Transcript of Home and Community-Based Services 101 Under CalAIM by Disability Rights Education and Defense Fund held on June 7, 2024.
- SILVIA: Thank you, Ally. My name is Silvia Yee. We are presenting, Erin and I are presenting "Home and Community-Based Services 101 Under CalAIM. I am a policy director with Disability Rights Education and Defense Fund. We are a support center in for IOLTA in California, and we are also a national disability rights law and policy organization, which is now in our 45th year, I believe. I'll just introduce myself a little bit, and then turn it over to Erin to introduce themself. I use she/her pronouns. I have short black hair, tan skin. I'm wearing glasses and earrings. I have a blurred background, and I am also rather informally dressed in a hockey jersey because I am proud that my hometown team, the Edmonton Oilers, have made the Stanley Cup playoffs. And I will turn it over to Erin. ERIN: My name's Erin Neff. I'm a Senior Staff Attorney at DREDF. I've been a lawyer for about 10 years. I have long black hair. I am mixed race, white and Asian. I'm wearing a white and gray plaid shirt that has no cultural or athletic significance. And, you know, thank you all for joining us today. My background is white, and just so people know, we give these visual descriptions for anyone who might be visually impaired who are joining the training so that they can still participate. And yeah, I think that is it. And we can get started. Oh, some preliminary matters. First, this will be provided for MCLE credit. After the training, you'll receive an evaluation to fill out of the training, and then after that you'll receive a certificate for the MCLE. If for whatever reason you do not receive that information, you can, I'm just gonna put in the chat the email address for our operations manager, which is Diana, and she will manage like getting the certificates and evaluations. So for any reason you don't receive that information, usually it's sent out a couple days after the training. It's Friday, so you'll probably get it early next week. If for any reason you don't receive that information, just email Diana D. Vega at DREDF.org. And that was the last statistical thing, and then we can move into the substance of the training. And yes, this is recorded. And the slides will also be shared along with the evaluation, thank you. SILVIA: Thanks, Erin. So to begin with, this presentation is about home and community-based services. We're emphasizing a little bit the connection to housing, however. Historically, Medi-Cal, which is Medicaid in California, has had some links to housing and has recognized the need to particularly address the lack of housing faced by a number of Medi-Cal beneficiaries. There have been programs under Medi-Cal, such as the Medi-Cal Health Homes Program, which tried to connect health with housing services and help transition to housing, more permanent housing, or at least temporary housing. There's also been other programs such as the Whole Person Care Pilot. There have been the program of Drug Medi-Cal Organized Delivery System, and a coordinated care initiative that was specifically aimed at people with dual eligibility for Medi-Cal and Medicare. So it isn't as if Medi-Cal and home and community-based services have been completely solid from housing, but in general, there is a distinction because federal Medicaid dollars cannot be used for housing, straight out for housing. And so that brings us to this whole, the CalAIM Housing program, which is a very big waiver. And before I go on, I'll just give you a little bit of a roadmap of this presentation. After we've introduced ourselves and gone over the housekeeping, we really have two main parts for this presentation. First is looking at CalAIM, the explaining what it is, giving an overview of it, and looking at how the program intersects with housing, and especially the services of enhanced case management and community supports. The second part of it, which Erin will cover, is a review of the Medi-Cal waivers that are offered in California that provide home and community-based services. And finally, we'll end with just a short look at how to complain about or appeal medical decisions, and including CalAIM. So looking at the next slide. That will be introducing the CalAIM goals and eligibility. So, CalAIM is short for California Advancing and Innovating Medi-Cal. It's the state's five-year plan to implement significant changes to the Medi-Cal program, and it's gonna take place over 2022 to 2027. The intent is to integrate healthcare more seamlessly with a variety of other social services. California is a huge state. We have had a collection of benefits, programs, Medi-Cal and otherwise in the state, and they're very fragmented. It's hard to navigate and negotiate them all. And in general, like Medi-Cal recognizes that. The Department of Healthcare Services, which is California's Medicaid agency, recognizes that. Because almost 90% of Medi-Cal is delivered through managed care, Medi-Cal plans play a really key role in CalAIM. And you'll note that, you know, 90% in California compares to about 74% of Medicaid beneficiaries enrolled in managed care nationally. Our state has a history of really relying on Medi-Cal plans. So, CalAIM has an explicit goal of increasing equity so that the program has a concept of population health, and the goal is to match the right patients to the right services at the right time. And if that sounds a little euphemistic, it really is. And of course everyone would like that to happen, it doesn't always happen. It's interesting to think about categorization versus individualized assessment. The CalAIM program is thinking a little bit in terms of categories, recognizing certain people in certain categories as having, facing greater health risk, facing greater environmental, and other barriers to maintaining care, and also facing greater risk of homelessness. So those are the categories, and you can prioritize those categories for getting extra assistance. On the other hand, there's individualized assessment, which is perhaps the highest goal. Like everyone gets an assessment that's tailored to what they as an individual need in terms of their health and other social needs. Individualized assessment takes a lot of care, a lot of time, a lot of money. Population management is a way to try to bridge that a little bit. The other goals of CalAIM a involve payment reform and greater accountability for the healthcare plans that deliver Medicare, Medicaid for the most part in California. So the two, I think, well, I'll address that right now too. The categories, some of the categories that CalAIM is really focused on are people with significant behavioral health needs, including people with mental illness, serious emotional disturbance, and or substance use disorder. It focuses on seniors and people living with disabilities. It looks at people experiencing homelessness who also have complex physical or behavioral health needs. Another category is people transitioning from jail or prison back to the community who also have complex physical or behavioral health needs. Children with complex medical conditions such as cancer, epilepsy, or congenital heart disease are also another category. And finally, children and youth in foster care. So, two CalAIM services new programs that are of particular interest to the attorneys that are serving people with disabilities, your clients, are enhanced case management and community supports, so the next few slides will be looking mostly at these programs. The next slide then is looking at the CalAIM housing community supports. You know, it's a pretty, it's a great list. We have in our slides some, some resources that will help you delve into them in more detail than we're able to cover in our time right here. DHCS threaded a line here between maintaining flexibility for plans and being prescriptive with the kinds of supports that they know are needed. The community supports are a substitute service. They include 14 possible supports that are supposed to be provided in lieu of other Medi-Cal services that may not currently be needed. And many of these services relate to housing in a range of ways. And they do include transitions or diversions from nursing homes, whether to assisted living facilities or private community-based living situation. I'll go through some of these here on this list. I'm just pushing out my glasses because I'm very nearsighted. So managed care plans and can choose, they're not mandated to provide all of these services. And across the state, you'll find that some plans have chosen some while others may have chosen different ones from this list, so that makes it a little harder. You can find out what your plan is providing, but it's not necessarily uniform across all plans or across the state. So a key one is just finding housing, transitioning into housing, and getting help with the applications, the whole process of finding housing. A second one is actually providing housing deposits, and that can include housing security deposits, utility setup fees, first and last month's rent, and the first month of utilities. Another key one is support and maintaining safe and stable housing, so that can include coordination with landlords, and that can be particularly important to people with disabilities who need to figure out modifications that can be allowed within the apartment or in a common area that are needed for the person to stay safely there. It can include help with annual housing recertification and with being linked to community resources that will help a tenant to avoid eviction. Another service is recuperative care, which is short-term residential care. For those without housing and who are still, they don't belong in a hospital anymore, but they still need to be recuperating from an illness or injury and may need some help with meals or personal care. Short-term, post-hospitalization housing looks at a place to recover after institutional care, and note that this requires a recent discharge from some institution. It could be a medical institution, clinical care, or it could be a behavioral institution. Respite services are available on an hourly or daily or nightly basis for care to be given in the member's home, and that can be especially important for someone who is receiving personal care assistance from a family member, or from someone who on a, perhaps a temporary basis or on a limited basis. There's also day habilitation, some of these we'll be looking at in later slides too. Day habilitation, which looks at helping provide skills to live at home and independently, so that can include mentoring on social, self-help, and adaptive skills. And also general support that can be needed for transitioning into housing, recovering from, you know, if a member is found inebriated in some way, high on something in the community, they're supposed to have available to them or can have available to them a sobering center. There can be assistance with getting medically supportive food, or physical or structural modifications like a ramp or air filtration in the apartment or home for a child or adult with asthma. And as you can see, this is a really a pretty wide ranging list, and it includes a lot of services that would really be helpful for a lot of clients, I think. There's also the reality though, which is that stable, safe, accessible, scattered site and sustainable or affordable housing is not readily available in many areas in California. And in addition, plans and the community-based providers who plans are supposed to contract with to provide community supports have reported various issues with getting these services in place. It's been hard to wrap up quickly enough to meet demands, and the hopes of those who are the architects behind CalAIM. Some of the issues including, include community-based organizations not having enough staff or systems in place to handle medical billing, and being wary of working so closely with large risk-averse managed care plan systems. Managed care plans have said they're not used to acting basically as grant makers to community-based organizations, and lack experience and understanding in how community-based organizations operate and are structured. Plans also feel a lot of time pressure from the Department of Healthcare Services to have everything in place. And all of this is just to say, while there is a large list of great services available and each plan should have explicitly some services that they offer, it may take some advocacy and time to actually get to the services for your client that are listed here. Looking at the next slide, we're just gonna look a little bit more at the housing transition and navigation services. So again, these are the kinds of services that a lot of people who need housing that are barriers for people who need housing. A tenant screening and assessment, and this raises a lot of issues. I think it's hard for clients to even know sometimes what they're being screened for or what is getting, what is stopping them from getting housing. There should be access to get help with an individualized housing support plan and help with setting up goals. And with this, I mean that some of that goes to the enhanced case management, and that's another service that is, that's one of the key services. It's potentially available to, potentially available to any Medi-Cal beneficiary, but it is at this point focused on the populations that I listed at the beginning, foster youth, people with disabilities, people who are unhoused. The goal is that that will be rolled out, that kind of case management will be rolled out to the entire medical population over time, and there are grants being paid that have been going on over the last year to help achieve that. Again, it's a matter of of time, of making it available, and of probably some pushing. There is a recognition that for many people with disabilities, for people who are unhoused, there is the linking of the services that are needed to stay healthy, to maintain housing. The coordination is often that missing element that, and if you are not feeling well, if you are have no base, if there's no place you feel safe, then it's also really hard to coordinate for yourself. If you can't pay your phone bill, if you can't, all of these are elements, it's very easy to have someone just fall off. So the enhanced case management can be a very valuable service, and that is not something that is, that only some plans can take up. That is supposed to be available through all plans, and for the priority populations, at least for now. Housing search, the time, the energy needed for that. Completing housing applications, which can be a problem, including for people who are English learners or who have limited English literacy. Benefits advocacy, and this is a key one, identifying and obtaining rental subsidy and coverage for expenses. The moving in starting housing is can be very challenging. Reasonable accommodations, environmental accommodations, we've mentioned a few of those before, relating to asthma, relating to ramps. It also includes things like grab bars, lots of other, and things like flashing alarms, being able to reach the mailboxes in one's lobby. Those are all components of kinds of accommodations. Landlord engagement. And I do recall that my co-presenter Aaron has spoken about, I think they've spoken about how someone can help you with landlord engagement, but at some level a landlord can be quite resistant to that, and that there's always a need to navigate that, and it can be very, it can be helpful to have a third party involved ensuring a safe living environment, and the whole thing, transition into housing, transportation, and a crisis plan, which is very important for many people with disabilities who may have a thinner margin of health than those who don't have disabilities. And I'll just add to go off what you were saying, Sylvia, is that, yeah, I've litigated a lot of cases with landlords, and they're often times like very unresponsive to tenants, especially when they're asking for something that requires a landlord to do something more than they would otherwise have to do. And I think in situations like this, it might be best to couch it in terms of requesting a reasonable accommodation. Like they should like in theory still engage with any sort of case management services, but if they're not and the person has a disability, and that might be why they're using some of these housing navigation services, you can also request that as a reasonable accommodation, and that has a little bit more force of the law in that the landlord really then legally has to respond to that. SILVIA: Thank you, Erin. So the next slide looks a little bit at the day habilitation programs, and those are pretty interesting. They really offer a variety of skills meant for self-help and socialization. And so some of that includes something as practical as how to behave in a benefits office with, I mean, which may seem strange, which may seem strange to some of you, but I think we've also had or heard of clients who are invited to leave by a security officer when it is at an office, assuming they can find a benefits office that is still actually open to people coming. Skills using public transportation, conflict resolution, interpersonal relationships, and so these are all in addition to the general self-help and independence needs of learning how to cope for yourself, cleaning, money management, and so forth. So those can be very useful as well, and one thing to really note is that peer mentoring should be a key component of all of, of all of these community-based services, these community supports because it's more, much more palatable to be having someone come alongside you who has been where you have been, or in a similar situation than someone who seems to have gotten their education from a book only. So that's just a recognition in the CalAIM program that peer mentoring is important and works. Noticing the time, I'm gonna go more quickly through the next couple of slides so I can hand it over to Erin. I think both of us would really like to get to some questions of possible at the end of this. Looking at housing tenancy, tenancy and sustaining services. I'm just looking through quickly to see if some of, yeah, some of the, yes, the interventions and behaviors, the education of rights and responsibilities. Tenants may not always know what their rights and responsibilities are, and landlords are not always the ones to tell you what the landlord's rights and responsibilities are, so it's important to get that element of education. Benefits, advocacy, as I said, this is a lifeline. It may not be enough, but it's something. And getting social security or getting other benefits that are important to just helping you stay alive are obviously important. Health and safety visits can also be a critical component, helpful to those who may need some level of monitoring, and general independent living services. So some of this has been mentioned in prior slides as well. And then the last slide in my part is just looking at eligibility, and this is, I mean, this does vary somewhat depending on the specific benefit. Earlier, as I said earlier, in potentially every Medi-Cal per individual, every member can qualify for these services. But there's also, there are also specific requirements such as for the housing services, meeting a HUD definition of homeless, of if that's the service you're looking for. If the service is for those who are homeless, then you need to meet the HUD definition of homeless, of being homeless, as well as the HUD definition of being at risk of homelessness. The HUD definition may not emphasize however the leading, wanting to leave, wanting and being able to leave a nursing home. So just noting that that is a component of CalAIM, having a serious mental illness, or a serious chronic condition, or being at risk of institutionalization. So these are all specific elements that may be required for the service that you're seeking from your plan. And just keeping in mind, again, the populations that CalAIM is really focused on, people with significant behavioral needs, youth and foster care, people experiencing homelessness who also have complex physical or behavioral health needs. If your client is in those categories, they, yeah, then that increases their chances of being eligible for these services. So we're just gonna transition over to looking at home and community-based waivers, and a little bit of an explanation I could have given earlier, but I saved for now, which is that the idea of waivers. Waivers are named that way because they allow states to waive the normal Medicaid requirements under the Medicaid Act, and the Medicaid Act sets up the rules of the joint federal and state program, which is funded by the feds and funded by state. And a few provisions, a few different provisions in the act allow the states to waive some of those rules and create programs that are intended for a specific group of Medi-Cal beneficiaries rather than all Medi-Cal beneficiaries. And those special programs in turn, and rather confusingly, are called waivers. So all of CalAIM is one huge waiver, and then there are also specific waiver programs that encompass and make available home and community-based services, and Erin will be going through those. ERIN: First I'm just going to drop in the Q&A... Oh, I think I'm gonna drop in the chat a link that answers Valerie's question, and then we can, just 'cause that's a little bit easier of a response and then we can get to, that's for the definitions of homelessness for HUD. Sylvia, if you can answer the other question, or we can get to that at the end. I was just in the middle of doing that as we're transitioning the slides. And so as Sylvia is saying, you know, the purposes of the waivers is to really help people with disabilities, to help people who are elderly, help people have certain illnesses be able to live more independently, and live in the community. It's for people who are Medi-Cal eligible, and then we'll go into the different specific waivers that are listed here. If you wanna move to the next slide. So the Assisted Living Waiver, this again is to help people remain in the community. It's an alternative to being placed in a nursing facility or other sort of institution that has a less independence and a higher level of care. This waiver also helps to facilitate transitioning for seniors and people with disabilities from a nursing facility to a less restrictive setting. For the people who are eligible for this waiver, they need to have a need of care that is at the nursing home level, and to those with Medi-Cal funded residents living in nursing facilities. It's important to note that in order to receive this area, it's limited to certain regions. And I apologize, I should have added those regions to the slides, but we can add those to the chat. And then to be eligible for this, unlike some of the other waivers that perhaps, sorry, age restrictions, this is for people who are 21 and older, for all the waivers, it's being Medi-Cal eligible, having a full scope Medi-Cal eligibility with zero share of costs, and someone who's able and willing to reside safely in an assisted living facility or publicly subsidized housing in one of the counties. As I mentioned, one of the specific areas, either that you live there or you're willing to move there. And the next slide, please. So the home and community based alternatives or HCBA waiver, this is specifically for care management services to people who are at risk of being in a nursing home or other sort of institutional placement. People who receive this waiver receive a care management team. People who are part of the care management teams are like nurses and social workers, and some of the benefits that the team provides includes medical resources, behavioral health resources and assistance. They can also provide in-home supportive services. And again, the idea is to stay and be part of the community, so they're also working with local community organizations to provide long-term support so that they can reside in the community. And when we say reside in the community, this is fairly broad. It could be someone who is residing with their family, someone who's, you know, residing in a more traditional apartment, leasing from a landlord situation. In order to be eligible for this, this is a person of any age who again is Medi-Cal eligible, meaning that same level of care of the nursing facility level of care. The waiver is also specific to people in certain target groups who have specific behavioral conditions, people with developmental intellectual disabilities. We'll get into this a little bit more later. There is a waiver specifically for people with developmental disabilities, and in general, you can't have more than one waiver. So even though you might, you're in this targeted group, there might be another waiver that's more appropriate to your disability or needs. You also have to meet certain financial eligibilities. Now, sorry, there's an odd typo in the last line, but I believe there is still currently a wait list for this type of waiver, and that information is available online and you can check out regularly, but there's been a wait list for almost a year now. And next slide, please. SILVIA: Yes. ERIN: Oh, go ahead. SILVIA: Sorry Erin, I'm sorry, I inserted the current, right, as of now it's 5,035 people on the wait list, that's what. ERIN: Oh. Sorry, I didn't know what that number was. SILVIA: Yeah, yeah, I just looked it up this morning, just to be clear. ERIN: I thought that was meant to be a date, and I was like, "Oh, it's an odd date." Okay. As of April, there's that many people on the wait list, unfortunately. And the next slide, please. So the Home and Community-Based Services Waiver for the developmentally disabled. So as I was saying, even though that previous waiver we went over target specific groups like people who are developmentally disabled, this waiver is specifically for people who are developmentally disabled. It might be a better waiver depending on a person's needs. So this allows a person with a developmental disability to live at home, again, residing in the community instead of a residential facility or nursing care facility where they're more isolated from the community. In order to be eligible for this waiver, you need to have formal diagnosis of an intellectual or developmental disability. Again, you need to be in one of the areas of the regional centers. There's 21 areas of that. Excuse me, I can add that to the chat after, or Sylvia, if you have a second to look up those areas. Your level of care required for this eligibility is equivalent to licensed healthcare facility for people with intellectual disabilities, so you'd be eligible to be in such an institution, but are able to live at home, and then are eligible for this waiver. And then you are eligible for full scope Medi-Cal eligibility. And if you're under that age of 18, institutional indeeming is a part of this, and what that basically means is that in order to assess your eligibility for the waiver and you're under 18, they won't look at the income of your parents. If you're a married individual, they won't look at the income of your spouse. That way it makes more people eligible for this waiver and for Medi-Cal, because it doesn't take into, it only takes into consideration the income assets and resources of the individual, which is really helpful because even, you know, if you're 18, you're still under your parents' health insurance, that your parents' health insurance might not cover the wide range of needs that a person with a developmental disability will have that Medi-Cal will cover, so that's why the institutional deeming is a part of the eligibility. Next slide, please. So the next one is the Multipurpose Senior Services Waiver, and the name would suggest this is specifically for people who are senior citizens, people who are 65 and older. Again, this is an alternative to a nursing care facility, and is enabling people to live in the community, to live more independently. So this comes with a wide range of services to help people who are senior citizens. There's some listed here, and this isn't an exhaustive list, so it includes case management, money management, overall supervision and care, personal care services, which can include adult daycare, someone coming into the home and providing personal care services, respite care, which as Sylvia talked about before enables a family member who might be caring for an elderly person to be able to get a respite from that and have someone else come in and provide services so that family member can have a break from that. Environmental accessibility adaptations, so this is, again, similar to what Silvia was explaining, where you might be adding bars to a shower to make things just more accessible for people who are elderly so that they can live and stay in their home. It also includes minor repairs, transportation to and from services, meal services so that elderly people are able to eat and take care of themselves. This could be delivered, this could be provide in a congregate setting. Communication services includes interpretation, translations, social reassurance, therapeutic counseling to help with mental health. It also includes emergency communication devices if a person's in an emergency situation, and it also includes stay-in home care if a person needs that, as well as someone to come in and help with cleaning and basic chores of the home. To be eligible for this waiver, again, you have to be 65 and older, a senior citizen, require a nursing level, a nursing facility level of care, be Medi-Cal eligible, and again, live in one of the counties that is required. Next slide, please. So the Medi-Cal Waiver Program, this is was formerly known as the AIDS Waiver. That name changed I think a couple years ago, but it's still the case that this waiver is specifically for people who HIV positive or have AIDS. So this provides case management and direct services to people living with HIV/AIDS. Again, as an alternative to being in a nursing home facility or being in a hospital or other form of hospitalization. The services that this waiver provides is disease management services, being able to manage having HIV, providing services to prevent the transmission of HIV, and providing resources, treatment services to manage and stabilize the health of person who has HIV or AIDS, and overall services to improve the quality of life and wellbeing of a person with HIV and AIDS. The waiver is also designed to really try to target underserved populations of people who are HIV positive, as well as provide a transition to people to an appropriate program of care based on their needs and how their health might change over time, to make sure that the treatment that they're receiving is matching their level of health at the time. To be eligible for this program, again, you have to be Medi-Cal recipient at a nursing facility level of care. You can't be enrolled in the program of all inclusive care for the elderly. You have to have HIV or AIDS with related signs, symptoms, or disabilities. You have to, in addition to being at a nursing facility level of care, you're scoring 60 or less on a cognitive and functional ability scale assessment. The waiver also applies to children under 13 who might have symptoms of HIV and AIDS, someone requiring in-home health services, and a situation where a home setting is safe both for the person with HIV and AIDS, and a service provider. Next slide, please. And this is back to Silvia. SILVIA: Thank you, Erin. I was just looking at some of the questions, and I think there's probably one there. And, oh, I know someone has raised a hand too. How about I just cover these last two slides we have, and then we can look at the hand. If that makes sense? ERIN: Yeah, SILVIA: So, okay, because these, the services that we're covering here are so much made available through plans. The plan processes are a pretty important part of the complaint. Oh, are we at medical services? Oh, I went past. Actually would like to go back one I think to the... Oh, I'm probably ahead then. Sorry. Oh no, it's my fault. Go back to the, go back to the one you were at. I'm sorry, thank you Ally. So we're looking at medic, we titled this "Medi-Cal Hearings," but in fact to get to the Medi-Cal hearings, you really need to be looking and working with your plan, or filing a complaint with them. One of the things is just calling medical, member services for help in being persistent, trying to, if you have, if you have an enhanced case management, your case worker should be able to help you. If your complaint is about enhanced case management, or not getting it, or not getting what you think you should be getting through it, then you'll be looking at filing a formal complaint or a grievance with your plan. They're supposed to give a response in 30 days and get back to you more quickly if it's a really urgent matter. And then you, with a Medi-Cal managed care plan, you can file an appeal. You will get a decision, and you should be able to file an appeal of that. I'm just going to get to another. Here we go. A lot of this is, I'm just getting sorry to a, right. Okay, an appeal of that because they should be, your plan should be giving you when they deny you something, when they say you're not eligible or for coverage, you should be getting something called a notice of action, an NOA, and that should include the decision, whether it was about eligibility or coverage or the effective date of coverage. It should have the decision on it. It should have the date, the decision is effective, as well as any changes to your eligibility status or your level of benefits. Any change in your medical status should be formalized to you in a notice of action. The notice of action also must include information about your hearing rights and how to appeal the decision if you disagree with that eligibility determination. I have heard of some advocates, some attorneys having trouble even getting the notice of action. And I've also heard sometimes of, from beneficiaries who say that they're not getting timely notices of action or they're being sent to the wrong place. So those are all issues that can happen, and then, you know, need to be considered as well. If you're just not getting it, a plan, I guess it's easy to say this, but a plan should not be doing that. And I think that should definitely be raised with advocates is as an advocate you can definitely be pursuing that, and there are also resources that we, which can provide after the health hotline hotline that the Western Center for Long Poverty and the National Health Program run here that provides backup for attorneys who are working on these, on Medi-Cal issues. So that would be very problem problematic if you can't get your notice of action because that date provides, it gives you information about when to file an appeal. So if you're looking for, to escalate this to go up to a Medi-Cal fair hearing or a state fair hearing, you have to do so within 90 days of getting the notice of action, or have some good cause for why you've extended beyond it, beyond that time. And if you can't, if you haven't gotten your notice of action at all, but arguably that's clearly good cause. And then going on, there is the Department of Managed Healthcare in California, a very unusual department nationally actually, which provides independent medical reviews and a complaint process. The Department of Managed Healthcare is unusual for crossing both private and public plans. Any managed care plan is subject to the jurisdiction of the Department of Managed Healthcare. The independent medical review process may not be as relevant to the services we've looked at here, the home and community-based services, enhanced case management or community supports because it's mostly a medical review. If your health plan denies or changes or delays your request for medical services, then you would file for an independent medical review, and DMHC will have people look at it and perhaps change the plan decision. And if it's an emergency treatment, then you can get a response faster. The complaint process may be more relevant to home and community-based services, and the ones who have covered here, DMHC has 45 days to respond and 7 of expedited. But that they do also strongly recommend or require that the plan process, grievance process has been gone through first. So you can't really just skip to them without complaining with the plan. So that's a quick overview of the process, and hopefully we have a little time left for questions. I think we have answered, tried to answer some of them in the Q&A, and then we did have the raised hand as well, so. Oh, okay, well I'll look at that one. And do you want to address the raised hand? Can we potentially take that? I'm not sure how that would. [ALLY] Yes, I just allowed the person, I think. Let me see. SILVIA: Valerie, I think? [VALERIE]: Yes, I apologize. I hadn't intended to raise my hand. I don't know if I did that inadvertently, I apologize. SILVIA: Oh, no problem. [VALERIE]: And thank you for answering my questions. Looking forward to that hotline information too for Western Poverty Center, et cetera, if you can provide that. SILVIA: Oh, yes. VALERIE: Thank you very much. SILVIA: Well, they're a backup to attorneys. [VALERIE]: Okay, yeah. SILVIA: More so than just the community, but yes. [VALERIE]: All right, thank you. SILVIA: Then there was a question in the chat, "Can someone is on the DD waiver also be on CalAIM?" You know, CalAIM applies... That's a really, really interesting question. CalAIM applies is intended to sort of transform a lot of the overall delivery of Medi-Cal in the state. So if you are on the DD waiver and you're also in a managed care plan, which I think you probably are, then I think you would be. Hmm. Erin, did you say that you want to address, to answer this? ERIN: No, you can go ahead. SILVIA: Oh, okay. Because I'm just sort of- ERIN: I was just like doing logistically that you were answering it. SILVIA: Oh, okay. The sign I got was that you would like to answer, so then I was like, "Oh, okay." Yeah, I mean, yes, you can only be on, what, I think it kind of depends on the source of the waiver too. Like, you couldn't be on a DD waiver and a home and community-based alternative waiver, for example. Those are the waivers that you are on one. The CalAIM is a type of waiver, but... Oh, thank you. Someone just wrote in the answer, which is that, hmm, two different people, but I think that's, Moira Gibney has said and told us that people on the DD waiver cannot access ECM, enhanced case management. And that makes sense, because the DD waiver, in theory provides an element of case coordination, but they can access some community supports if they're not a duplication of what is already available through the DD waiver, and I think that makes a lot of sense. And thank you, Sabrina. Sabrina Epstein has also let us know that CalAIM is an 1115 demo. It's like, waivers are all called waivers because they have things in common, they're waving elements of the Medicaid Act, but they're authorized by different sections of the Medicaid Act. So CalAIM is an 1115 demo, and this one that is affecting Medi-Cal quite broadly. The 1915 C waivers include the DD waiver and the other waivers that Erin went through, so Sabrina thinks that you should be able to do both, and I thanks both to Moira and to Sabrina who have essentially said like they're both right. You can access some elements of the CalAIM services, the programs and services made available through CalAIM as long as they're not duplicative of what you already should be getting through the DD waiver. Those are great questions, thank you. Thank you to both Sabrina and Moira and for the original question. Are there any other questions that any of you have? We're at 12:54, so we do have a few minutes. And I certainly also recognize that the people on this on this webinar are fantastic resources, so. Okay. If we don't have specific questions, we might, we might just let you go earlier. Are there any more housekeeping matters, Erin? ERIN: Well, I'll just, Valerie just asked, "Is there a website for more info?" We'll share the slides, but I would just suggest checking out the California government websites for DHCS on the waivers, like the best and most updated information are gonna be on the California government websites for the waivers or the housing programs. SILVIA: Right, and we have tried to put in the notes of the slides a number of the resources that were helpful to us. One of the more recent ones, well, relatively recent that DHCS put out is a kind of a cheat sheet to the community supports and enhanced case management services, and it is trying to get across what is in the discretion of the plan and what is mandated by the state. And there's this, it varies, which does of course make it complicated, and it varies somewhat depending on the level of risk that is attributed to an individual member. So, that is quite an annoying thing in some ways. But, so that cheat sheet is useful, and the DHCS has put out a number of fact sheets that provide more details on both of these services. Yeah, and I'll leave it at that for now. One more thing on the, I mean, we've looked pretty quickly at the sort of the grievance complaint process. Okay, two sort of more caveats. My understanding is that if you are a member of a plan that does provide, that says it provides certain services and you have been evaluated for them and get them, and then the plan decides, "Hmm, you don't need them anymore, we're gonna change it," that is I believe something you can complain about and grieve. And the other thing is a caveat to know that the budget in California has been hit badly. In May the governor put out a budget revise, and some, there is probably some impact from there, but it's not finalized yet, 'cause the budget hasn't, itself hasn't been fully finalized and signed. It will be later in June. There's also some interaction between the legislature and the governor's proposed May revise. For instance, the governor proposed not making IHSS, in-home supportive services, available to immigrants, even despite the expansion of Medi-Cal to many immigrant populations, to pretty well most immigrant populations at this point. The legislature pushed back on that. So there can be an impact on things like the number of waiver slots that have been added, and there have been some additions. Not enough to, back in January there were some waiver slots added and they weren't enough to wipe out the wait list, but it was nice to have them for people in the second or third year of the waiver that, so that we need to keep an eye on that for potential changes. Okay. I am going to I think leave it at that for now if there are no further questions, and, yeah, thank you so much for joining us. Erin, anything? ERIN: Nothing on my end, have a great weekend everybody. Thank you for joining us. SILVIA: Thank you.
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