social services and other supports to help meet needs like housing or food. The goal is to reduce the use of hospital services, including emergency services, leading to more efficient and effective use of county resources. The WPC Pilots will identify high-risk individuals and coordinate care through individual care plans that will hopefully result in better health. Up to $300 million in federal funding will be available annually for the WPC pilots, which require the county entities to put up the dollars to be matched.

CMS is reviewing the WPC Pilot attachments. DHCS hopes to get these pilots moving forward by releasing applications soon. They expect applications to be due in mid-May. DHCS will issue FAQs and more details next month after the attachments are approved by CMS.

Other Elements of the Waiver

The Waiver also requires the state to conduct four independent assessments of the Medi-Cal program and evaluation of waiver initiatives:

  1. Medi-Cal Managed Care Access Assessment: To ensure health plan compliance with network adequacy and timely access requirements.
  2. Uncompensated care assessments for designated public hospitals and across all hospital providers that serve Medi-Cal beneficiaries.

The Waiver also requires DHCS to conduct evaluations of the Waiver GPP and PRIME programs.

See Medi-Cal 2020 Waiver website for more information and helpful links.

SB 75 – Health for Kids Implementation

DHCS is updating the Eligibility and Enrollment Plan, which provides an overview of how they will transition the restricted scope kids to full-scope Medi-Cal, as well as those who are not currently in the program. DHCS did not indicate when the plan will be shared with the public, but indicated that it would be soon. A webinar to update the public on implementation efforts will be scheduled once the Eligibility and Enrollment Plan is done.

Information on SB 75 implementation can be found here: http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/sb-75.aspx

Much of the work on SB 75 implementation is happening in the AB 1296 Immigration workgroup, which meets every other Wednesday: http://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/AB1296_Immigration.aspx

 Health Home Initiative Update

Under Section 2703 of the Affordable Care Act states have incentives, including a 90% match rate for 2 years, to set up health homes for patients with complex needs. Enacted in 2013, AB 361 specifies California’s approach to delivering an intensive set of services (care management, care coordination, health promotion, transitional care, individual and family support) to the top 3-5% of Medi-Cal beneficiaries with the most complex medical needs, including individuals experiencing homelessness.  Today’s meeting touched on the county roll-out schedule, program eligibility criteria (very tight), and overall project timeline. For more information, visit the DHCS HHI home page.

Coordinated Care Initiative Update

Like most dual eligible demonstration projects in the U.S., California’s Coordinated Care Initiative (CCI), “Cal Medi-Connect,” has had a rough, slow start. This is not surprising, given that setting up these programs requires extensive stakeholder engagement and coordination of care across different settings and levels of care, including community-based long term services and supports. Beneficiaries need extensive outreach and education so they can understand how they can benefit from coordinated care and how to select the right managed care plan for their needs. For these reasons and others, argues Community Catalyst, these programs need more time to work (see blog).

As we saw again in this meeting, the state’s enrollment of 125,257 (approximately 10% of those eligible) relative to the size of the state’s dual eligible population (1.3 million) is more disappointing than the national average (26% of those eligible signed up as of last May). Yet the satisfaction rates of those that participate are high: 85% of enrollees are satisfied with the amount of time providers spend with them, for example. A recent CMS assessment commends the state’s robust stakeholder process and ombudsman program.

Learn more about CCI and Other Dual Eligible Demonstration Initiatives:


  • The Next Medi-Cal Stakeholder Meeting is Monday, May 16.
  • The Medi-Cal 50th Anniversary celebration is May 24th at the Sacramento Convention Center will feature a panel, videos and stories of beneficiaries and providers (While there will be no balloon drop or ice sculptures, expect other announcements and surprises.)