AB 2348: Medi-Cal: enhanced care management and community supports.

14184.205.

(a) (1) Subject to subdivision (f) of Section 14184.102, the department shall implement an enhanced care management (ECM) benefit in accordance with this section.

(2) (A) For purposes of this section, “enhanced care management” or “ECM” means community-based, high-touch coordination and comprehensive care management services designed to address the clinical and nonclinical needs on a whole-person-care basis of certain target populations of Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans.

(B) ECM services comply with the ECM service model, as defined by the department, and include access to a lead care manager, outreach and engagement, comprehensive assessment and care management planning, coordination of care, health promotion, comprehensive transitional care, member and family support, and coordination of and referral to community and social support services.

(b) (1) The ECM benefit shall be available on a statewide basis to an eligible Medi-Cal beneficiary who is enrolled in an applicable Medi-Cal managed care plan and who meets the criteria for one or more target populations, as determined by the department. A Medi-Cal beneficiary is excluded from ECM while enrolled in a 1915(c) waiver program, or while receiving California Community Transitions (CCT) Money Follows the Person (MFTP) services, or otherwise eligible for other high-intensity care management services, as defined by the department. ECM shall be available to a qualifying dual eligible beneficiary, as described under Section 14184.200, except for a dual eligible beneficiary enrolled in a fully integrated program for members who are dually eligible for Medicare and Medicaid, Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs), and the Programs of All-Inclusive Care for the Elderly (PACE).

(2) ECM only shall be available as a covered Medi-Cal benefit under a comprehensive risk contract with a Medi-Cal managed care plan. A Medi-Cal beneficiary who is eligible for ECM shall enroll in a Medi-Cal managed care plan in order to receive those services.

(c) Target populations shall include the following, consistent with the department’s eligibility criteria, and to the extent approved in the CalAIM Terms and Conditions:

(1) Children or youth with complex physical, behavioral, developmental, or oral health needs, including, but not limited to, those eligible for California Children’s Services, those involved or with a history of involvement in child welfare or the juvenile justice system, or youth with clinical high-risk syndrome or a first episode of psychosis.

(2) Individuals experiencing homelessness.

(3) High utilizers with frequent hospital admissions, short-term skilled nursing facility stays, or emergency room visits.

(4) Individuals at risk for institutionalization and eligible for long-term care services.

(5) Nursing facility residents who want to transition to the community.

(6) Individuals with serious mental illness (SMI), and children with serious emotional disturbance (SED) or substance use disorder (SUD).

(7) Individuals transitioning from incarceration requiring immediate transition of services to the community.

(d) Notwithstanding any other law, for any time period in which a Medi-Cal beneficiary is eligible to receive ECM services through enrollment in their Medi-Cal managed care plan, the beneficiary shall not receive duplicative targeted case management services as described in Section 14132.44 or otherwise authorized in the Medi-Cal State Plan, as determined by the department.

(e) Medi-Cal managed care plans shall consult and collaborate with Medi-Cal behavioral health delivery systems for the delivery of ECM for beneficiaries with an SMI, SED, or SUD.

(f) If a Medi-Cal managed care plan proposes to keep some level of ECM in-house instead of contracting with direct providers, the Medi-Cal managed care plan shall demonstrate to the state that its ECM benefit is appropriately community based and shall provide a rationale for not contracting with existing providers.

(g) (1) The department shall develop, in consultation with Medi-Cal managed care plans and other appropriate stakeholders, a monitoring plan and reporting template for the implementation of ECM pursuant to this section.

(2) The department shall annually publish a public report on reported ECM utilization data, populations served, and demographic data, stratified by age, sex, race, ethnicity, and languages spoken, to the extent statistically reliable data are available.

(3) (A) The department shall also publish the information described in paragraph (2) on the department’s internet website on a quarterly basis, to the extent feasible.

(B) This paragraph shall become inoperative on January 1, 2032.

14184.206.

(a) Subject to subdivision (f) of Section 14184.102, a Medi-Cal managed care plan may elect to cover those community supports 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, as described in subdivision (c).

(b) (1) Approved community supports pursuant to this section shall be available only to beneficiaries enrolled in a Medi-Cal managed care plan under a comprehensive risk contract, subject to paragraph (2).

(2) Approved community supports shall not supplant other covered Medi-Cal benefits that are not the responsibility of the Medi-Cal managed care plan under the comprehensive risk contract, including, but not limited to, in-home supportive services provided pursuant to Article 7 (commencing with Section 12300) of Chapter 3, and Sections 14132.95, 14132.952, and 14132.956.

(3) An enrolled Medi-Cal beneficiary shall not be required by their Medi-Cal managed care plan to use the community support.

(c) Subject to subdivision (f) of Section 14184.102, community supports that the department may approve include, but need not be limited to, all of the following when authorized by the department in the comprehensive risk contract with each Medi-Cal managed care plan and to the extent the department determines that the community support is a cost-effective and medically appropriate substitute for the applicable covered Medi-Cal benefit:

(1) Housing transition navigation services.

(2) Housing deposits.

(3) Housing tenancy and sustaining services.

(4) Short-term post-hospitalization housing.

(5) Recuperative care or medical respite.

(6) Respite.

(7) Day habilitation programs.

(8) Nursing facility transition or diversion to assisted living facilities, including, but not limited to, residential care facilities for the elderly or adult residential facilities.

(9) Nursing facility transition to a home.

(10) Personal care and homemaker services.

(11) Environmental accessibility adaptations or home modifications.

(12) Medically supportive food and nutrition services, including medically tailored meals.

(13) Sobering centers.

(14) Asthma remediation.

(d) The department shall publicly post on its internet website a list of which community supports are offered to enrollees by each Medi-Cal managed care plan.

(e) (1) The department shall, for each community support, publish and maintain policy guides and all-plan letters on the department’s internet website that define model coverage standards and policy, including specification of service definitions, eligibility criteria for members, and eligibility criteria for providers, in a manner that is sufficiently comprehensive and detailed to allow a Medi-Cal managed care plan to adopt the department’s guidance, in whole, as the plan’s coverage policy.

(2) A Medi-Cal managed care plan shall adopt community supports policies, consistent with the department’s guidance and Section 438.3(e) of Title 42 of the Code of Federal Regulations.

(3) The department shall engage stakeholders, including Medi-Cal managed care plans and providers of each community support, through existing processes prior to publishing updates to the guidance described in paragraph (1).

(f) A Medi-Cal managed care plan shall provide information on the available community supports in its member handbook and plan website, including any limitations on community supports on the plan website.

(g) (1) The department shall develop, in consultation with Medi-Cal managed care plans and other appropriate stakeholders, a monitoring plan and reporting template for the implementation of community supports pursuant to this section.

(2) The department shall annually publish a public report on reported community supports utilization data, populations served, and demographic data, stratified by age, sex, race, ethnicity, and languages spoken, to the extent statistically reliable data are available.

(3) (A) The department shall also publish the information described in paragraph (2) on the department’s internet website on a quarterly basis, to the extent feasible.

(B) This paragraph shall become inoperative on January 1, 2032.

(h) The department shall conduct an independent evaluation of the effectiveness of community supports in accordance with the parameters and timeframes specified in the CalAIM Terms and Conditions.

(i) The department shall take into account the utilization and actual cost of community supports in developing capitation rates.

(j) In order for Medi-Cal managed care to effectively manage the delivery of the community supports for Medi-Cal beneficiaries, the department shall provide ongoing technical assistance to Medi-Cal managed care plans. A Medi-Cal managed care plan shall educate its in-network community support providers on policies, instructions, and requirements to maintain compliance with Medi-Cal policies in order to effectively deliver community support services.

(k) (1) The department shall establish a standard timeline and process for regular updates to community supports policy guides. The standard timeline and process for regular updates shall include all of the following:

(A) The department shall post proposed policy changes for public input for a minimum of two weeks before finalizing policy changes.

(B) The department shall publicly release written policy changes no later than six months prior to the effective date of the policy changes.

(C) The department shall designate an effective date for policy changes as January 1 or July 1 of an applicable year.

(2) The department may authorize an exception to the standard timeline and process described in paragraph (1) if needed to ensure effective delivery of community supports, as determined by the department. If the department authorizes an exception under this paragraph, the department shall notify interested stakeholders and shall provide a rationale for the exception.

(l) For purposes of this section, the following definitions apply:

(1) “Community supports” means those alternative services and settings administered according to Section 438.3(e)(2) of Title 42 of the Code of Federal Regulations.

(2) “Comprehensive risk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations.

(3) “Nonprofit community provider” means a locally available community-based nonprofit organization that has direct experience with providing services to Medi-Cal beneficiaries in the county or region where the organization operates.

(m) (1) By March 31, 2029, the department shall provide to the appropriate policy and fiscal committees of the Legislature information in writing necessary to inform legislative consideration of transitioning community supports to benefits that are required to be covered under the Medi-Cal program, including information on cost, effectiveness, and provider availability.

(2) The information provided pursuant to paragraph (1) shall draw from the final community supports evaluation prepared by the department as required by the CalAIM Special Terms and Conditions and as submitted to the federal Centers for Medicare and Medicaid Services by December 31, 2028.