State of California and Cal AIM Presentation Imperial

State of California and Cal. AIM Presentation Imperial Health Authority March 9, 2020 Prepared by Pacific Health Consulting

STATE LEADERSHIP Governor Newsom focused on HEALTH Leadership in Health Richard Figueroa, Cabinet Secretary, Health Nadine Burke Harris, MD, Surgeon General Mark Ghaly, MD, Secretary, HHS Agency

State Landscape Cont. Governor Newsom Agenda Universal coverage – slow but sure – starting with undocumented adults 19 -26 and over 65 Coverage mandate penalty for California - encourages enrollment Increased subsidies for Covered California enrollees – enrollment up 40% Health Care for All Californians Commission Housing and Homelessness as a health issue

State Landscape Cont. Executive Order carving out retail medications from Health Plans back to the state – still moving forward Impacts 340 b payments to safety net providers Proposition 56 payments through health plans to providers to increase Medi-Cal payments Focus on children – new Pediatric Preventative Services quality measures and accountability Childhood trauma and developmental screening MFAR – Medicaid Fiscal Accountability Regulations Reprocurement of commercial health plans Cal. AIM

REPROCUREMENT SCHEDULE for Commerical Plans • • • Stakeholder feedback webinar in April 2020 30 -day feedback/comment period after webin Draft RFP will be released by December 202 Final RFP by June 2021 Final RFP responses by August 2021 Procurement process finalized by December 2021

IMPERIAL HEALTH AUTHORITY DECISIONS re: REPROCUREMENT • Discussions with HHS Agency and DHCS re: process • Suggestions to HHS/DHCS about criteria for commercial plan • Decision about RFP for local health plan • Timeline for local health plan decisions • Role of Health Authority in decisionmaking

Cal. AIM GOALS 1. Identify and manage member risk and need through Whole Person Care/Health Home approaches and addressing Social Determinants of Health 2. Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility 3. Improve quality outcomes and drive delivery system transformation through

Cal. AIM “Core” Initiatives EVOLVING 20+ initiatives COMBINING 1115 WAIVER, 1915 b WAIVER, STATE PLAN AMENDMENTS FOCUS ON HIGH COST, COMPLEX PATIENTS ON MEDI-CAL • Population Health Management for all health plan members • Expanded Focus on Complex Care and Social Determinants of Health • Enhanced Care Management and “In Lieu of Services” • Big Changes in Plan Responsibilities for Benefits/Populations • Carve in Long Term Care and organ transplants, Carve out Rx, D-SNP, rate changes • Emphasis on “Integration” – Physical, Behavioral Health, Oral Health • Full Integration Plans (selected plans), , MH IMD SMI Waiver, BH Payment • Uncertainty about final proposals and financing

MANAGE MEMBER RISK IMPROVE OUTCOMES • Patient Centered Population Health Strategy • Enhanced Care Management Benefit • In Lieu of Services • Shared Risk, Shared Savings and Incentives • Dental Benefits

CONSISTENT SEAMLESS SYSTEM • Standardized Benefit Statewide • Mandatory Enrollment in Managed Care • Regional Rates for Managed Care • Long Term Services and Supports and DSNP • NCQA accreditation for Medi-Cal Managed Care Plans • Enhanced County Oversight and Monitoring • Behavioral Health Reform

FOCUS ON FUTURE • Full Integration Pilots • IMD/SED Waiver • Long Term Plan for Foster Care

Enhanced Care Management + ILOS Timeline Proposed statewide implementation of ECM benefit by 1/2021 for mandated populations and 1/2023 for individuals transitioning from incarceration Key Details ECM + ILOS would be a new statewide benefit replacing WPC and HH addressing holistic, interdisciplinary approach to non-clinical and clinical needs of target populations. By 7/2020, plans must submit transition plans for establishing ECM model of care and efforts to involve WPC and HH provider types. Funding level unknown, WPC programs not fully funded ILOS benefit for all members that meet medical necessity requirements

Enhanced Care Management + ILOS cont’d ECM Mandatory Populations High utilizers with frequent ER visits and admissions. Individuals at risk for institutionalization with SMI, children with SED/SUD and co-occurring conditions. Individuals in the community at risk for SNF admission SNF residents wanting and able to transition to community settings Children with complex care needs Individuals experiencing chronic homelessness or at risk of homelessness

ILOS MENU OF OPTIONS IN LIEU OF SERVICES 1. Housing transition navigation services 8. Nursing Facility transition, diversion 2. Housing Deposits 9. Nursing facility transition to home 3. Housing Tenancy and Sustaining Services 10. Personal care beyond IHSS and homemaker services 4. Short-term posthospitalization housing 11. Environmental accessibility adaptations (home modifications) 5. Recuperative Care 6. Respite 7. Day habilitation programs 12. Meals, medically tailored meals 13. Sobering centers

2019 October 29, 2019 • Cal. AIM Proposal Released November 2019 – February 2020 • Stakeholder Engagement

2020 January 1, 2020 -December 31, 2020 • Develop REGIONAL RATE-SETTING Develop shared savings/risk and plan incentives July 1, 2020 • Submit plan for transitioning existing programs (WPC, HHP, TCM) into ECM and ILOS • Transition PRIME to managed care directed payment under QIP

2021 PHM implementation* • ECM and ILOS model of care submission (transition WPC, HHP) • LTC and TRANSPLANTS carved in, MSSP carved out • PHARMACY CARVE-OUT implementation • PLAN INCENTIVES and blended LTC/SPD rate implementation • Mandatory managed care enrollment non-duals • Regional Rates Phase I • Implement shared savings/risk model • Adopt new definition of MEDICAL NECESSITY for SMHS •

2023 January 1, 2023 • Full implementation of REGIONAL RATES (earliest implementation date) • Mandatory enrollment for DUALS • All MMCP to operate D-SNPs • ECM model of care proposal for reentry population • Continue tiered, retrospective shared savings/risk model • Continue full integration implementation readiness activities and planning

2024 January 1, 2024 • Full integration pilots GO-LIVE date • Implementation prospective shared savings/risk and plan incentives methodologies

2025 January 1, 2025 • NCQA ACCREDITITATION for plans and delegates by 2025

KEY TAKE-AWAYS • These are just proposals. . . 2020 will reveal details. • Health Authority needs to focus on • Cal. AIM • Reprocurement • Our current priorities align with the goals: • Identify and manage risk • Improve quality outcomes