In December 2021, CMS approved California’s request for two waivers to implement its ambitious California Advancing and Innovating Medi-Cal (“CalAIM”) program for Medi-Cal, the state’s Medicaid program. The state has touted CalAIM as “a long-term commitment to transform and strengthen Medi-Cal, offering Californians a more equitable, coordinated, and person-centered approach to maximizing their health and life trajectory.”
Medi-Cal plays a crucial role in providing mental health services in the state.In California, two entities are responsible for delivering Medi-Cal mental health services to enrollees: a Medi-Cal Health Plan (MCP) is responsible for providing non-specialty mental health services (NSMHS), and a County Mental Health Plan (MHP) is responsible for providing specialty mental health services (SMHS). In fiscal year 2019-2020, over 2 Million Californians – approximately six percent of the State’s population – received mental health services paid for by Medi-Cal.Thus, CalAIM has the potential to make great improvements in ensuring that Medi-Cal beneficiaries get the mental health health services they need.
While California’s divided mental health delivery system has developed over the last several decades as a way of ensuring that Medi-Cal beneficiaries have access to needed mental health services, it has also become a convoluted and complex system for beneficiaries to navigate to get their care, underscoring the need for proper oversight from state regulators. The waivers, as well as the state’s reprocurement of the MCP managed care contracts in 2024, presents an opportunity to do just that.
Federal regulations promulgated in 2016 to govern the delivery of services to people in Medicaid through managed care delivery systems prompted many important changes in California to modernize the way the state monitors MCPs and MHPs delivery of mental health services. For example, MHPs and MCPs are now required to meet specific benchmarks for network adequacy (including timely access to services) and provide a more robust notice and appeals process for enrollees. While these requirements have been a step in the right direction to increase accountability of the plans that deliver mental health services in Medi-Cal, much more is needed to ensure that beneficiaries have access to the services they need.
With CalAIM and the newly approved waiver and managed care plan contract requirements to implement it, California now has an important opportunity to go even further to ensure that it is monitoring these plans and enforcing their compliance with state and federal rules aimed at ensuring that Medi-Cal beneficiaries have access to needed mental health services.
The waiver terms and conditions set forth expectations that the state must meet throughout the five-year term of the waiver. The terms and conditions specifically require California to publicly develop and post a county MHP dashboard that is “based on performance data of each county and/or county mental health plan included in the annual EQR technical report and/or other appropriate resources.” The dashboard must present an “easily understandable summary of quality, access, timeliness, and translation/interpretation capabilities regarding the performance of each participating mental health plan.” The dashboard data must be updated no less than annually. This condition of the waiver is in line with one of the state’s stated priorities for its CalAIM initiative to transform and strengthen Medi-Cal: “Improve quality outcomes, reduce health disparities, and transform the delivery system through value‑based initiatives, modernization, and payment reform.”
The dashboard requirement has the potential to shed significantly more sunlight on how Medi-Cal delivers SMHS to beneficiaries, and how County MHPs are performing and complying with their obligations under the law and the waiver. While California already publishes a variety of reports on SMHS, the dashboard requirement has the potential to bring together this information in a way that is more accessible and meaningful to ensure that beneficiaries, providers, advocates, and other stakeholders can see how their County MHP is performing and what access barriers to SMHS exist in their county.
The waiver also requires the state to arrange for an independent evaluation or assessment of access to care in the Specialty Mental Health program, and submit the findings ninety (90) days after the end of the second year of the waiver. Such an assessment is also critical to determine if and how the MHPs are meeting the needs of enrollees as a result of the early implementation period of the waiver.
The new MCP contract request for proposals also includes specific requirements to provide timely NSMHS for enrollees consistent with the CalAIM “no wrong door” policies even prior to a determination of a diagnosis, or when NSMHS were not included in a member/enrollee’s individual treatment plan. Plans must also provide NSMHS concurrently with SMHS if those services are not duplicative and coordinated with the MHP. Additionally, MCPs will need to provide “closed loop referrals” to the SMHS delivery system to ensure services are actually received by a MHP provider, will be required to use standardized transition tools for such referrals, and will be obligated to provide Enhanced Care Management to target populations that include children with serious emotional disturbances and adults with serious mental illness.
While California has recently started publishing data about the number of MCP enrollees in each plan accessing NSMHS per year, additional data regarding what specific services beneficiaries are utilizing, is still needed, and the data should be presented in a more accessible and user-friendly manner. The managed care performance dashboards do not provide that level of detail, but only provide summary information about NSMHS use statewide.
But simply improving the reporting of existing data and including additional contract requirements is not enough. To make the promises of CalAIM real, California must do more to monitor County MHPs and MCPs and publicly report on their performance and how access and outcomes have improved. Furthermore, unlike MCPs and Drug Medi-Cal Organized Delivery Systems, which go through annual audits by the state, County MHPs are only subject to audits once every three years. Moreover, there is often a delay of several months between those reviews, and the state’s posting of corrective action plans. In addition, since MHPs are only reviewed every three years, there is significant lag between any findings of deficiencies that result in a corrective action plan, and reporting on whether the plan has complied with the terms of that corrective action plan and corrected the deficiency.
To truly meet the goals of CalAIM, California must move toward an annual audit of all plans, including County MHPs, and provide more timely reporting on deficiencies identified, corrective action agreed to, and whether the corrective action has been implemented and successful. This information should be incorporated into the SMHS dashboard to ensure that stakeholders can evaluate the performance of County MHPs, and ultimately, identify where improvements are needed to ensure that Medi-Cal beneficiaries have access to the SMHS they need. Similarly, MCPs should be evaluated to ensure compliance with their legal and contractual requirements, including timely access to, and the provision of, NSMHS, as well as compliance with their care management responsibilities to ensure enrollees can seamlessly receive mental health services from both plans when enrollees need both NSMHS an SMHS at the same time and are referred or transitioned to the SMHS delivery system.
California has articulated a bold vision for improving access to mental health services in Medi-Cal. Now it must take steps to back up that vision with the action needed to make mental health access real for Medi-Cal beneficiaries.