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Hooper, Lundy & Bookman, P.C. (HLB) wants to make hospitals aware of current adjustments being imposed by certain MACs denying reimbursement for Medicare bad debts for the alleged failure to maintain “continuous” collection efforts during the 120-day period following the issuance of a bill to the patient for unpaid co-pay and deductible amounts. MACs are asserting that a patient is more likely to pay these amounts during the 120-day period, so continuous efforts are allegedly required to meet the obligation of hospitals to engage in a “genuine, rather than token collection effort,” in accordance with PRM-I, §310.  Read More ›

On October 28,2019 the California Department of Health Care Services (the “Department”) released the Medi-Cal Healthier California for All (formerly known as CalAIM) initiative. Recently, in support of the Department’s initiative, Governor Newsom released his proposed 2020-21 state budget which includes a large investment in the initiative. In particular, the proposed budget includes $695 million (including federal funds) in 2020-21 for the initiative, growing to $1.4 billion per year in 2021-22.1

The Medi-Cal Healthier California for All initiative seeks to implement broad delivery system, program and payment reform across the Medi-Cal program. This initiative reflects the Newsom Administration’s desire to use Medi-Cal to address a variety of issues facing California’s most vulnerable residents, such as homelessness, children with complex medical conditions, the increasing need for access to behavioral health care services and for services for formerly incarcerated individuals, and to address the growing age populations. The initiative also provides the framework for upcoming waiver renewals and program and payment reforms across the Medi-Cal program. In short, Medi-Cal Healthier California for All reflects the future of the Medi-Cal delivery system and will have broad ranging impacts for Medi-Cal providers and California’s 13.5 million Medi-Cal beneficiaries.

Medi-Cal Healthier California for All’s Overarching Goals and Proposals

The proposed plan under this initiative includes a number reforms affecting Medi-Cal managed care, long-term care, behavioral health, and other county programs and services. The Department’s nearly 180 page Medi-Cal Healthier California for All Proposal sets forth three overarching goals and specific proposals to achieve these goals.2

Goal 1: Identify and manage member risk and need through Whole Person Care approaches and addressing the Social Determinants of Health. Related proposals include:

• Medi-Cal managed care plan (“MCP”) incentive payments linked to investment in Enhanced Care Management and In Lieu-of Services (“ILOS”) infrastructure. MCPs would need to partner and share the incentive payments with providers.
• MCP coverage of a statewide Enhanced Care Management benefit to address clinical and non-clinical needs of beneficiaries.
• MCP coverage of ILOS, which are flexible wrap-around services provided as a substitute to other Medi-Cal covered services such as ER utilization through integration with Care Management.
• Transition the current Health Homes Program and Whole Person Care pilots to a statewide benefit.

Goal 2: Move the Medi-Cal program to a more consistent and seamless system by reducing complexity and increasing flexibility. Related proposals include:

• Full integration plans, which \would cover physical health, behavioral health, and oral health under one contracted entity.
• Standardization the benefits that are provided and the populations enrolled through MCPs statewide.
• Regional Rates for MCPs.
• Transition to Statewide Managed Long Term Services and Supports (MLTSS).
• Behavioral Health proposals, including administrative integration of specialty mental health and substance use disorder services into one behavioral health managed care program.

Goal 3: Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems, and payment reform. Many of the proposals incorporated throughout the initiative relate to this goal to improve quality outcomes.

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For media assistance, please contact Maura Fisher at 202-580-7714.