California Health Care Foundation recently released the Aurrera Health Group-authored series, Medi-Cal Home and Community-Based Services: Understanding Overlaps and Gaps. The series describes similarities and differences between CalAIM (California Advancing and Innovating Medi-Cal) Community Supports and two Medi-Cal home and community-based services (HCBS) waivers – the Assisted Living Waiver (ALW) and Home and Community-Based Alternatives Waiver (HCBA)—and one HCBS demonstration program, California Community Transitions (CCT). The explainers are intended to offer background information and considerations for policymakers and HCBS stakeholders as California considers increasing the role of managed care in HCBS as part of state’s goal for Managed Long-Term Services and Supports (MLTSS).

Background

HCBS allow older adults and people with disabilities to live in their own home or community, rather than a nursing facility or institution. These services and supports can include case management, community transition services, personal care and homemaker services, and home modifications.

California, like many other states, uses waiver authorities such as the Section 1915(c) HCBS waiver, or demonstration programs to provide HCBS to eligible Medi-Cal members. As part of CalAIM and MLTSS, the state is aiming to integrate certain HCBS programs into its managed care delivery system. Currently, Medi-Cal managed care plans (MCPs) can choose to provide one or more of 14 Community Supports to address members’ health-related social needs, including community transition services, personal and homemaker services, and home modifications. In some cases, these Community Supports address similar needs to individuals participating in an HCBS waiver and/or demonstration programs.

The purpose of this series is to identify gaps and areas of overlap between current HCBS waiver and demonstration programs and Community Supports to help policymakers ensure that any integration of HCBS into managed care does not create disparities in access and care for older adults and people with disabilities. To produce the report, Aurrera Health reviewed literature and state documents and interviewed HCBS providers to identify potential challenges and opportunities that policymakers and stakeholders can consider as planning for the future of HCBS advances.

Key Findings

The following is a summary of key findings from the series.

Community Supports have a lot of overlap with HCBS waiver and demonstration services, but there are critical services that are not included in Community Supports offerings. The ALW is most similar to the Nursing Facility Transition/Diversion to Assisted Living Facilities Community Support, while the CCT demonstration most closely aligns with the Community Transition Services/Nursing Facility Transition to Home and Housing Bundle Community Supports. However, while there are some similarities between HCBA waiver services and Community Supports, several medically critical services are not available through Community Supports. These services include continuous nursing and supportive services and private duty nursing. As California’s Department of Health Care Services (DHCS) considers which waivers or demonstration programs will transition to managed care, DHCS will need to determine which services MCPs must cover to ensure access for all Medi-Cal members. MCPs should work with waiver providers to offer the same bundle of services to help minimize any gap in critical care for HCBS populations.
The availability of HCBS providers varies across the state, as many struggle with a shortage of direct care workers and have limited capacity to take on MCP processes, including contracting and billing. The state could work with MCPs to offer incentives for providers to support their participation and streamline MCP processes thereby reducing administrative burden for providers. HCBS providers will need financial and technical assistance to scale up their operations and invest in their workforce. MCPs and HCBS providers should partner and work collaboratively to ensure there is an adequate network of providers for Medi-Cal members.
MCPs lack experience managing HCBS, which often includes intensive and ongoing home and community-based nursing care and other home-based supportive services. MCPs will need education on the role HCBS providers play in supporting nursing home residents to receive the care they need to live safely at home or in the community. In recent years, DHCS has transitioned long-term care institutional benefits to managed care; if HCBS shifts to MLTSS, DHCS could follow the lead of other states that incentivize MCPs to transition members out of institutions to a more cost-effective, lower acuity setting. MCPs can work with waiver agencies and other HCBS providers to build relationships with HCBS providers and enhance MCPs’ understanding of the HCBS delivery model.

The full series comparing ALW, CCT and HCBA with Community Supports offered through managed care, including reference tables and member case studies, is available on the CHCF website. Aurrera Health is proud to support CHCF’s work to improve long-term care in California and help policymakers and stakeholders navigate the implementation of new initiatives and policy reforms.

If you want to learn how Aurrera Health Group can assist your organization in advancing policies and informing stakeholder discussions regarding HCBS and delivery system reform, please contact Kristal Vardaman.