Medi-Cal: enhanced care management and community supports.

Section 3 (new Section 14184.209) is entirely removed, which would have required the department to continue convening the CalAIM Implementation Advisory Group until January 1, 2032.

The ECM target population list changed from 'include, but shall not be limited to' (open-ended) to 'include the following' (closed list), meaning only the seven listed populations qualify for ECM and the department can no longer add additional populations without new legislation.

Removed the reference to the Family Mosaic Project from the list of programs that exclude a beneficiary from ECM eligibility, and removed the Cal MediConnect demonstration reference from the dual eligible beneficiary exception.

Removed the requirement for the department to produce model managed care coverage standards by July 1, 2027 for plan years beginning January 1, 2028, along with the requirement that plans explain any deviation from those standards.

Removed the requirement for Medi-Cal managed care plans to track and report to the department the number and percentage of providers that are nonprofit community providers, and for the department to publish an annual report on that data.

The public comment period for proposed community supports policy changes was shortened from a minimum of one month to a minimum of two weeks before finalizing changes.

Changed the technical assistance obligation: previously plans were required to 'continue to provide technical assistance to providers of these services,' now plans must 'educate its in-network community support providers on policies, instructions, and requirements to maintain compliance with Medi-Cal policies.'

Target populations for ECM are no longer open-ended ('include, but shall not be limited to'). The new language limits them to those 'consistent with the department's eligibility criteria, and to the extent approved in the CalAIM Terms and Conditions,' making federal approval a gating requirement.

New requirement that each Medi-Cal managed care plan must adopt community supports policies consistent with department guidance and Section 438.3(e) of Title 42 CFR, creating a direct compliance obligation on plans.

New requirement that Medi-Cal managed care plans must educate their in-network community support providers on policies, instructions, and requirements to maintain compliance with Medi-Cal policies for effective delivery of community support services.

New requirement that the department's March 31, 2029 legislative report on transitioning community supports to mandatory Medi-Cal benefits must draw from the final community supports evaluation prepared under the CalAIM Special Terms and Conditions and submitted to CMS by December 31, 2028.

The public comment period for proposed policy changes to community supports is reduced from a minimum of one month to a minimum of two weeks. The old requirement for updates to commence on January 1 or July 1 is retained, and the six-month advance release requirement is kept.

The quarterly website publication requirement for ECM and community supports utilization data is now explicitly stated as 'to the extent feasible' and becomes inoperative on January 1, 2032 (previously stated as 'through December 31, 2031').

The department's obligation regarding model coverage standards is restructured: instead of producing a one-time set of model standards by July 1, 2027, the department must now 'publish and maintain policy guides and all-plan letters' on its website that define service definitions, member eligibility criteria, and provider eligibility criteria in a manner sufficient for plans to adopt in whole.

The entire new Article 5.52 (Sections 14184.1000) establishing 'CalAIM Successor Programs' was deleted. This article would have created a standalone legal framework for continued community supports coverage starting January 1, 2027, including requirements for an Evidence of Coverage document, technical assistance, policy update procedures, and a condition that implementation depend on federal financial participation availability.

All references to 'CalAIM Terms and Conditions' were removed from sections 14184.205 and 14184.206. ECM and community supports are now governed solely by the statutory text itself rather than by a separate set of terms and conditions tied to the CalAIM initiative.

The phased implementation timeline for ECM was deleted. The old version specified different start dates (January 1, 2022; January 1, 2023; July 1, 2023) depending on whether a plan operated in counties where the Whole Person Care pilot or Health Home Program had been implemented. The new version simply states ECM 'shall be available on a statewide basis' without those dates.

Section 14184.209 (CalAIM Implementation Advisory Group) now explicitly includes a sunset provision: 'This section shall remain in effect only until January 1, 2032, and as of that date is repealed.'

Public reporting requirements for both ECM and community supports were changed from annual to quarterly publication. A new requirement was added that the department must also publish this information on its internet website on a quarterly basis through December 31, 2031.

An additional exclusion was added for ECM: beneficiaries who are 'otherwise eligible for other high-intensity care management services, as defined by the department' are now excluded from ECM, broadening the carve-out beyond just 1915(c) waivers, Family Mosaic, and CCT MFTP.

The definition of 'community supports' in section 14184.206 was narrowed by removing the phrase 'approved in the CalAIM Terms and Conditions,' leaving only the reference to federal regulation (Section 438.3(e)(2) of Title 42 CFR).

The March 31, 2029 legislative report requirement was modified to specify the information must be provided 'in writing' to the appropriate policy and fiscal committees.

The bill now amends existing Sections 14184.205 (ECM) and 14184.206 (community supports) in addition to adding successor program provisions, rather than only adding a new Article 5.52 for post-CalAIM programs.

The federal financial participation condition ('to the extent that federal financial participation is available and is not otherwise jeopardized') is removed from the opening of the successor programs provision (Section 14184.1000(a)), though it remains in Section 14184.1000(j).

A new statutory definition of 'enhanced care management' is added: community-based, high-touch coordination and comprehensive care management services including lead care manager access, outreach, assessment, care planning, coordination, health promotion, transitional care, member/family support, and referral to community and social supports.

The term 'community provider' is renamed to 'nonprofit community provider,' and a new provision clarifies that the tracking and reporting requirement does not restrict plans from contracting with providers that do not fit this definition.

References to CalAIM Terms and Conditions are removed from the ECM implementation requirement (Section 14184.205) and from community supports authorization (Section 14184.206), making these benefits operate under the statute directly rather than through federal waiver terms.

If a managed care plan keeps ECM in-house instead of contracting with direct providers, it must demonstrate to the state that its ECM benefit is appropriately community-based and provide a rationale for not contracting with existing providers.

A specific list of 14 approvable community supports is added, including housing transition navigation, housing deposits, tenancy services, post-hospitalization housing, recuperative care, respite, day habilitation, nursing facility transition, personal care services, environmental modifications, medically supportive food and nutrition services, sobering centers, and asthma remediation.

The 'Evidence of Coverage' document is renamed to 'model managed care coverage standards and policy,' and a new requirement is added that if a plan deviates from these model standards, it must provide the department a specific explanation and justification for the deviation.

A new exclusion is added: ECM beneficiaries who are 'otherwise eligible for other high-intensity care management services, as defined by the department' are excluded from ECM.

Public reporting on ECM utilization data, populations served, and demographic data changes from annual to quarterly publication.

Public reporting on community supports utilization data also changes from annual to quarterly publication.

Managed care plans must provide information on available community supports in their member handbook and plan website, including any limitations.

The department must conduct an independent evaluation of the effectiveness of community supports per parameters in the CalAIM Terms and Conditions.

The department must take into account the utilization and actual cost of community supports when developing capitation rates for managed care plans.

By March 31, 2029, the department must provide to the legislative policy and fiscal committees information necessary to inform consideration of transitioning community supports to benefits required to be covered under Medi-Cal, including cost, effectiveness, and provider availability data.

The CalAIM Implementation Advisory Group sunset date changes from December 31, 2030 (Assembly version) to January 1, 2032 (Senate version), and is moved to a new standalone Section 14184.209.

The standalone Section 14184.1001 from the Assembly version (which contained its own Evidence of Coverage and reporting requirements) is eliminated; those provisions are consolidated into the amended Section 14184.206.

New subdivision (j) in Section 14184.1000 states that the entire section shall be implemented only to the extent that federal financial participation is available and not otherwise jeopardized, extending this condition beyond just the coverage provision in subdivision (a).

New subdivision (k) in Section 14184.1000 allows the Department of Health Care Services to implement the section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking further regulatory action, subject to the policy update requirements in subdivision (f). This bypasses the formal rulemaking process under Government Code Chapter 3.5.

Provisions previously housed only in Section 14184.1001 (Evidence of Coverage document, policy review and update, community provider tracking, advisory group) were consolidated into Section 14184.1000 as subdivisions (d) through (i), while Section 14184.1001 retains its original content, creating overlapping provisions across both sections.

In the review-and-update provision, language was changed from 'related policies produced and developed pursuant to subdivision (a)' to 'policy guidance related to community supports' and from 'effective and efficient delivery of CalAIM programs' to 'effective and efficient delivery of services,' broadening the scope slightly.

New Section 14184.1001 requires the department to produce a model Evidence of Coverage document by July 1, 2027, containing comprehensive instructions on eligibility and coverage policies sufficient for a managed care plan to adopt in whole as its own coverage policy.

The department must engage stakeholders, including community providers of each community support, and solicit and accept feedback when developing the Evidence of Coverage document.

Medi-Cal managed care plans must track and report to the department the number and percentage of their providers that qualify as 'community providers' and the number and percentage of services provided by those providers. The department must organize this data by plan and publish a report at least annually.

Until December 1, 2030, the department must regularly review and update the Evidence of Coverage document and related policies to ensure effective delivery of CalAIM programs.

The department must continue convening the CalAIM Implementation Advisory Group until December 31, 2030.

The department must post policy changes publicly for a minimum of one month before making updates, and must release written updates no later than six months before the effective date (which must be January 1 or July 1). Exceptions are allowed for urgent issues including changes in federal approvals or federal financial participation availability.

Defines 'community provider' as a locally available community-based nonprofit organization that has direct experience providing services to Medi-Cal beneficiaries in the county or region where it operates.