California – Medical Homes
California is developing medical home policies as part of comprehensive delivery reform strategies in a Section 1115 Medicaid waiver renewed in November 2010. There are three key initiatives in California’s Bridge to Reform, and each of these initiatives have included language that has implications for the development of medical homes for Californians.
1. Low Income Health Program:
California’s Section 1115 Medicaid waiver renewal expands access to county-based Low Income Health Programs for low-income adults (aged 19-64) who do not qualify for Medi-Cal (Medicaid). Also known as the Health Care Coverage Initiative, as many as 500,000 low-income uninsured residents will enroll in a medical home under this waiver.
At a minimum, Low Income Health Program medical homes must provide:
- a primary health care contact;
- an intake assessment;
- care coordination, care management, case management, and transitions among levels of care;
- use of clinical guidelines and other evidence-based medicine when applicable, focused on continuous improvement in quality of care;
- timely access to qualified health care interpretation as needed and as appropriate; and
- health information, education, and support in a culturally competent manner.
2. Delivery System Reform Incentive Pool
As part of the Section 1115 waiver, the federal government is providing up to $3.3 billion in matching funds over five years for a Delivery System Reform Incentive Pool (DSRIP). As part of this incentive pool, county and state hospitals will have an opportunity to receive funds for a number of initiatives, including investments in new and innovative care models such as medical homes. Specific payments will be tied to meeting certain process measures, including patient enrollment into medical homes.
3. Mandatory Enrollment of Seniors and People with Disabilities (SPDs) into Managed Care Plans:
The seniors and people with disabilities (SPD) population (380,000 individuals) and 1 million duals (eligible for both Medicaid and Medicare) are expected to receive medical home services before the waiver expires in 2015.
Furthermore, California’s Section 1115 Medicaid waiver allows the state to test the following delivery systems for children with special health care needs within the California Children’s Services program:
- Accountable Care Organizations;
- Enhanced Primary Care Case Management;
- Managed Care; and
- Specialty Health Plans.
In October 2011, the California Department of Health Care Services announced five regional pilot programs beginning in 2012 to provide patient-centered coordinated care. Three of the five pilot programs explicitly reference providing medical homes to eligible children.
For additional information on the Bridge to Health Reform waiver, please see the following resources:
In addition, California’s Public Employees’ Retirement System (CalPERS) is pursuing an accountable care organization (ACO) pilot with Blue Shield of California in its role as a health care purchaser. To learn more about accountable care activity in California, including this pilot, visit the California page of NASHP’s State Accountable Care Activity Map.
Federal Support: California has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
California has also received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”
Last Updated: April 2014