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The 2020-21 Budget: Re-Envisioning Medi-Cal—The CalAIM Proposal


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The 2020-21 Budget: Analysis of the Medi-Cal Budget

February 14, 2020 - In this report, we provide high‑level background on the Medi‑Cal program and an overview of the major drivers of year‑over‑year spending changes in the Governor’s budget. We also discuss the administration’s recent submittal (late January 2020) of a modified managed care organization (MCO) tax proposal. We then provide analysis and recommendations on a series of key issues: (1) Recently proposed draft federal regulations referred to as the “Medicaid Fiscal Accountability Regulation;” (2) proposals related to the Medi‑Cal pharmacy services benefit; (3) the Governor’s proposal to expand comprehensive Medi‑Cal coverage to otherwise eligible seniors regardless of immigration status; (4) proposed changes to rate‑setting for skilled nursing facilities; (5) issues related to county administration of eligibility and enrollment functions in Medi‑Cal; and (6) the Governor’s proposal to end dental managed care in the current two pilot counties and instead provide dental care as a fee‑for‑service benefit statewide. We conclude this report with a summary of our recommendations.

Corrected 2/20/20: Corrected to remove Alameda County from the list counties participating in the Coordinated Care Initiative.

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Improving Medi-Cal Managed Care Plan Quality

May 5, 2015 - Oversight of the quality of care provided by Medi-Cal Managed Care (MMC) plans is an increasingly important issue for the Legislature to examine, as MMC enrollment and the geographic reach of MMC have grown significantly over the past decade. In this report, we analyze the quality of MMC plans and current DHCS efforts to improve MMC plan quality, and consider additional steps and alternative approaches, such as P4P, the state could take to monitor plans and stimulate quality improvement in MMC.

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The 2019-20 Budget: Analysis of the Carve Out of Medi-Cal Pharmacy Services From Managed Care

April 5, 2019 - This report analyzes one of the two initiatives included in the Governor's executive order: to transition the pharmacy services benefit in Medi‑Cal, the state’s largest low‑income health care program, from managed care to entirely a fee‑for‑service (FFS) benefit directly paid for and administered by the state.

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The 2019-20 Budget: Using Proposition 56 Funding in Medi-Cal to Improve Access to Quality Care

February 22, 2019 - This report analyzes the use of Proposition 56 (2016) funding in Medi‑Cal to improve access to quality care. First, we provide background on how Medi‑Cal services are financed within Medi‑Cal’s multiple delivery systems. Then, we review how access and quality are monitored, primarily within Medi‑Cal’s managed care delivery system. We summarize how Proposition 56 funding in Medi‑Cal has been used to date, and the changes proposed under the Governor’s 2019‑20 budget. Next, we assess Medi‑Cal managed care plans’ performance on selected state access and quality standards. Finally, we provide issues for consideration and recommendations on how to use Proposition 56 funding in Medi‑Cal going forward to improve access to quality care.

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The 2014-15 Budget: Analysis of the Health Budget

February 20, 2014 - The report analyzes the Governor's 2014-15 health budget proposals. In it, we (1) provide an analysis of the impact the implementation of the Patient Protection and Affordable Care Act (ACA)--known as federal health care reform--is having on the Medi-Cal program; (2) analyze the Governor's budget proposal to exempt certain, but not all, classes of Medi-Cal providers and services from retroactive recoupments of payment reductions; and (3) assess the fiscal outlook for the California Health Benefit Exchange, also known as Covered California.

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The 2020-21 Budget: The Governor’s Homelessness Plan

February 11, 2020 - In this report we provide the Legislature context for the state’s homelessness crisis, provide an update on major recent state efforts to address homelessness, assess the Governor’s 2020‑21 homelessness plan, propose a framework to help the Legislature develop its own plan and funding allocations, and offer an alternative to the Governor’s 2020‑21 budget proposal.

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The 2019-20 Budget: Analysis of the Medi-Cal Budget

February 13, 2019 - In this report, we describe the major changes and proposals in the Governor's proposed $100.7 billion (all funds) Medi-Cal budget. Specifically, we advise the Legislature to seriously consider renewing the managed care organization tax, despite the Governor not proposing to do so; present issues for consideration related to the Governor's proposed expansion of comprehensive Medi-Cal coverage for young adults regardless of immigration status; and provide an initial assessment of the Governor's proposals to use Proposition 56 funding in Medi-Cal to extend and expand provider payment increases. We recommend approval of the Governor's proposals to improve fiscal oversight of the Medi-Cal budget, and also recommend that the Legislature require the administration provide additional information to the Legislature in an effort to improve fiscal oversight and transparency of this very large, complex budget going forward.

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[PDF] The 2012-13 Budget: Integrating Care for Seniors and Persons With Disabilities

February 17, 2012 - California’s system for providing health and social services to low-income seniors and persons with disabilities (SPDs) receiving Medicare and/or Medi-Cal is not coordinated. This lack of care coordination may lead to SPDs being unnecessarily hospitalized or placed in skilled nursing facilities rather than remaining in their own homes—resulting in poor outcomes for recipients and higher costs for the federal and state governments. As part of the 2012-13 budget, the Governor attempts to address this issue by proposing to integrate health and social services into managed care for most SPDs. In this report, we provide background information on the Medi-Cal and Medicare Programs and describe recent federal and state legislation to address fragmented care delivery. We discuss the potential merits of the Governor’s proposal, but raise several implementation issues and concerns. Finally, we make recommendations that encourage care coordination for SPDs by first completing and evaluating a currently authorized integrated care demonstration project in four counties rather than expanding the demonstration statewide as proposed by the Governor— an action that we think is premature. We also encourage the consideration of other ways to test the integration of benefits for SPDs.

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[PDF] The 2013-14 Budget: Coordinated Care Initiative Update

February 27, 2013 - In 2012, the Legislature authorized the Coordinated Care Initiative (CCI) as an eight-county pilot to demonstrate the integration of Medi-Cal and Medicare benefits for "dual eligibles"--beneficiaries eligible for both benefits. The CCI will also integrate long-term services and supports (LTSS) under Medi-Cal managed care in the eight counties for dual eligibles and seniors and persons with disabilities covered only by Medi-Cal. The Governor's budget delays the start date of CCI implementation to September 1, 2013, resulting in lower 2013-14 savings than initially anticipated. Joint federal-state decisions regarding key financing and operational aspects of CCI are pending, creating uncertainty regarding the timely and successful implementation of CCI. We recommend that the Legislature clarify the legal status of CCI to go forward and consider authorizing CCI to test greater integration of In-Home Supportive Services--a particular LTSS--under managed care.

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[PDF] Overview of Major Health Proposals in 2020-21 May Revision

May 19, 2020 - Assembly Budget Subcommittee No. 1 on Health and Human Services

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[PDF] The 2013-14 Budget: Maximizing Federal Reimbursement for Parolee Mental Health Care

May 6, 2013 - Historically, the state has spent tens of millions of dollars annually from the General Fund for the California Department of Corrections and Rehabilitation (CDCR) to provide mental health treatment services to mentally ill parolees. Our analysis indicates that federal Medicaid reimbursements could be attained for some of the costs of these existing services. Moreover, the amount of federal reimbursements could increase significantly under the federal Patient Protection and Affordable Care Act (ACA) if the Legislature chooses to expand Medi-Cal to provide health coverage to most low-income individuals, as authorized by ACA. In order to maximize the federal reimbursements that will be available for parolee mental health treatment, especially if the state expands Medi-Cal eligibility, we recommend that CDCR (1) provide increased Medi-Cal application assistance for mentally ill parolees to ensure that all eligible parolees are enrolled, (2) develop a process—in collaboration with the Department of Health Care Services (DHCS)—to claim federal reimbursement for the costs of assisting inmates with benefits applications, and (3) develop a process—in collaboration with DHCS—to claim federal reimbursement for parolee mental health treatment services provided to parolees. If the state took these steps, we estimate it could achieve net General Fund savings of about $6 million in 2013-14 and $28 million annually upon full implementation in 2014-15 (assuming the state implements the Medi-Cal expansion).