Enhancing Federal Monetary Participation for Shoppers Served by the Division of Developmental Companies

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Abstract

The Supplemental Report of the 2020‑21 Finances Act requires our workplace to judge Medi‑Cal enrollment processes amongst shoppers of the Division of Developmental Companies (DDS) and supply choices to extend enrollment with the purpose of accelerating federal funding for regional heart (RC)‑coordinated providers.

Potential Further Medi‑Cal Enrollment of DDS Shoppers Is Pretty Restricted. DDS can draw down federal funding for most of the providers it offers to DDS shoppers if the buyer is enrolled in Medi‑Cal, has authorized immigration standing, lives in a group‑primarily based setting, and receives a minimum of one RC‑coordinated service. At the moment, eight in ten out of about 320,000 total DDS shoppers already are enrolled in Medi‑Cal. Amongst adults, we discover little potential for added Medi‑Cal enrollments or further federal funding for DDS providers. We discover that the potential to attract down further federal funding in DDS rests largely with kids who would qualify for Medi‑Cal via an eligibility pathway known as “institutional deeming.” This eligibility pathway—obtainable to sure greater‑wants kids—considers solely the kid’s (not the household’s) revenue in figuring out Medi‑Cal revenue eligibility. We estimate there’s the potential to enroll as much as 7,000 further kids in Medi‑Cal via this eligibility pathway.

On Internet, Growing Medi‑Cal Enrollment Amongst DDS Shoppers Would Truly Enhance State Prices Total. The state would save about $24 million Basic Fund within the DDS funds if DDS have been capable of enroll all 7,000 further kids in Medi‑Cal. Nevertheless, it could incur Medi‑Cal prices in different departments (for providers resembling medical and dental care or In‑House Supportive Companies) of about $70 million, for a web state value of about $46 million Basic Fund, or $6,600 per youngster.

Suggestions. If the Legislature’s predominant purpose have been to economize, growing Medi‑Cal enrollment amongst DDS shoppers wouldn’t obtain that purpose. Nevertheless, if it has a coverage foundation for wanting to extend Medi‑Cal enrollment amongst DDS shoppers, we advocate it take into account one or each of the next choices to take action in a comparatively value‑efficient means:

  • Offering extra fingers‑on Medi‑Cal enrollment help via devoted liaisons and enrollment staff at counties and/or devoted workers at RCs. The executive value of this selection would vary from about $2 million to $15 million and a few of these prices can be eligible for federal Medicaid funding.
  • Offering extra schooling and improved supplies about Medi‑Cal and the associated Medicaid waiver program administered by DDS, resembling by altering complicated terminology, translating types at the moment supplied solely in English, internet hosting instructional occasions, or bettering coaching of RC workers. The overall administrative value of such choices doubtless wouldn’t exceed $2 million.

We advocate in opposition to requiring Medi‑Cal enrollment amongst eligible shoppers, as proposed by the Governor’s administration in Could 2020. (A client who selected to not enroll would have needed to pay the RC the equal of what Medicaid would have paid for RC‑coordinated providers.) Not solely would this method value the state cash on web, however it probably would discourage some households from searching for wanted RC‑coordinated providers.

Introduction

The Division of Developmental Companies (DDS) at the moment serves a comparatively small share of shoppers who’re eligible for, however not enrolled in, Medi‑Cal, the state’s Medicaid program, and Medicaid residence‑ and group‑primarily based providers (HCBS) applications (which fund an array of providers and helps that permit folks to stay in group‑primarily based settings, somewhat than in institutional settings). Consequently, the state can’t draw down federal Medicaid funds to assist pay for DDS providers supplied to those shoppers—the state (via the Basic Fund) at the moment pays 100 percent of the fee. The Supplemental Report of the 2020‑21 Finances Act requires our workplace to judge Medi‑Cal enrollment processes and establish the obstacles to enrollment amongst these DDS shoppers. The Supplemental Report requires our workplace to offer choices to handle these obstacles with the last word purpose of accelerating federal monetary participation for regional heart (RC)‑coordinated providers. Our analysis might take into account alternatives for streamlining the enrollment course of and educating shoppers and their households/representatives about Medi‑Cal applications. Lastly, the Supplemental Report requires us to incorporate an estimate of potential Basic Fund financial savings ensuing from elevated federal monetary participation in addition to an estimate of potential prices ensuing from further administrative actions and elevated utilization of Medi‑Cal advantages exterior the DDS system.

This report builds on preliminary findings reported in an April 2021 interim replace and incorporates 4 predominant sections: (1) background about how Medicaid works within the DDS system and the Medi‑Cal eligibility and enrollment processes, (2) findings in regards to the potential for Medi‑Cal and waiver uptake amongst DDS shoppers and about varied enrollment challenges, (3) assessment of the fiscal implications of enrolling extra shoppers in Medi‑Cal and of 4 choices for growing enrollment in these applications, and (4) recommendations for the Legislature.

As RC‑coordinated providers supplied to infants and toddlers below age three in DDS’s Early Begin program usually are not eligible for Medicaid reimbursement via DDS, we focus our evaluation on DDS shoppers—usually age three and older—who are eligible for RC‑coordinated providers below the Lanterman Developmental Disabilities Companies Act (Lanterman shoppers). These are the providers that may draw down federal Medicaid funds within the DDS system.

Background

How Medicaid Works within the DDS System

Practically All of DDS’ Service Classes Are Eligible for Federal Medicaid HCBS Reimbursement. Practically all the sorts of residence‑ and group‑primarily based providers coordinated by RCs for DDS shoppers are eligible to obtain federal Medicaid HCBS matching funds. Such providers embody residential providers, impartial and supported dwelling providers, day applications, transportation, supported employment, and respite providers. As well as, a number of the time spent on case administration by RC workers for shoppers enrolled in Medi‑Cal is eligible for Medicaid Focused Case Administration funding. Among the many sorts of providers that aren’t eligible to obtain federal HCBS matching funds are funeral providers, tutor providers, day care supplied by a member of the family, and non permanent motel rooms utilized in emergency conditions.

Medi‑Cal Enrollment of DDS Shoppers Permits DDS to Entry Federal Funding for HCBS Companies Coordinated by RCs. DDS can draw down federal Medicaid funding to help HCBS providers coordinated by RCs and supplied to sure shoppers who’re enrolled in Medi‑Cal. This federal HCBS funding has supported a minimum of 30 percent of DDS prices since 2011‑12 as proven in Determine 1.

Figure 1 - Department of Developmental Services Budget

For providers funded by Medi‑Cal for Medi‑Cal‑eligible shoppers within the DDS system, service prices are shared evenly between the state and federal governments. (The state additionally operates a 100 percent state‑funded Medi‑Cal program for sure people who usually are not eligible for the federally matched program as a consequence of immigration standing.) If a client is just not eligible for federally matched Medi‑Cal, the state funds the whole value of RC‑coordinated providers.

RC‑Coordinated Companies Draw Down Federal HCBS Funding in Two Predominant Methods. There are two main authorities for federal funding for HCBS providers within the DDS system—(1) a Medicaid 1915(c) HCBS waiver (which we check with because the “waiver”), which has been in place for DDS since 1982, and (2) a Medicaid state plan modification (which we check with because the “1915(i) SPA”), which has been in place since 2009. The distinction between the 2 is predicated on the extent of care required by the buyer, with the waiver serving to fund HCBS providers for these with extra intensive wants. California additionally has different Medicaid waivers (which can be found to DDS shoppers) which might be managed in different departments, such because the House‑ and Group‑Primarily based Options waiver, managed by the Division of Well being Care Companies (DHCS). A person solely might be enrolled in a single waiver at a time. (Amongst DDS shoppers enrolled in a waiver, most are within the waiver administered by DDS.) This report is concentrated on the waiver and 1915(i) SPA managed by DDS, the eligibility for that are described beneath.

  • Waiver Eligibility: Shoppers have to be a authorized resident, enrolled in full‑scope Medi‑Cal, stay in a group‑primarily based setting, and obtain a minimum of one RC‑coordinated service. (Some people—significantly kids—obtain solely case administration from RCs and both don’t want RC‑coordinated providers or obtain the wanted providers exterior of the RC system, resembling via colleges.) In addition they should want a stage of care equal to that supplied at an intermediate care facility (ICF) for the developmentally disabled, a licensed well being facility that’s thought-about a extra institutional setting. An ICF stage of care is outlined as having two average or extreme help wants in a number of of the next areas: self‑assist, resembling dressing or toileting; social‑emotional to handle such points as aggression, self‑injurious conduct, or working away; or well being, resembling tracheostomy care, apnea monitoring, or oxygen remedy. To enroll, the buyer, guardian, guardian, or authorized consultant should full a DDS kind known as the “Medicaid Waiver Shopper Selection of Companies/Residing Association” (which we check with because the “DDS selection kind”) indicating that they’ve chosen a group‑primarily based residence for the buyer, somewhat than an ICF.
  • 1915(i) SPA Eligibility: Shoppers have to be a authorized resident, enrolled in Medi‑Cal, and stay in a group‑primarily based residence. They don’t want the identical stage of care as somebody enrolled within the waiver. No types or enrollment are required for the 1915(i) SPA; DDS can search reimbursement from Medicaid as soon as the buyer makes use of an RC‑coordinated HCBS service.

Medi‑Cal Pays for a Number of Companies, however the DDS Finances Displays Solely Case Administration and HCBS Companies. Along with HCBS providers coordinated by RCs, DDS shoppers who’re enrolled in Medi‑Cal additionally might obtain different Medi‑Cal providers, resembling medical and dental care, and probably could also be eligible to obtain in‑residence supportive providers (IHSS). (Medi‑Cal additionally funds non‑HCBS providers supplied in additional institutional settings, like ICFs or expert nursing amenities [SNFs]). Whereas RC workers might assist shoppers entry these different Medi‑Cal providers, the prices of those Medi‑Cal providers usually are not mirrored within the DDS funds. Reasonably, these prices are mirrored in different state departmental budgets, such because the DHCS funds for well being care providers (together with ICFs and SNFs) and the Division of Social Companies funds for IHSS. As well as, colleges additionally may match with DHCS to hunt Medi‑Cal reimbursement for therapies supplied to kids with developmental disabilities or delays.

Medi‑Cal Eligibility and Enrollment for DDS Shoppers

Medi‑Cal Eligibility Pathways. Earlier than enrolling within the waiver or turning into eligible for 1915(i) SPA reimbursement, DDS shoppers should first enroll in Medi‑Cal. People with developmental disabilities are inclined to qualify for Medi‑Cal via one of many following eligibility pathways, additionally proven in Determine 2:

  • Automated Eligibility Primarily based on Supplemental Safety Earnings/State Supplementary Fee (SSI/SSP) Qualification. People who obtain SSI/SSP money help are robotically eligible for Medi‑Cal. SSI/SSP is obtainable to people who’re age 65 or older, blind, or disabled and whose revenue and assets fall beneath specified thresholds. Of the DDS shoppers enrolled in Medi‑Cal, the majority—about 61 percent—turned eligible as a result of they obtain SSI/SSP.
  • Earnings‑Eligibility. Medi‑Cal is a way‑examined program. Within the DDS context, barely greater than 20 percent of shoppers enrolled in Medi‑Cal arrive via the revenue‑eligibility pathway, together with kids whose households are revenue‑eligible.
  • Institutional Deeming. This eligibility pathway identifies kids within the DDS system whose households usually are not revenue‑eligible for Medi‑Cal, however who may benefit from enrolling within the waiver as a result of they stay in a group setting and require an ICF stage of care. Due to the wanted stage of care, this pathway disregards the dad and mom’ revenue and considers solely the kid’s revenue to find out Medi‑Cal eligibility. (A toddler’s revenue contains any youngster help or belief fund revenue.) Institutional deeming is also an possibility for a married grownup who requires an ICF stage of care, however whose partner’s revenue would disqualify them for Medi‑Cal. On this case, the partner’s revenue might be disregarded in figuring out Medi‑Cal eligibility. Total, considerably fewer than 10 percent of DDS shoppers enrolled in Medi‑Cal are eligible through institutional deeming and most are kids.
  • Different. There are a couple of different methods DDS shoppers can enroll in Medi‑Cal. For instance, till the age of 26, present and former youth within the foster care system are robotically eligible for Medi‑Cal (roughly 1.4 percent of DDS shoppers enrolled in Medi‑Cal are eligible for this purpose).

Determine 2

Predominant Medi‑Cal Eligibility Pathways Amongst
Division of Developmental Companies Shoppers

2019‑20

Medi‑Cal Eligibility Pathway

Whole

Below Age 18

Age 18 and Older

SSI/SSP

61%

44%

73%

Earnings

22

29

17

Institutionally deemed

9

21

1

Differenta

8

6

9

Totals

100%

100%

100%

Counties Handle Medi‑Cal Enrollment. Whereas RCs handle waiver enrollment and DDS manages 1915(i) SPA reimbursements, county governments handle Medi‑Cal eligibility determinations, together with for DDS shoppers. California makes use of a federally permitted software, which is similar for each Medi‑Cal and Lined California. Folks might apply on-line, by mail, in individual on the county workplace, or by telephone. The eligibility course of makes use of details about every member of the family in a family—such as revenue, assets, measurement of family, and incapacity—to decide the scope of advantages obtainable to the household and the household’s share of value, if any (most frequently, there isn’t a share of value). The method is guided by federal regulation. If the applicant(s) is eligible for Medi‑Cal via multiple pathway, the method is designed to robotically base eligibility on what’s most useful (by way of scope of advantages and share of value) for the applicant(s). If an RC has decided that a person requires an ICF stage of care, however that they will not be eligible for Medi‑Cal via typical revenue‑primarily based pathways and ought to be thought-about below institutional deeming, they are going to ship the county a DHCS referral kind indicating that the “eligibility willpower waives parental and spousal revenue and assets.” The county will then ship an software on to the buyer and client’s household. The DHCS waiver referral kind instructs the county to ship each the buyer in addition to the RC a discover when the Medi‑Cal willpower has been accomplished. As well as, the DHCS Medi‑Cal Eligibility Procedures Guide notes that the county might share ongoing eligibility data with the RC.

Medi‑Cal Enrollment Help Choices Are Accessible. There are a number of choices obtainable to help people with Medi‑Cal functions, a few of that are tied to the Lined California software course of. For instance, a public company (RCs are thought-about public businesses in laws) can file an software on behalf of a person who can’t apply on their very own. An applicant can designate somebody as their Medi‑Cal licensed consultant (RCs or particular person RC service coordinators might be designated as such) to help with the appliance and work together with the county. As well as, county eligibility staff might be positioned off‑website (resembling at a hospital) or make off‑website visits to help candidates. Through Lined California, sure organizations—together with nonprofit group organizations—can turn into Licensed Software Entities or Licensed Enrollment Entities with licensed counselors. The latter can enroll an applicant in Medi‑Cal (or a Lined California plan).

RCs Handle Waiver Enrollment. Two various kinds of RC workers handle waiver enrollment:

  • Certified Mental Incapacity Professionals (QIDPs) Guarantee Shoppers Meet Necessities for Waiver Enrollment. Most RCs have small groups of devoted workers who specialize within the space of federal applications. These workers embody a number of QIDPs, as required by DDS’ settlement with the federal authorities. Along with ascertaining whether or not a client meets the ICF stage of care standards for preliminary waiver enrollment, QIDPs additionally handle required annual waiver recertifications. As well as, federal applications workers routinely evaluation case data to see who else is likely to be eligible for the waiver. The federal applications groups might terminate shoppers from the waiver if the extent of care required has modified or the buyer has misplaced Medi‑Cal eligibility. DDS and the federal authorities repeatedly audit RCs to make sure federal waiver reimbursements have been claimed correctly.
  • RC Service Coordinators Work Straight With Households. RC service coordinators work straight with shoppers and their households to facilitate waiver enrollment with help from QIDPs. The service coordinator usually is chargeable for guaranteeing the household has reviewed and signed the DDS selection kind. As well as, a service coordinator might establish a client as probably eligible for the waiver and alert federal applications workers.

Medi‑Cal Can Be Used for Major or Secondary Insurance coverage Protection. If a person, resembling a toddler who’s eligible via institutional deeming, already has personal medical insurance protection, Medi‑Cal can act as a secondary payer for main insurance coverage co‑pays or uncovered prices. In some situations, a household could also be required to pay a share of value for well being care providers earlier than Medi‑Cal funds are supplied. This usually occurs when revenue is greater (both the household’s revenue below typical revenue‑primarily based pathways or the kid’s revenue below institutional deeming).

For a Small Share of Beneficiaries, Medi‑Cal Seeks Compensation for Companies From Their Estates After Loss of life. The Medi‑Cal program is federally required to hunt compensation from the estates of Medi‑Cal beneficiaries upon their dying, if they’ve an property topic to probate and meet different standards. The standards have been narrowed by state statute in 2017 to restrict property restoration to the minimal required by federal regulation. Property restoration applies to a person who both was completely institutionalized (at a SNF, ICF, or different medical facility) or acquired HCBS providers at age 55 or older. It doesn’t apply if there’s a surviving partner or registered home accomplice, a surviving youngster below age 21, or a surviving youngster who’s blind or disabled. If the person owned a house on the time of dying that’s value 50 percent or lower than the common residence within the county, that residence is just not topic to property restoration.

Findings

On this part, we first present a abstract of Medi‑Cal, waiver, and 1915(i) SPA statistics amongst DDS shoppers. We then focus on the bounds to potential Medi‑Cal uptake (and thus waiver and 1915(i) SPA enrollment), a number of the potential causes folks might select to not enroll, and a number of the challenges that exist within the enrollment course of.

About Eight in Ten DDS Shoppers Already Are Enrolled in Medi‑Cal. Determine 3 exhibits about 254,000 out of about 320,000 DDS shoppers (or 79 percent) have been enrolled in Medi‑Cal in 2019‑20. Of the 254,000 enrolled in Medi‑Cal, a complete of 187,000 (or 74 percent) acquired a minimum of one RC‑coordinated service, a prerequisite for waiver or 1915(i) SPA eligibility; about 132,000 of these shoppers (or 52 percent of these enrolled in Medi‑Cal) have been enrolled within the waiver, whereas about 48,000 (or 19 percent of these enrolled in Medi‑Cal) acquired 1915(i) SPA reimbursement.

Figure 3 - Assessing Current and Potential Eligibility Among DDS Consumers for Federal HCBS Funding.png

Among the many 7,000 who acquired an RC‑coordinated service, however didn’t obtain waiver or 1915(i) SPA reimbursement, many lived in ICFs or SNFs, which, for essentially the most half, makes them ineligible for HCBS funding. Moreover, a number of the 7,000 have been enrolled in a waiver program administered by one other division. As famous earlier, people solely might be enrolled in a single waiver at a time.

About 67,000 DDS shoppers (or 21 percent) weren’t enrolled in Medi‑Cal, however importantly, greater than half of those shoppers (about 37,000) did not obtain an RC‑coordinated service and wouldn’t be eligible for waiver enrollment or wouldn’t obtain 1915(i) SPA reimbursement. Beneath, we focus on the potential for enrolling the remaining 30,000 individuals.

Uptake Potential

Potential Further Enrollment of DDS Shoppers in Medi‑Cal Is Pretty Restricted. The proportion of DDS shoppers enrolled in Medi‑Cal has elevated over the previous decade. In 2010, 74 percent of shoppers have been enrolled in Medi‑Cal, whereas right this moment, 79 percent are enrolled. Amongst kids, enrollment has elevated by greater than 10 percentage factors since 2010, from 59 percent to 71 percent. The close by field describes a number of the efforts taken lately to extend enrollment. Consequently, most shoppers eligible for Medi‑Cal doubtless already are enrolled.

Earlier Efforts to Enhance Federal Reimbursement for RC‑Coordinated Companies

There have been a number of initiatives within the Division of Developmental Companies (DDS) system to maximise the variety of shoppers drawing down federal Medicaid residence‑ and group‑primarily based providers (HCBS) funding. For instance, DDS used to set waiver enrollment targets for regional facilities (RCs) and supply a fee to RCs for every new client enrolled within the waiver, though this incentive was eradicated in 2010‑11 as a price‑financial savings measure. In 2009, the state pursued the Medicaid state plan modification (1915(i) SPA) in an effort to obtain federal reimbursement for Medi‑Cal‑enrolled shoppers who acquired RC‑coordinated HCBS providers however didn’t require an intermediate care facility stage of care. Chapter 37 of 2011 (AB 104, Committee on Finances) added a brand new requirement that upon consumption and evaluation for RC providers, the buyer should present a duplicate of their well being profit card, partly to permit RCs to maximise federal waiver and 1915(i) SPA reimbursements amongst these enrolled in Medi‑Cal. RCs’ contracts with DDS additionally stipulate that the RC will pursue an “aggressive enrollment effort” to make sure keen and eligible shoppers are enrolled within the waiver.

The mixed impact of those efforts (and probably the rollout of the Affected person Safety and Reasonably priced Care Act) has boosted the general proportion of DDS shoppers receiving federal Medicaid HCBS funding to about 56 percent (about 71 percent of shoppers enrolled in Medi‑Cal). The proportion of all shoppers enrolled within the waiver (simply over 40 percent) has elevated a number of proportion factors since 2006‑07 and the introduction of the 1915(i) SPA has led to a different 15 percent of DDS shoppers drawing down federal funding for his or her RC‑coordinated HCBS providers.

Uptake Potential Seemingly Restricted to Kids By means of Institutional Deeming. Of the roughly 30,000 individuals who weren’t enrolled in Medi‑Cal in 2019‑20 and who did obtain an RC‑coordinated service, about 16,000 have been adults. Each DDS and RCs point out that almost all adults who’re eligible for Medi‑Cal are already enrolled, that means that this group doubtless contains adults who usually are not eligible for some purpose, for instance, being an undocumented immigrant or having revenue that’s too excessive.

The remaining group of about 14,000 consumers are kids. To obtain federally matched Medicaid funding, these kids must have authorized immigration standing and both be revenue‑eligible via their household or qualify via institutional deeming. We don’t count on all 14,000 would meet these standards. We usually assume that if a toddler’s household is revenue‑eligible for Medi‑Cal, they doubtless would have enrolled already. This implies essentially the most viable eligibility pathway is institutional deeming, which (a) ignores the household’s revenue and appears solely on the youngster’s revenue and (b) requires that the kid want an ICF stage of care (which qualifies them for the waiver). Even ignoring the household’s revenue, nonetheless, a few of these kids might have their very own revenue from a belief or from youngster help at a stage that disqualifies them for Medi‑Cal. Moreover, utilizing present waiver enrollment proportions as a information, we all know that a minimum of a few of these kids don’t require an ICF stage of care. (As well as, we will assume that households of kids with a very excessive stage of want doubtless have used the institutional deeming possibility already.) Lastly, we all know that RC workers repeatedly evaluation shoppers’ casefiles to find out if there are people who is likely to be eligible for Medi‑Cal who usually are not enrolled. Primarily based on these elements, in addition to discussions with DDS, we estimate that about half, at most, of the potential pool of kids, or about 7,000 children, might enroll in Medi‑Cal through institutional deeming.

Medi‑Cal and Waiver Enrollment Challenges

We spoke to DDS, the Affiliation of Regional Heart Businesses, a number of RCs, a number of households, Incapacity Rights California, and the County Welfare Administrators Affiliation, and carried out a survey of RCs (19 of 21 responded) to higher perceive the Medi‑Cal and waiver enrollment processes and causes that some households might select to not enroll or have bother enrolling. As a result of collaborating within the 1915(i) SPA doesn’t require something further of shoppers—as soon as they’re enrolled in Medi‑Cal and start to obtain RC‑coordinated HCBS providers, DDS can search federal reimbursement for these providers—the the rest of the report focuses on Medi‑Cal and waiver enrollment.

Causes Provided for Not Enrolling in Medi‑Cal or the Waiver or Being Hesitant to Do So. Some themes emerged about causes sure households both don’t wish to enroll their client member of the family in Medi‑Cal or the waiver or that made them hesitant within the strategy of doing so. The next points seem to occur with some frequency:

  • Choice for his or her present industrial medical insurance.
  • Doubt that there’s any profit to enrolling in Medi‑Cal (particularly because the client will obtain the identical RC‑coordinated providers regardless).
  • Hesitancy or unwillingness to offer delicate private and revenue data to Medi‑Cal, significantly via institutional deeming (to qualify a toddler for institutional deeming, the household nonetheless has to offer details about every member of the family). As well as, if the guardian is undocumented, the hesitancy to offer delicate data is heightened.
  • Issues amongst households that they’re “waiving” some type of proper or management by enrolling their youngster within the waiver.
  • Issues amongst households that the DDS selection kind (which asks about institutional settings) and/or that the phrase “institutional deeming” may imply they’re agreeing to put their client member of the family in an establishment.

Points that look like much less frequent embody:

  • Perceived stigma about accessing Medi‑Cal, which is known to be a authorities program for low‑revenue people.
  • Issues about accessing a profit they understand as meant for extra needy households (and probably depriving a needier household of this profit).
  • Having to satisfy with their RC service coordinator yearly (somewhat than each three years) for the needs of waiver recertification.
  • Issues about Medi‑Cal property restoration.

Challenges Related With the Medi‑Cal Enrollment Processes. Our findings point out that the Medi‑Cal preliminary enrollment and annual renewal processes have some challenges, each for RCs and for households. These embody:

  • Familiarity. Some households wish to, or probably wish to, enroll their youngster in Medi‑Cal, however lack consciousness or understanding of Medi‑Cal and the potential advantages.
  • Paperwork. Some households have bother finishing Medi‑Cal paperwork or offering required documentation. As well as, each RCs and households point out that households who’ve enrolled their youngster in Medi‑Cal are annoyed by the quantity of paperwork required at preliminary enrollment and at annual renewal.
  • Time Traces. If a household has been referred for institutional deeming, they’ve 30 days after receiving the Medi‑Cal software to submit it, together with required documentation, again to the county earlier than the referral expires. RCs point out this 30‑day turnaround might be problematic for some households. For shoppers already enrolled in Medi‑Cal, in the event that they miss the annual renewal deadline, they’re terminated from Medi‑Cal and have to start the preliminary enrollment course of anew.
  • Lack of Liaisons. RCs be aware that the Medi‑Cal enrollment course of (significantly when they’re recommending a household enroll in Medi‑Cal through institutional deeming) goes far more easily when the county has a liaison or eligibility employee devoted to working with RC workers and RC households and who’s educated of the DDS system. Many counties should not have devoted workers, nonetheless.
  • Information of DDS. When a county has a excessive fee of turnover amongst Medi‑Cal eligibility staff, understanding of the DDS system and of the institutional deeming course of particularly typically is missing. For instance, even the nomenclature used for institutional deeming is completely different. Whereas DDS and RCs use the phrase “institutional deeming,” the county and Medi‑Cal Eligibility Procedures Guide usually use “DDS waiver” or “DD waiver.”
  • Communication Between Counties and RCs. Though the referral kind that RCs ship to counties point out that the county ought to ship a notification again to the RC when the Medi‑Cal eligibility willpower is full, some RCs say the county doesn’t notify them. This makes monitoring Medi‑Cal enrollment (and claiming federal funding) harder for RCs.

Challenges Related With Waiver Enrollment Course of. RCs be aware that the DDS selection kind and the DHCS waiver referral kind are supplied solely in English regardless that many shoppers and their households are extra fluent in different languages. They be aware that below institutional deeming, the requirement that the kid be receiving an RC‑coordinated service might be sophisticated by a scarcity of accessible service suppliers. This was raised a number of instances within the context of respite providers. For instance, the household could also be licensed by the RC to obtain respite providers, however they could be unable to discover a respite supplier. This compromises each waiver and Medi‑Cal eligibility since eligibility below institutional deeming hinges on receipt of RC‑coordinated providers. Lastly, a number of RCs indicated {that a} lack of standardized waiver coaching from DDS makes it tough for RC service coordinators to grasp the method.

Evaluation

Within the first a part of our evaluation beneath, we estimate the potential fiscal impact if the state have been profitable in maximizing Medi‑Cal and waiver enrollments among the many pool of doubtless eligible DDS shoppers. We estimate the potential fiscal impact within the DDS funds after which on state spending total. Within the second a part of our evaluation, we take into account and consider potential choices for growing these enrollments. Every possibility comes with a possible administrative value to implement it, in addition to commerce‑offs and sure various ranges of success at growing Medi‑Cal and waiver enrollments. We focus on these concerns for every possibility.

Fiscal Implications of Growing Medi‑Cal and Waiver Uptake Amongst DDS Shoppers

Attempting to maximise federal help of the DDS system (and thus cut back state prices within the DDS funds) was the unique impetus for this report. Whereas we estimate that elevated Medi‑Cal and waiver uptake would end in modest state financial savings within the DDS funds, there can be prices for the Medi‑Cal advantages administered by different state departments. We estimate that these prices would outweigh the financial savings within the DDS funds, leading to a web value to the state.

Fiscal Impact within the DDS System

As mentioned within the earlier part, the most probably pool of potential new enrollees is kids who can be eligible for the waiver below institutional deeming—at most, about 7,000 in 2019‑20. At a per individual value of about $7,000 in 2019‑20, the state spent about $49 million Basic Fund for the RC‑coordinated providers supplied to those kids. If we assume that each one of those kids have been eligible for Medi‑Cal and the waiver through institutional deeming, that each one of them have been enrolled, and that the DDS prices of the kids’s providers remained roughly the identical, DDS would save about half that value—$24 million—due to federal Medicaid reimbursements (on the 50 percent match fee for HCBS providers).

Added State Prices Exterior the DDS System

Though DDS doubtless might obtain some financial savings by drawing down federal funding for kids who’re at the moment 100 percent state funded, there can be added Medi‑Cal prices exterior the DDS system for providers resembling IHSS and for normal Medi‑Cal medical insurance prices. Most DDS shoppers who’re enrolled in Medi‑Cal through institutional deeming are in price‑for‑service Medi‑Cal (somewhat than in a managed care plan). In 2019‑20, amongst DDS shoppers below age 18 and eligible via institutional deeming, the common annual per individual price‑for‑service value in Medi‑Cal (excluding any prices mirrored within the DDS funds) was about $10 million Basic Fund ($20,000 total funds). These Medi‑Cal prices embody IHSS prices. If all 7,000 children could possibly be enrolled, we estimate 2019‑20 Medi‑Cal prices at roughly $70 million Basic Fund ($140 million whole funds). This quantity—$70 million Basic Fund—represents a possible most value. The Medi‑Cal prices for kids newly enrolled through institutional deeming probably could possibly be decrease than the prices for kids already enrolled via institutional deeming (as a result of these with extra intensive wants might have sought this selection already).

Backside Line for the State—A Internet Price. Enrolling extra DDS shoppers below the age of 18 in Medi‑Cal and the waiver through institutional deeming would end in web prices to the state. Whereas we estimate that enrolling an extra 7,000 children in Medi‑Cal would save about $24 million Basic Fund within the DDS system, the opposite Medi‑Cal prices for these kids can be about $70 million Basic Fund. Consequently, the web Basic Fund prices can be $46 million, or about $6,600 for every youngster added (primarily based on knowledge from 2019‑20). Importantly, this value estimate doesn’t embody administrative prices to extend enrollment, that are mentioned within the subsequent part.

Methods to Enhance Medi‑Cal and Waiver Enrollment Amongst DDS Shoppers

Whereas enrolling extra DDS shoppers in Medi‑Cal would enhance state prices, growing Medi‑Cal uptake amongst these shoppers might produce other advantages and tackle different legislative targets. For instance, whereas shoppers’ RC‑coordinated providers wouldn’t change essentially after enrolling in Medi‑Cal, they’d now be capable to entry different providers exterior the DDS system via the Medi‑Cal program. This might advance the legislative targets of bettering entry to wanted providers throughout the state’s varied well being and human providers applications. Beneath, we assess 4 predominant approaches that we now have recognized that could possibly be taken individually or together to extend uptake in Medi‑Cal and the waiver: (1) requiring enrollment amongst those that are eligible, (2) incentivizing enrollment, (3) providing fingers‑on enrollment help, and (4) providing extra schooling and improved supplies to households and RC workers. We additionally estimate the potential value to implement every possibility. (These prices—largely administrative in nature—are separate from and along with the programmatic web prices of elevated Medi‑Cal and waiver enrollments that outcome from implementation of the choices.) We focus on a number of the predominant benefits and challenges related to every possibility and assess every possibility utilizing the next standards:

  • Is the Possibility a Price‑Efficient Approach to Enhance Medi‑Cal and Waiver Enrollment? Would the choice doubtless end in considerably elevated Medi‑Cal and waiver enrollment amongst DDS shoppers? Are the prices cheap given the related fiscal and coverage advantages? Are there any unintended outcomes?
  • Is the Possibility Possible? Would the choice be simple to implement and operationalize throughout the 21 RCs?
  • Is the Possibility Equitable? How would the choice have an effect on completely different teams and shoppers? How does the choice affect shoppers’ entry to providers?

Require Enrollment Amongst These Who Are Eligible

Requiring Enrollment Was Proposed in 2020. Within the Governor’s 2020‑21 Could Revision, the administration proposed requiring shoppers to enroll in Medi‑Cal (if eligible) to allow RCs to hunt Medicaid reimbursements for RC‑coordinated providers. If the buyer selected to not enroll in Medi‑Cal when eligible, they’d have been required to pay the RC the equal of what Medicaid would have paid for RC‑coordinated providers. This proposal was not adopted as a part of the ultimate funds package deal; as an alternative, our workplace was requested to submit this report.

Potential Price to Require Medi‑Cal Enrollment. There can be commonplace further administrative prices to course of an elevated variety of Medi‑Cal and waiver functions (this assumes the onus is on the household to proactively submit the appliance). (If DDS or RCs have been to help households within the software course of, the prices for these added providers can be much like the prices of the third and fourth choices we describe beneath.) For households that select to not enroll their client member of the family in Medi‑Cal, there can be administrative prices—doubtless lower than $1 million yearly—for RCs to invoice and accumulate fee from these households for half the price of any RC‑coordinated providers supplied to the buyer.

Benefits of Requiring Medi‑Cal Enrollment. Requiring Medi‑Cal enrollment—or in any other case requiring the household to cowl the federal portion of the price of RC‑coordinated providers—would be essentially the most direct methodology for attempting to extend Medi‑Cal enrollment amongst Medi‑Cal‑eligible DDS shoppers. This method might persuade households which have hesitated or been unwilling to use for Medi‑Cal (or who understand a stigma) to take action by offering a monetary disincentive.

Challenges With Requiring Medi‑Cal Enrollment. Making Medi‑Cal enrollment a requirement might discourage households from searching for RC‑coordinated providers within the first place or from accessing all the RC‑coordinated providers for which the buyer is allowed. Furthermore, some people and households uncomfortable with signing up for Medi‑Cal might not be capable to afford what would have been the federal portion of the price of the RC‑coordinated providers. Consequently, this method could possibly be extra punitive in nature than the three different approaches mentioned beneath, given {that a} household must pay for or forgo providers if they didn’t wish to enroll the buyer in Medi‑Cal. Whereas the requirement wouldn’t negate the statutory entitlement to RC‑coordinated providers supplied by the Lanterman Act, it could create a brand new prerequisite (making use of usually to all DDS shoppers) to receiving providers that didn’t exist earlier than. (We be aware that within the DDS system, there at the moment is one program, Self‑Dedication, that not too long ago started requiring Medi‑Cal enrollment if one is eligible. We describe this system and new requirement within the close by field.)

Self‑Dedication Program Requires Medi‑Cal Enrollment When Its Individuals Are Eligible

Comparatively New House‑ and Group‑Primarily based Companies (HCBS) Waiver Helps Pay for the Self‑Dedication Program (SDP). The Division of Developmental Companies (DDS) receives Medicaid funding for a small variety of shoppers who’re enrolled in Medi‑Cal and DDS’ SDP (about 750 people as of August 31, 2021). Medicaid funding is supplied via an HCBS waiver permitted in 2018 (which we check with because the “SDP waiver”). The SDP waiver has the identical intermediate care facility stage of care standards because the waiver. The variety of shoppers enrolled on this program will most probably enhance, as this system was made obtainable statewide on July 1, 2021 after a 3‑12 months part‑in interval (throughout which enrollment was restricted to 2,500 consumers).

SDP Will Require Medi‑Cal Enrollment, if Eligible. Though participation within the SDP is just not restricted to people who’re eligible for Medi‑Cal (because it was throughout the part‑in interval), laws related to the not too long ago enacted 2021‑22 budget stipulates that customers who’re eligible for Medi‑Cal should apply for it in a well timed method in an effort to take part in this system. (At the moment, DDS is engaged on the main points of implement this new coverage.) Below the brand new SDP coverage, Medi‑Cal‑eligible DDS shoppers who don’t want to enroll in Medi‑Cal couldn’t take part in Self‑Dedication. Whereas they nonetheless would be capable to entry common RC‑coordinated providers below the Lanterman Act without charge to them, they’d have much less management over the design of their service plan and number of service suppliers.

Evaluation of Requiring Medi‑Cal Enrollment. This selection can be the most probably of the 4 to maximise Medi‑Cal enrollment amongst DDS shoppers in a comparatively value‑efficient means. We don’t anticipate vital administrative or feasibility hurdles since counties and RCs already handle Medi‑Cal and waiver enrollment, respectively. As a result of this requirement might discourage some shoppers from searching for RC providers, nonetheless, this selection doubtless would have disparate impacts amongst shoppers. Particularly, this selection might cut back entry amongst shoppers whose dad and mom who’re undocumented or are in any other case hesitant to enroll in Medi‑Cal, however who can’t afford to pay a share of value for RC‑coordinated providers. Furthermore, this selection would create a pre‑requisite for Lanterman Act providers that didn’t exist beforehand.

Incentivize Enrollment

One other method to extend Medi‑Cal uptake amongst DDS shoppers is to offer an incentive to shoppers and their households for enrolling. One such incentive at the moment exists within the DDS system for households whose minor youngster receives DDS providers. The charges related to two of three household price applications—the Household Price Participation Program and the Annual Household Program Payment—are waived when the minor client is enrolled in Medi‑Cal. The extent to which these applications (which have been applied in 2005 and 2011, respectively) led to elevated enrollment in Medi‑Cal (as a result of households wished to keep away from paying the charges) is unclear. Whereas DDS Medi‑Cal enrollment knowledge present a slight uptick in enrollment amongst kids (from 59.4 percent to 62.3 percent) between 2010 (earlier than the Annual Household Program Payment took impact) and 2012, the reason for this uptick might have been the results of multiple issue. We be aware that Medi‑Cal enrollment of kids as of 2019‑20 (70.9 percent) was a lot greater than in 2012 (62.3 percent). This enhance might mirror the waiver of household charges, rollout of the Affected person Safety and Reasonably priced Care Act in 2014, efforts made by RCs to extend enrollment, extra households needing Medi‑Cal usually, or a mix of those.

Price to Incentivize Enrollment. The state would incur a price to manage and pay for incentives, nonetheless, the whole value is unsure since it could depend upon how incentives are designed. A easy hypothetical instance is a money incentive to newly enrolled shoppers. A $100 incentive (for example) for every of the 7,000 consumers would value $700,000. There can be commerce‑offs with any incentive design, nonetheless. As an illustration, would incentives solely be supplied to newly enrolled shoppers? Would incentives be supplied yearly to make sure folks renew their Medi‑Cal enrollment? Are there noncash incentive choices? What stage of incentive would have the specified impact of inflicting folks to enroll?

Benefits of Incentivizing Enrollment. Correctly focused incentives might make going via the Medi‑Cal software course of extra engaging to households which might be hesitant as a consequence of administrative burdens and different related issues.

Challenges With Incentivizing Enrollment. An incentive method wouldn’t assure shoppers enroll in Medi‑Cal. Furthermore, what sorts of incentives can be simplest at encouraging households to enroll shoppers in Medi‑Cal are unknown.

Evaluation of Incentivizing Enrollment. Design and implementation of this method can be comparatively complicated and the fee is unsure. As well as, how greatest to construction the inducement to have the supposed impact is unknown, particularly since incentives exist already for the doubtless pool of potential enrollees (kids). Given current incentives, the effectiveness of further incentives could also be restricted. Moreover, we’re not conscious of apparent examples or precedents for an incentive method in different well being and human providers applications. If the Legislature pursued this method, we recommend it take into account who would profit from receiving incentives—solely these shoppers newly enrolling in Medi‑Cal or these already enrolled in Medi‑Cal as effectively?

Present Arms‑On Enrollment Help

For households which have bother navigating the Medi‑Cal software course of, one other method is to offer fingers‑on help. Such help might take completely different types, however some choices embody:

  • Present Devoted Liaisons on the County. Making certain these liaisons perceive the DDS system and institutional deeming particularly can be essential.
  • Have County Eligibility Employees On‑Web site at RCs. Relying on the variety of shoppers served, these eligibility staff might work at RCs half time or full time.
  • Encourage Households to Enable RC Workers to Act as Approved Representatives for Shoppers. Doing so would permit RC workers to help with Medi‑Cal functions and comply with up with the county. If a household is just not snug making RC workers a licensed consultant, RC workers nonetheless might present extra fingers‑on help to households who want it.

Prices to Present Arms‑On Enrollment Help. This selection would require extra workers at counties and/or at RCs. Primarily based on the present value of a county eligibility employee, including a minimum of one new full‑time eligibility employee in every of the state’s 58 counties (for instance) to behave as a devoted liaison or to work on‑website at RCs would value roughly $10 million. Primarily based on the present value of an RC specialist‑sort worker, including one or two specialists in every of the state’s 21 RCs would value roughly $2 million to $5 million. Medicaid reimbursements would cowl a number of the prices of those further county and RC workers.

Benefits of Offering Arms‑On Enrollment Help. A number of of the approaches described above wouldn’t dissuade a household from searching for RC providers (because the requirement method may) and will alleviate a number of the administrative burden and confusion related to enrolling in Medi‑Cal. Households already enrolled in Medi‑Cal additionally may benefit from a extra assist. For instance, county and/or RC workers might present households reminders about Medi‑Cal renewal deadlines and provide to assist with the renewal course of. As well as, having devoted county liaisons or having county eligibility staff on‑website at RCs would make the waiver enrollment course of simpler for RCs since they’d have county workers available to reply questions and supply useful data (such because the dates by which households should renew their Medi‑Cal enrollment).

Challenges With Offering Arms‑On Enrollment Help. Simply because fingers‑on enrollment help is obtainable doesn’t imply a household will reap the benefits of it and use it to enroll their member of the family in Medi‑Cal. Furthermore, offering devoted county liaisons and/or eligibility staff for DDS shoppers would enhance county staffing prices. Had been the state to require counties to offer this service, the state doubtless must pay for the related value. If RCs acted as licensed representatives or supplied help in one other means, this may add prices to the RC operations budgets.

Evaluation of Offering Arms‑On Enrollment Help. Whereas there isn’t a assure extra shoppers would enroll in Medi‑Cal, offering extra fingers‑on help to assist them enroll might tackle a number of the points raised in interviews and surveys in regards to the software course of being tough and complicated. These modifications may benefit each these already enrolled in Medi‑Cal and people newly enrolling. Furthermore, bettering entry to Medi‑Cal enrollment providers might assist these households and shoppers who’re most deterred by the method enroll.

Present Extra Schooling and Improved Supplies About Medi‑Cal and the Waiver to Households and RC Workers

We heard from RCs and households that sure facets of the Medi‑Cal and waiver enrollment course of or the way in which that these applications are introduced to households could possibly be improved. A few of these facets are inside the state’s management to vary simply, whereas others usually are not. For instance, the institutional deeming course of requires the household to finish the total Medi‑Cal software, offering private and revenue details about every family member, regardless of the household searching for Medi‑Cal solely for the kid who’s a DDS client. This course of doubtless can’t be modified simply, nonetheless, on condition that the Medi‑Cal software kind (which can be the Lined California kind) and course of for figuring out eligibility follows federal tips and has federal approval.

There are different facets of the enrollment course of or presentation of knowledge, nonetheless, that will be a lot simpler to handle. For instance, some households could also be unaware of the vary of potential Medi‑Cal advantages, resembling IHSS, or that they might have Medi‑Cal cowl personal insurance coverage co‑pays or different out‑of‑pocket medical bills of their youngster. Growing schooling and offering improved supplies might come within the type of higher standardization of knowledge, necessities about when and the way data is supplied, elevated alternatives for offering the schooling (resembling webinars or workshops), and elevated coaching for RC service coordinators who then relay data to households. For instance, the next modifications could possibly be thought-about:

  • Waiver‑associated types (the DDS selection kind and the DHCS waiver referral kind) are solely supplied in English at the moment. These and different instructional supplies could possibly be translated into different languages.
  • DDS and DHCS might change the language used on types and in instructional supplies, resembling waiver and institutional deeming, to make them extra consumer‑pleasant and accessible. They may seek the advice of with households and different stakeholders to pick out language that’s extra comprehensible.
  • Schooling could possibly be supplied in codecs which might be accessible to households from a variety of backgrounds. For instance, this may require on-line or in‑individual occasions be provided in a number of languages or have interpreters current.
  • The terminology utilized by RC and county workers could possibly be standardized to cut back miscommunication between these businesses.
  • Extra data could possibly be supplied to households in regards to the statutory modifications made in 2017 to restrict what’s recovered from the estates of deceased beneficiaries.
  • DDS might interact all 21 RCs in common coaching and academic alternatives to make sure RC workers, together with service coordinators, perceive Medi‑Cal, the total vary of Medi‑Cal advantages probably obtainable to shoppers, the waiver, and enrollment processes for every, amongst different matters. These kind of RC trainings would have the additional benefit of offering RC workers the chance to share their very own greatest practices and focus on examples of complicated instances.

Prices to Offering Extra Schooling and Improved Supplies. There doubtless can be prices within the low tens of millions of {dollars} for this method. Whereas we count on a few of these prices (resembling altering types or standardizing data) could possibly be absorbed by DDS, including workers to develop and translate instructional supplies or conduct boards or trainings (or paying a contractor for these providers) would enhance prices to a point (doubtless no more than $2 million in whole). Some actions involving translation or interpretation doubtless could possibly be coated by a latest ongoing augmentation DDS acquired within the 2021‑22 budget ($10 million Basic Fund) for language entry and cultural competency orientations and coaching.

Benefits of Offering Extra Schooling and Improved Supplies. Households might make extra knowledgeable selections primarily based on constant and extra complete details about Medi‑Cal with higher instructional outreach. Notably together with fingers‑on enrollment help, this method might dispel misinformation about Medi‑Cal. For some households, understanding the opposite advantages of Medi‑Cal exterior the DDS system, resembling IHSS and/or protection of personal insurance coverage co‑pays, could possibly be incentive sufficient for them to use. Furthermore, offering higher and extra constant data might have advantages for these households already enrolled in Medi‑Cal.

Challenges With Offering Extra Schooling and Improved Supplies. Elevated schooling wouldn’t assure a household would enroll the buyer in Medi‑Cal. Furthermore, given the comparatively restricted pool of potential enrollees, the price of the outreach might outweigh the advantages of enrolling extra shoppers in Medi‑Cal and the waiver.

Evaluation of Choice to Present Extra Schooling and Improved Supplies. This method would come with quite a few low‑value choices for growing consciousness about Medi‑Cal advantages and the enrollment course of. It additionally is very possible—it would contain modifications to types; translation of types; and improvement and implementation of trainings, webinars, and different outreach and schooling choices. Whereas a few of these efforts would take extra time, planning, and stakeholder engagement than others, they don’t require altering something vital about enrollment guidelines or laws. This selection might enhance fairness by guaranteeing that each one households perceive the vary of advantages for which they’re obtainable, in a language and format they perceive.

Suggestions

Primarily based on our fiscal evaluation, enrolling extra DDS shoppers in Medi‑Cal and the waiver wouldn’t save the state cash on web and truly would enhance state prices on condition that extra people can be receiving state advantages throughout applications in a number of departments. Accordingly, if the first legislative purpose of accelerating Medi‑Cal and waiver enrollments in DDS have been to economize, then our evaluation means that maximizing these enrollments wouldn’t obtain that outcome.

Nevertheless, if the first legislative purpose have been to maximise uptake in profit applications for which people are eligible, the Legislature might take into account possibility 3 (offering fingers‑on enrollment help) and/or possibility 4 (offering extra schooling and improved supplies to households and RC workers). The relative advantages of possibility 3 versus possibility 4 relies on legislative priorities. For instance, if the Legislature wish to enhance enrollments among the many eligible, however accomplish that with out growing administrative prices considerably, we advocate it require DDS to pursue possibility 4. If the Legislature is much less anxious about administrative prices, and sees profit in serving to each new enrollees in addition to these already enrolled with fingers‑on help, it might take into account requiring DDS and counties to pursue possibility 3. At a minimal, we advocate the Legislature require DDS and DHCS to translate types (the DDS selection kind and the DHCS waiver referral kind) into languages utilized by DDS shoppers and their households. This can be a easy, low‑value method to enhance enrollments amongst a minimum of a number of the eligible, however at the moment unenrolled, people.

We don’t advocate the Legislature pursue choices 1 (requiring enrollment) or 2 (incentivizing enrollment). Possibility 1—which had been proposed by the administration as a funds resolution in 2020—not solely wouldn’t save the state cash on web, however it probably would discourage some low‑revenue or undocumented households from searching for wanted RC‑coordinated providers. Possibility 2 would include an unsure value, be sophisticated to design and implement, and will not be significantly efficient.

Conclusion

The aim of this report was to discover methods to extend Medi‑Cal enrollment amongst DDS shoppers as a method to enhance federal reimbursements via the waiver and 1915(i) SPA and to offer a fiscal estimate of the whole affect on state spending. We discover that the potential for growing Medi‑Cal enrollment amongst DDS shoppers is proscribed, given that almost all eligible adults are enrolled already and plenty of kids don’t obtain an RC‑coordinated service (a prerequisite for institutional deeming). Furthermore, we discover that though extra enrollments would save the state cash within the DDS system, they’d result in a web value to the state as soon as different Medi‑Cal prices are thought-about. The Legislature nonetheless may see a coverage rationale for enrolling extra eligible people in Medi‑Cal, nonetheless, and we discover that offering fingers‑on help and bettering and increasing schooling and consciousness in regards to the Medi‑Cal and waiver applications can be the most effective approaches for attaining that purpose.

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