Many Medi-Cal Changes Underway: An Overview and the Impact on Children

Senior Policy Research Associate

The State of California has embarked on multiple efforts over the last few years to transform the way health care is delivered in the Medi-Cal program.

These efforts illustrate Governor Newsom’s larger vision for reform, including those that hold promise to improve outcomes for children. California Advancing and Innovating Medi-Cal (CalAIM), managed care plan reprocurement, the Comprehensive Quality Strategy, and the Children and Youth Behavioral Health Initiative are all examples of these efforts. Details on each of these areas of work have been recently released that indicate how the needs of children and their families are being considered in different ways.

This blog outlines new Medi-Cal benefits and initiatives currently being implemented by the California Health and Human Services Agency (CalHHS) and the Department of Health Care Services (DHCS). It also reviews how children and their families may be impacted.

CalAIM. CalAIM is a long-term plan to transform Medi-Cal. The stated goal is to create a health care delivery system that is more equitable, coordinated, and person-centered. CalAIM’s first reforms started in January and additional changes will continue through 2027.

While CalAIM is intended to help all Medi-Cal enrollees, many of the reforms focus on improving care for people with complex needs, like individuals experiencing homelessness and those exiting the criminal justice system. Among children, focus populations include those with complex medical conditions or who are in foster care. Recently, DHCS convened a CalAIM Children’s Advisory Group, signaling an opening to consider the specific ways that CalAIM may lead to innovation for all children.

There are many aspects of CalAIM including Population Health Management (PHM) and Enhanced Care Management (ECM). PHM will require Medi-Cal managed care plans starting in 2023 to assess and address the needs of members with tailored interventions focused on wellness and prevention. ECM is a new Medi-Cal benefit and a subset of PHM for certain populations with complex clinical and non-clinical needs. It will provide community-based, interdisciplinary, high-touch, and person-centered service coordination for members. ECM will go live for certain child populations in July 2023.

Comprehensive Quality Strategy (CQS). The CQS is a strategic planning document to improve the quality and equity of Medi-Cal health care. Every state Medicaid agency is required by the Federal government to have a quality strategy, and the Department of Health Care Services submitted a final version to the Centers for Medicare & Medicaid Services (CMS) in February. The CQS takes a multiyear view of quality to address individual and system-level drivers of health.

The CQS has three clinical focus areas: children’s preventive care, maternity care and birth equity, and behavioral health integration. It describes how these focus areas will be embedded into a health equity roadmap, payment reform, and quality metrics. Part of these metrics is the Department of Health Care Services’ Bold Goals: 50x2025. These are planned improvements in Medi-Cal, including closing racial/ethnic disparities in well-child visits and immunizations by 50% and ensuring all managed care plans exceed the 50th percentile for children’s preventive care measures.

Reprocurement. For the first time since the early 1990s, the State is rewriting the contracts that dictate managed care plans’ responsibilities and reprocuring which commercial managed care plans provide Medi-Cal services. Ninety percent of all children in Medi-Cal – or about 1.1 million children under age five – receive their care from managed care plans. Therefore, the contract details and the effectiveness of state oversight dramatically impact the experience and health outcomes for children enrolled in Medi-Cal.

The DHCS Request for Proposals includes specific provisions to improve children’s services. For example, managed care plans will now need to ensure outreach to families whose children have not received preventive services, and provide annual training to providers on required preventive care. DHCS will require more from managed care plans in the area of community engagement and community investment. For example, managed care plans must have MOUs to coordinate programs and services for members with community partners such as First 5 commissions. Managed care plans must respond to the RFP by April 11, 2022, and new contracts will go live in 2024. The RFP also includes new requirements to improve transparency, health care quality, equity, and access.

Dyadic Care Benefit. Starting January 2023, Medi-Cal will cover dyadic care, integrated physical and behavioral health screenings and services, for the whole family. Dyadic care provides simultaneous treatment for the child and parent/caregiver during a child’s medical visit, under the child’s Medi-Cal coverage. These services will include screening, assessment, evaluation, and case management services, in addition to integrated behavioral health services. This benefit will allow clinics to bill for the implementation of models such as Healthy Steps.

Children and Youth Behavioral Health Initiative. The 2021-22 State budget created the Children and Youth Behavioral Health Initiative, investing $4.4 billion in services to enhance, expand, and redesign the behavioral health systems for children and youth ages 0-25. Areas of focus include increasing workforce capacity, building an accessible behavioral health services platform, and increasing school-based and school-linked behavioral health services. The state’s new Medi-Cal dyadic services benefit is part of this effort. While that benefit is groundbreaking and a critical policy change for serving the needs of children and families, there are other opportunities within the CYBHI to ensure young children under age five are provided a strong ecosystem of social-emotional care, including services provided in the home and community.

Family Therapy Benefit. In summer 2020, the Department of Health Care Services clarified that family therapy is a covered Medi-Cal benefit, including for children who are at risk for behavioral health concerns but do not have a mental health diagnosis. In family therapy, at least two family members receive therapy together provided by a mental health provider. Children can receive up to five family therapy sessions before a mental health diagnosis is required. In addition, children with risk factors for mental health disorders or parents/caregivers with related risk factors are eligible for family therapy without the visit limitation.

Community Health Workers. Community Health Worker (CHW) services will become a Medi-Cal benefit starting July 1, 2022. CHWs provide preventive health services such as health education and navigation. CHWs are trusted members of their community who help address health and health-related social needs. Details on this benefit are still being developed, but CHWs should be able to provide services to children and their families.

The emphasis on children’s preventive care in these efforts represents a significant shift in how the State approaches reforms in the Medi-Cal program. State reforms and innovation in Medi-Cal have historically focused on the highest utilizing and highest cost individuals. As a generally healthy and low-cost population, the needs of young children have flown under the radar which has come at a cost. In 2019 in Medi-Cal managed care, only 26% of children received 6 of the 8 recommended well-child visits in their first 15 months of life, and only 25% of children received the recommended developmental screenings in the first three years of life.

An increased commitment to children is most clearly illustrated in the recently released policy agenda for children and families enrolled in Medi-Cal. Medi-Cal’s Strategy to Support Health and Opportunity for Children and Families is guided by the principles of addressing health disparities and implementing a whole-child, preventive approach informed by families. It elevates the need to provide family-based care, including increasing access to programs like home visiting, and to improve pediatric preventive care. An important announcement in this document is the planned hiring of a child health champion, the Assistant Deputy Director in the Quality and Population Health Management Division. This person will be responsible for engaging stakeholders on issues related to Medi-Cal enrolled children and their families. Staffing this position will be a crucial next step in defining additional implementation details related to children for all that is outlined above.

Although the implementation of the vision in this strategy will take many years to implement, these new efforts and benefits are historic and follow many years of First 5 and partner advocacy for improved systems and whole-child, whole-family approaches. There is much work ahead, and the State, managed care plans and providers will need support, collaboration, and dedication to realize the promises these initiatives represent.