A direct care worker sits beside an older woman on a sofa chair, showing her something on a tablet as they both look at each other and smile.

The California Health Care Foundation recently released a new explainer as part of the Aurrera Health Group-authored series, Medi-Cal Home and Community-Based Services: Understanding Overlaps and Gaps. The series, which was initially released in January 2025 describing one demonstration and two waiver programs and updated in April to add a fourth, describes similarities and differences across various California Medi-Cal programs designed to serve members with Home and Community-Based Services (HCBS) needs:

CalAIM (California Advancing and Innovating Medi-Cal) Community Supports and Enhanced Care Management
Assisted Living Waiver
Home and Community-Based Alternatives Waiver
California Community Transitions, and
Multipurpose Senior Services Program HCBS waiver (MSSP) - NEW!

The purpose of this series is to identify gaps and areas of overlap between the HCBS and CalAIM programs 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 explainers, 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. The latest installment in the series addresses MSSP.

Background

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. Medi-Cal members may also have access to CalAIM’s Enhanced Care Management (ECM).

HCBS and MSSP both 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. ECM provides care coordination and comprehensive care management in a similar manner to the care management offered under MSSP. However, not all MSSP recipients may qualify for ECM.

Key Findings

Transitioning MSSP waiver services to managed care through Community Supports and ECM could result in potential service gaps. The following is a summary of key findings from the MSSP explainer.

Community Supports and ECM provide some services that overlap with MSSP, but do not encompass the full range of supports that MSSP offers. MSSP offers key services that are not covered by ECM or Community Supports, such as adult day care, counseling and therapeutic services, and social supports. MCPs should ensure continuity of care during a potential transition of services to managed care, including adopting existing MSSP policies and procedures where possible. Likewise, MCPs should utilize the expertise of MSSP providers and their relationships with local vendors for essential services (e.g., home repairs and home-delivered meals) to ensure care needs are met.
Many MSSP providers do not have the necessary infrastructure and systems to comply with MCP data and reporting requirements. Most MSSP providers have not been able to invest in fully interoperable electronic health record (EHR) systems to manage participant data that may be required by MCPs. MCPs could work closely with MSSP providers to address challenges providers face in adapting to plan operations and consider regional collaboration among MCPs to standardize reporting requirements and reduce administrative burden. The Department of Health Care Services (DHCS) and CDA could also streamline requirements and provide resources and technical assistance to MSSP providers to strengthen their reporting capacity and infrastructure.
The previous carve-in of MSSP into managed care created confusion and implementation challenges for some MSSP providers and MCPs. If MCPs are to take on a greater role in delivering MSSP services, DHCS and CDA may consider applying lessons learned from the carve-in and subsequent carve-out of MSSP during California’s Coordinated Care Initiative when shaping policy. For example, standardizing MCP operations where possible and delineating provider and plan care management responsibilities could help ensure smoother implementation.

The full series comparing MSSP, 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 services and supports in California and help policymakers and stakeholders navigate the implementation of new initiatives and policy reforms.

This work highlighted considerations for strengthening managed care-provider relationships in HCBS delivery systems. These considerations may be increasingly relevant to states turning to managed care to address budget constraints while maximizing HCBS access. If you want to learn how Aurrera Health Group can assist your organization in informing the design of HCBS delivery system reform, please contact Kristal Vardaman.