What is happening?
The Governor’s Coordinated Care Initiative (CCI) was passed into law as part of the FY 12-13 budget. The main details of the CCI are contained in SB 1008. Additional details, including those affecting IHSS, are contained in SB 1036. These bills were signed into law by Gov. Brown on June 27, 2012.
What is the Coordinated Care Initiative (CCI)?
The CCI is intended to improve the health care system for seniors and people with disabilities who are Medi-Cal recipients. Too often, these people must deal with a fragmented and uncoordinated system of care. The CCI aims to improve service delivery for all Medi-Cal recipients, but particularly those who need coordination the most: the 1.1 million people eligible for both Medicare and Medi-Cal coverage (“dualeligibles”) and the 160,000 Medi-Cal-only beneficiaries who rely on long term services and supports (LTSS).
First, it expands the Dual Eligible Demonstration, which was previously passed into law in 2010. This Demonstration will combine all medical, hospital, and long term supports and services (including IHSS) for dual-eligible individuals into a coordinated care model. The purpose of coordinating this care is to ensure that dual-eligibles are able to receive the right services, in the right place, at the right time. The Demonstration will – for the first time in California – financially and administratively unify the Medicare and Medi-Cal programs.
Second, the CCI will also enroll all Medi-Cal recipients into managed care for their long term supports and services (including IHSS). Most IHSS recipients who only receive Medi-Cal (non-duals) are already enrolled in managed care for their health care. By including long term supports and services as a managed care benefit, the State hopes to create a more coordinated and efficient system of care.
What are Long Term Supports and Services (LTSS)?
Long-Term Supports and Services (LTSS) include a variety of care options offered over an extended period of time to seniors and people with disabilities. These services are designed to meet medical, personal, and social needs in a variety of settings or locations to enable a person to live as independently as possible. The CCI defines specific programs under the list of available LTSS, including In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), and skilled nursing facility services.
What is managed care/coordinated care?
Coordinated care is a response to the fragmented delivery of health and social services in many health systems. The coordination of care is a principal goal of managed care plans, which offer an organized network of providers for primary and preventive care. Hospitals, physicians, social workers, long term care providers and others are members of this network.
When will the CCI start?
CCI enrollment is scheduled to begin no sooner than January 2014. There are eight counties in the CCI: Alameda, Los Angeles, San Bernardino, San Diego, San Mateo, Santa Clara, Orange, and Riverside. In Los Angeles County, enrollment will phase in over 15 months, and in San Mateo the enrollment period will be 4-5 months. For all other counties, enrollment will phase-in over 12 months. Further expansion into additional counties and ultimately statewide will be based on approval from the Legislature.
What will happen to my recipient’s care?
Once a recipient is enrolled in a managed care plan, the plan will be responsible for providing a full range of services, including both medical and acute care and long term supports and services. Managed care plans will coordinate the needs of each recipient individually while aiming to improve overall health care outcomes.
How will my recipient learn more about this change?
Written notices will be mailed to recipients at least 90 days before this change takes place in their county. In accordance with the Governor’s budget proposal, the first notices that any beneficiaries would receive about these transitions would come no earlier than July 2013. They will receive information on how their care will change, when the change will happen, and their available choices. This information should be available in different formats and languages in order to fit the recipient’s needs.
What is a care coordination team?
Care coordination teams will be offered to recipients as a way to better manage their diverse care needs. If a recipient chooses to have a care coordination team, the team may include his or her primary care physician, nurses, social workers, or IHSS provider (if the recipient chooses).
Can I still serve as the IHSS provider for my recipient?
Yes. The CCI will not affect the administration of IHSS services; therefore, the care you provide for your recipient should remain uninterrupted during this transition. Assessments, eligibility, and program administration will remain a county function throughout the course of the CCI implementation, so there will be no change in the way the IHSS program is administered.
Will my recipient lose the right to self-direct his or her IHSS services?
No. The CCI protects recipients’ rights to self direct all aspects of their care. IHSS recipients will maintain their right to hire, fire, and supervise their IHSS provider.
Can family members still serve as IHSS providers?
Yes. The CCI will not affect the administration of IHSS or the ability of a recipient to self direct his or her care. Because self direction is protected, recipients may still choose to have a family caregiver provide IHSS services.
Will my recipient lose any IHSS hours?
No. The administration of the IHSS program will remain a county function. Counties will continue to perform assessments and determine eligibility for IHSS. There should be no change in the way IHSS hours are determined. Although IHSS will be considered a managed care benefit, managed care plans are prevented from reducing IHSS hours.
Who will conduct future assessments of my recipient’s need for IHSS?
The county social workers will continue to be responsible for determining IHSS eligibility and conducting needs assessments. Health plans may authorize additional IHSS hours above a social worker’s assessment, but may NOT reduce the amount of hours authorized by the county social worker or how those hours are allocated.
Can the managed care plan change any of my recipient’s IHSS hours or services?
A managed care plan may authorize additional IHSS hours above a social worker’s assessment. If a plan decides to increase a recipient’s hours, it will be at the plan’s expense. Managed care plans may NOT reduce the amount of hours authorized by the county social worker.
Counties will continue their role in administering the IHSS program. They will contract with health plans for the provision of services, such as conducting assessments and determining IHSS hours for recipients. The structure of the Public Authority (PA) will change once the CCI is implemented in each county. Counties will have the choice of absorbing the role of the PA, continuing to fund a PA, or contracting out for PA services. In the meanwhile, local PAs will continue their administrative duty to run a provider registry, provide training, provide orientation for recipients and providers, and conduct criminal background checks for providers. However, a new Statewide Authority (California In-Home Supportive Services Authority) will become the new “employer of record” for IHSS providers once the CCI is fully implemented in a county. As the employer of record, the Statewide Authority will become responsible for collective bargaining with the unions who represent IHSS providers.
Will my recipient still have the right to appeal assessments and other IHSS actions under the CCI?
Yes. Recipients who receive IHSS services through managed care under the CCI will retain all their current appeal rights. This includes their ability to request a reassessment and their right to a fair hearing.
Does my recipient have to enroll in managed care?
If a recipient is a dual-eligible prior to enrollment, he or she can choose to not participate in the Dual Eligible Demonstration. However, even if they do not participate in the Demonstration, they will be required to enroll in managed care for their long term supports and services (IHSS).
If your recipient is a non-dual, he or she must enroll in managed care for long term supports and services (including IHSS).
Are any IHSS recipients exempt from the CCI
Yes. Recipients exempt from mandatory enrollment under CCI include recipients who have other health care coverage; recipients who receive services through the foster care program; recipients who are under the age of 21; recipients who are determined to have medically necessary reasons determined by the department; or those who are enrolled in home-and-community based waivers (not including CBAS, MSSP, or 1915 (c) waiver for persons with developmental disabilities). Please note: This is a general list of exemptions, we recommend that a recipient contact the Department of Health Care Services to confirm if they are exempt or not.
Why is the state making this change?
Caring for dual-eligibles has become very expensive. While dual-eligibles make up less than 10% of Medi-Cal beneficiaries, they account for almost 25% of the program’s costs. In Medicare, they make up 21% of the population but account for 36% of the total cost. These cost pressures have led the state and federal governments to consider new ways of providing care for this population. The state developed the Coordinated Care Initiative because it believes coordinating care through a managed care plan will save money and improve health outcomes.
How do we know if the CCI will be successful?
The Department of Health Care Services (DHCS) will be developing a “plan readiness” process to ensure that managed care plans are ready to provide services. Managed care plans will have to submit a plan readiness proposal to the Legislature before they can provide services under the CCI. A plan for monitoring and evaluation will also be created to ensure that managed care plans are meeting certain standards and performance measures. The Legislature will use this information in their decision to approve the expansion of the CCI into other counties and eventually statewide.
What could stop the CCI?
The State needs federal approval by February 1, 2013, to move forward with the CCI. Also, if the CCI is unable to create cost savings or if it compromises health outcomes for recipients, then the Director of Health Care Services, the Director of Finance, or the Legislature can terminate or modify the terms of the CCI.
How will the CCI impact IHSS?
IHSS will become a managed care benefit as a result of the CCI. The IHSS program itself will remain virtually the same for both recipients and providers. Program eligibility and administration will remain the same, but some things are subject to change over the course of the CCI. Please see our FAQ: Statewide Collective Bargaining handout for additional information about how the CCI will affect IHSS specifically.
For more information about the Coordinated Care Initiative or to give feedback to the state regarding the CCI, you can visit the state’s website – www.calduals.org.
Documents released by the California Department of Healthcare Services on August 24, 2012 offer an overview of the CCI, as set out in SB 1008 and SB 1036. They also highlight new information, including the following:
- Although analysis is still ongoing, about 560,000 dual eligible beneficiaries are now estimated to be eligible for passive enrollment into the duals demonstration. DHCS estimates between 60 percent and 80 percent of eligible beneficiaries to enroll in the eight selected counties (Alameda, San Mateo, Santa Clara, Los Angeles, Orange, San Diego, Riverside, & San Bernardino).
- Mandatory Medi-Cal managed care enrollment will apply to all 1915(c) and developmentally disabled waiver beneficiaries, except for those residing in intermediate care facilities for the developmentally disabled (ICF-DD). This is a clarification of the policy.
- Beneficiaries with HIV/AIDS will be included in mandatory Medi-Cal enrollment but may opt out in any month. This is designed as a beneficiary protection to maintain continuity of care.
Please click on the links below to find the following fact sheets:
- CCI Overview: A high-level explanation of the program.
- CCI Population Chart: Updated table showing groups included in and excluded from the demonstration and mandatory Medi-Cal enrollment
- CCI Population Summary: A summary of the participating populations CCI Beneficiary Protections: Given the importance of consumer protections, DHCS has summarized consumer protections included in the CCI.
- CCI Legislative Reporting Requirements: DHCS is dedicated to transparency in the development and implementation of the CCI. This fact sheet describes reporting requirements to the Legislature included in the CCI.
- CCI Stakeholder Engagement Requirements: DHCS is committed to ensuring consumers have a voice in CCI development and implementation. The CCI bills include stakeholder involvement requirements, as explained in this fact sheet.