Medi-Cal: enhanced care management and community supports., the official text

An act to amend Sections 14184.205 and 14184.206 of, and to add and repeal Section 14184.209 of, the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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.
Existing law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, requires 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. Under existing law, target populations include, among others, high utilizers with frequent hospital admissions, short-term skilled nursing facility stays, or emergency room visits, and individuals experiencing homelessness.
This bill would recast the definition of ECM, referring to community-based, high-touch coordination and comprehensive care management services, as specified. The bill would delete certain provisions that designate 2022 or 2023 timelines for commencing ECM coverage, depending on whether or not a Medi-Cal managed care plan operates in a county in which the Whole Person Care pilot program or the Health Home Program was implemented.
Existing law, subject to CalAIM implementation, authorizes a Medi-Cal managed care plan to elect to cover community supports. Under existing law, community supports that the department is authorized to approve include, among others, housing transition navigation services and medically supportive food and nutrition services.
This bill would require the department, by July 1, 2027, to produce model managed care coverage standards and policy, reflecting best practices, for each community support provided for plan years beginning on January 1, 2028. If a managed care plan deviates from the standards and policy, the bill would require the plan to provide to the department a specific explanation and justification for that deviation. The bill would require the department to provide ongoing technical assistance to managed care plans and to require the plans to continue to provide technical assistance to providers of community supports. The bill would require the department to publicly post any policy changes for stakeholder input, and to publicly release written updates to the department’s policy guidance, as specified.
The bill would require a managed care plan to track and report to the department certain quantitative data regarding nonprofit community providers, as defined, and would require the department to publish a report on these data not less than annually. The bill would require the department to continue to publish certain information on its internet website on a quarterly basis through December 31, 2031. The bill would require the department, by March 31, 2029, to provide to the legislative committees 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.
The bill would require the department, until January 1, 2032, to continue to convene the CalAIM Implementation Advisory Group that is in effect on January 1, 2026, and as most recently updated. For purposes of the above-described provisions on ECM and community supports coverage, the bill would remove references to their implementation in accordance with CalAIM Terms and Conditions.

The people of the State of California do enact as follows:

SECTION 1.
Section 14184.205 of the Welfare and Institutions Code is amended to read:
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 or the Family Mosaic Project, 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, including Cal MediConnect during the duration of the demonstration authorized in Section 14132.275, 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, but shall not be limited to, the following, consistent with the department’s eligibility criteria:
(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) The department shall also continue to publish the information described in paragraph (2) on the department’s internet website on a quarterly basis through December 31, 2031.

SEC. 2.
Section 14184.206 of the Welfare and Institutions Code is amended to read:
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 under the comprehensive risk contract:
(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) By July 1, 2027, the department shall produce model managed care coverage standards and policy for each community support provided pursuant to subdivision (a), for plan years beginning on January 1, 2028.
(2) The model managed care coverage standards and policy shall reflect best practices and shall provide comprehensive and detailed instructions on model eligibility and coverage policies sufficient for a Medi-Cal managed care plan to adopt, in whole, as its coverage policy.
(3) The department shall engage stakeholders, including community providers of each community support, and shall solicit and accept feedback in developing the model managed care coverage standards and policy.
(4) If a managed care plan deviates from the model managed care coverage standards and policy, the plan shall provide to the department a specific explanation and justification for that deviation.
(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) The department shall also continue to publish the information described in paragraph (2) on the department’s internet website on a quarterly basis through December 31, 2031.
(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 to enhance the ability of Medi-Cal managed care plans and providers to effectively provide community supports, the department shall provide ongoing technical assistance to Medi-Cal managed care plans and shall require Medi-Cal managed care plans to continue to provide technical assistance to providers of these services.
(k) (1) The department shall post any policy changes publicly for stakeholder input for a minimum of one month before making updates to its community supports policy guidance.
(2) The department shall publicly release written updates to its community supports policy guidance, including the model managed care coverage standards and policy, no later than six months prior to the effective date of the policy update. Updates shall commence on an effective date of January 1 or July 1 of the applicable year. Exceptions shall be allowed to address urgent issues, as determined by the department, including changes in federal approvals and the availability of federal financial participation. If an exception is allowed under this subdivision, interested stakeholders shall be notified, and a rationale for the irregular update shall be provided.
(l) (1) A Medi-Cal managed care plan shall track and report to the department the number and percentage of the plan’s providers that fit the definition of “nonprofit community provider” in paragraph (3) of subdivision (m), and the number and percentage of services provided by these community providers. The department shall organize these data by plan and shall publish a report on these data not less than annually.
(2) This subdivision does not restrict plans from contracting with a provider that does not fit the definition of a nonprofit community provider.
(m) For purposes of this section, the following definitions apply:
(1) “Community supports” means those alternative services and settings administered according to paragraph (2) of subsection (e) of Section 438.3 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.
(n) 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.

SEC. 3.
Section 14184.209 is added to the Welfare and Institutions Code, to read:
14184.209.
(a) The department shall continue to convene the CalAIM Implementation Advisory Group that is in effect on January 1, 2026, and as most recently updated.
(b) This section shall remain in effect only until January 1, 2032, and as of that date is repealed.