SEPTEMBER 2023 Issue Brief CalAIM Explained for Assisted Living Community Operators C alifornia's assisted living and adult residential care served in less restrictive environments like assisted liv- communities are beginning to partner with Medi- ing or adult residential care communities.3 Cal managed care plans as part of implementing A Opening up new market opportunities, which could CalAIM (California Advancing and Innovating Medi-Cal), boost occupancy levels in competitive markets and which started in January 2022. Although CalAIM seeks to support stabilization of occupancy in older properties. benefit all Medi-Cal enrollees, this brief focuses on its pro- visions for older adults, explaining how it aims to increase A Diversifying the payer mix, with the potential to access and to improve the delivery of long-term services strengthen financial stability. and supports. Under CalAIM, assisted living and adult A Collaborating with community-based agencies to residential care operators can tap into the Enhanced Care supplement core residential services that could result Management (ECM) benefits and optional Community in better outcomes and increased resident retention. Supports services through contracts with managed care plans (MCPs).1 This creates new opportunities outside of A Negotiating rates that better align with regional mar- the existing Assisted Living Waiver to expand access to ket demands and individual care needs. assisted living and adult residential communities and to enhance the quality of life for Medi-Cal enrollees.2 However, there are considerations and challenges that assisted living operators must pay attention to when entering into a contract with an MCP. Participating in Opportunities and the delivery system through such a contract may require changes to internal processes and systems. Some con- Considerations siderations include these: As with any new initiative, there are opportunities, challenges, and unknowns with this fledgling partner- A Navigating more oversight, reporting, and infrastruc- ship between assisted living and adult residential care ture requirements to meet MCPs' approval and billing operators (referred to throughout this brief as "licensed standards. operators") and MCPs. Licensed operators will have to A Changing workflows to meet stricter regulatory determine if contracting with MCPs to serve eligible requirements related to comprehensive assessments, members through CalAIM aligns with the organization's care coordination and documentation, and updated business strategy. This begins with analyzing internal pro- residency agreements and house rules. cesses and systems and assessing external requirements and market demands. A Managing operational uncertainties related to new types of contractual agreements around eligibility, The potential benefits to licensed operators of engaging admission, and retention requirements for residents, with MCPs under CalAIM include these: including potential regulatory restraints around Supplemental Security Income recipients. A Increasing access to assisted living and adult resi- A Addressing MCP-specific invoicing, documentation, dential programs for Medi-Cal enrollees. Estimates coding, and prior authorization requirements before suggest that a significant percentage of people living approving and paying out claims.4 Also, residents are in skilled nursing facilities, at least 9%, could be better billed separately for room and board, which creates an providers offering care coordination. These services must additional layer of operational complexity. be provided under ECM: A Negotiating rates with MCPs, which will require that A Outreach and Engagement operations and marketing teams can clearly articulate the care needs and associated costs for providing care $ Assisted living operators could either serve as ECM to MCP enrollees. providers themselves or collaborate with others to identify and engage people in nursing facilities who A Planning for possible service disruptions due to poten- could thrive in an assisted living community, or to tial changes in MCP service areas.5 In January 2024, get referrals from people in the community at risk MCPs will enter into new contracts with California's of institutionalization. Department of Health Care Services, and some will leave service areas, enter them, or both. In addition, A Comprehensive Assessment and Care Management each year MCPs can choose to stop covering optional Plan Community Supports benefits, which may require A Enhanced Coordination of Care renegotiating payments or relocating residents. A Health Promotion CalAIM Overview A Comprehensive Transitional Care The primary ways that assisted living operators could A Member and Family Supports partner with MCPs are through ECM and Community A Coordination of and Referral to Community and Social Supports, two key initiatives within CalAIM with the Support Services potential to improve care for older adults. The ECM policy guide provides more detail that may ECM is a new Medi-Cal managed care benefit that pro- help clarify this benefit.6 vides intensive coordination of health and health-related services to address the clinical and nonclinical needs of Community Supports are also provided by MCPs as alter- MCP enrollees in nine "populations of focus." The three natives to traditional medical services or settings, and are relevant ECM populations for assisted living operators optional for MCPs to offer. These include 14 services that include these: address challenges, including social drivers of health, that contribute to unnecessary and costly delivery of care. A A Adults living in the community and at risk for long- key goal of Community Supports is to let enrollees obtain term care institutionalization care in the least restrictive setting possible and to remain A Adult nursing facility residents transitioning to the in community settings, as appropriate. community Of the Community Supports available, two have the A Adults at risk for avoidable hospitalization or emer- most potential to support Medi-Cal enrollees who qual- gency department utilization. This includes those who ify for assisted living and residential care: Skilled Nursing meet one or both of these conditions: Transition/Diversion to Assisted Living and Respite Care. $ Five or more emergency room visits in a six-month All Community Supports have specific qualification crite- period that could have been avoided, or ria that can be found in the Community Supports policy guide.7 $ Three or more unplanned hospital and/or short- term skilled nursing facility stays in a six-month CalAIM encourages - but does not require - MCPs period to provide these supports in service areas where they are needed. MCPs choose which Community Supports Under ECM, a licensed operator could either provide will be offered by service area, and these elections are care coordination or develop relationships with ECM updated every six months. In a given county, each MCP CalAIM Explained for Assisted Living Community Operators www.chcf.org 2 can add new Community Supports every six months A Services provided by the day or overnight on a short- and can stop offering a specific Community Support term basis because of the absence of, or need for once a year. At the time of publication, 74 plans in 39 relief for, those normally providing the care. of California's 58 counties were offering Skilled Nursing A Services that attend to the managed care plan mem- Transition/Diversion, and 97 plans in 57 counties were ber's basic self-help needs and other activities of daily offering Respite Care.8 living, including interaction, socialization, and continu- ation of usual daily routines ordinarily performed by Skilled Nursing Transition/Diversion to those who normally care for and/or supervise them. Assisted Living Some licensed operators are also considering offer- The most notable opportunity within Community Support ing Short-Term Post-Hospitalization and Recuperative services for assisted living operators is Skilled Nursing Care (Medical Respite), two Community Supports ser- Transition/Diversion. Medi-Cal MCP enrollees residing in vices especially geared toward people experiencing a skilled nursing facility or at home, but at a high risk of homelessness. needing skilled nursing care, may be eligible to choose to live in a contracted assisted living community. This service is designed to prevent unnecessary institutional- ization and promotes supportive person-centered living. CalAIM and the Assisted Participating MCPs negotiate rates with licensed opera- Living Waiver tors based on individual needs and market demands CalAIM's ECM and Community Supports and the Assisted in the region. The state provided nonbinding pricing Living Waiver (ALW) program are separate programs. guidance for this and other Community Supports.9 This CalAIM is a statewide reform of the Medi-Cal program guidance offers information on potential rates for MCPs and expands access to assisted living and adult residen- and providers to consider for the transition itself and for tial care through MCPs. The MCPs administer optional ongoing services. The guidance clarifies that the two ser- services known as Community Supports and a benefit vices could be combined into a single rate, and while called Enhanced Care Management. The ALW is a distinct it prices ongoing services hourly, it also references the waiver program that has limited capacity and geographic per diem tiers of the Assisted Living Waiver. Participating coverage and remains outside of managed care. Unlike licensed operators are reimbursed for providing care and the ALW program's statewide reimbursement tiers set by support with personal care, medication oversight, and the Department of Health Care Services, reimbursement observation by round-the-clock on-site direct care staff. for services under CalAIM is negotiated locally. The resident is responsible for the payment of room and board (typically using SSI/SSDI income), while the MCP picks up the cost of wraparound services that support Next Steps help with activities of daily living. Assisted living and residential care operators who part- ner with MCPs can increase Medi-Cal enrollees' access to appropriate care and services, which could improve their Respite Services quality of life. In addition, operators can diversify their Respite services are provided to caregivers of MCP mem- services and payer mix by partnering with MCPs. When bers who require intermittent temporary supervision. The approaching managed care plans, assisted living opera- services are provided short term to relieve caregivers and tors should be prepared to: are nonmedical. Licensed operators may contract with MCPs to offer short-term respite services. A Demonstrate the ability to meet the MCP members' needs and preferences, including providing support Respite services offered by licensed operators could for activities of daily living and independent activities include these: of daily living based on individual needs, medication CalAIM Explained for Assisted Living Community Operators www.chcf.org 3 management, person-centered assessments, service About the Authors plans, and oversight. Paula Hertel, MSW, is founder of Senior Living Consult, specializing in strategic, operational, and marketing A Use effective documentation and interventions to services to senior living organizations. Additionally, she reduce negative outcomes (e.g., fall mitigation plans, advises ancillary service providers, helping to identify hospital readmission mitigation, behavior manage- and address emerging needs and opportunities. Hertel ment programs, medication management protocols, also serves as a board member and education cochair for care coordination and quality improvement programs). the California Assisted Living Association. A Provide accurate and timely billing based on eligibility criteria. Athena Chapman, MPP, is president and Elizabeth Evenson is associate vice president at Chapman A Support care coordination through regular partner Consulting, which provides strategic planning, meeting meetings focused on key quality indicators such as facilitation, organizational support, market research, and changes in condition, incident reviews, demographic regulatory and statutory analysis to organizations in the information, and move-in/move-out data. health care field. Finally, assisted living and residential care operators About the Foundation should carefully consider how contracting with MCPs The California Health Care Foundation is an independent, to provide services to Medi-Cal enrollees under CalAIM nonprofit philanthropy that works to improve the health aligns with their organization's mission, strategic focus, care system so that all Californians have the care they and long-term sustainability. need. We focus especially on making sure the system works for Californians with low incomes and for commu- nities who have traditionally faced the greatest barriers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improvement in a com- plex system. For more information, visit www.chcf.org. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemak- ers to create a more responsive, patient-centered health care system. CalAIM Explained for Assisted Living Community Operators www.chcf.org 4 Endnotes 1. "CalAIM Enhanced Care Management and Community Supports," Dept. of Health Care Services (DHCS), accessed August 2, 2023. 2. "Assisted Living Waiver," DHCS, accessed August 10, 2023. 3. Jesse Bedayn, "No Way Out: How the Poor Get Stranded in California Nursing Homes," CalMatters, January 20, 2022. 4. CalAIM Data Guidance: Billing and Invoicing Between ECM/ Community Supports Providers and MCPs (PDF), DHCS, updated April 2023; and Enhanced Care Management and Community Supports Coding Options (PDF), DHCS, updated March 2022. 5. Medi-Cal Managed Care Plans by County (as of 2023 and 2024) (PDF), DHCS, April 2023. 6. CalAIM Enhanced Care Management Policy Guide (PDF), DHCS, updated July 2023. 7. Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide (PDF), DHCS, updated July 2023. 8. CalAIM Community Supports - Managed Care Plan Elections (PDF), DHCS, updated June 2023. 9. Non-Binding ILOS Pricing Guidance (PDF), DHCS, updated August 5, 2021. CalAIM Explained for Assisted Living Community Operators www.chcf.org 5