Medi-Cal: Len Finocchio, DrPH Associate Director California Department of Health Care Services

Transcription

1 Medi-Cal: An Overview of the Managed Care Delivery System Len, DrPH Associate Director California Department of Health Care Services Medi-Cal At a Glance California s Medicaid Program Largest Medicaid program in the country (enrollees) Second largest total expenditures in the country Accounts for the 2nd largest share of the state s general fund Source of coverage for 7.7 million Californians Nearly 1 in 5 California residents 1 in 3 children Majority of people living with HIV/AIDS 2 1

2 Relevant State Departments California Primary and Acute Health Services Single State Agency In-home Support Services (IHSS) Adult Day Health Care Services and MSSP Regional Center and Developmentally Disabled Community Based Services Mental Health and Substance Use Services 3 Medi-Cal Delivery Systems Ø Fee for Service Ø Medi-Cal Managed Care Ø PACE Program for All-Inclusive Care for Elderly 4 2

3 Brief history of Medi-Cal Managed Care Now 1983 Waivers (CenCal in Santa Barbara, Health Plan of San Mateo) 1993 Clinton administration expands DHS authority to implement Two-Plan and COHS. California expands county-based Medi-cal managed care BBA encouraging more expansion of managed care Hospital waiver proposed to CMS to cover more SPDs Waiver transition SPDs into managed care. Now Duals demonstration, CHIP transition, and Rural Expansion Transition Medi-Cal expansion population from LIHP 5 Medi-Cal Managed Care Models Geographic Managed Care (GMC) Ø State contracts with various commercial plans in county (2 Counties) Two Plan: Ø State contracts with one local public plan and one commercial plan (14 Counties) County Organized Health System: Ø State contracts with a local public plan (14 Counties plus one proposed County) Of the 7.7 million Medi-Cal beneficiaries, 4.9 million are enrolled in a Medi-Cal Managed Care Plan 6 3

4 California Two-Plan Models County Plans Total Members Alameda Alameda Alliance for Health, Anthem Blue Cross 162,933 Contra Costa Contra Costa Health Plan, Anthem Blue Cross 90,475 Fresno CalViva Health, Anthem Blue Cross 232,952 Kern Kern Family Health, Heath Net 160,325 Kings CalViva Health, Anthem Blue Cross 24,938 Los Angeles LA Care, Health Net 1,490,412 Madera CalViva Health, Anthem Blue Cross 30,468 Riverside Inland Empire Health Plan, Molina Healthcare 273,519 San Bernardino Inland Empire Health Plan, Molina Healthcare 323,587 San Francisco San Francisco Health Plan, Anthem Blue Cross 71,325 San Joaquin Heath Plan of San Joaquin, Anthem Blue Cross 128,643 Santa Clara Santa Clara Family Health, Anthem Blue Cross 153,897 Stanislaus Anthem Blue Cross, Health Net 84,670 Tulare Anthem Blue Cross, Health Net 120,131 Totals 3,348,275 7 California GMC Models County Plans Total Members Sacramento Anthem Blue Cross, Health Net, Kaiser Foundation, Molina Healthcare 231,465 San Diego Care 1st Health Plan, Community Health Group, Health Net, Kaiser, Molina Healthcare 273,700 Totals 504,

5 California COHS County Plans Total Members Marin Partnership Health Plan of CA 17,755 Mendocino Partnership Health Plan of CA 20,905 Merced Central California Alliance for Health 76,117 Monterey Central California Alliance for Health 76,736 Napa Partnership Health Plan of CA 14,950 Orange CalOptima 392,426 San Luis Obispo CenCal 26,491 San Mateo Health Plan of San Mateo 64,676 Santa Barbara CenCal 66,121 Santa Cruz Central California Alliance for Health 36,222 Solano Partnership Health Plan of CA 63,308 Sonoma Partnership Health Plan of CA 55,936 Ventura Gold Coast Health Plan 105,756 Yolo Partnership Health Plan of CA 27,149 Totals 1,047,548 9 PACE organizations in California Nearly 3,400 Medi-Cal Beneficiaries are enrolled in PACE organizations throughout California. Applications are being processed for potential new PACE organizations in Los Angeles, Orange, and San Bernardino counties. Current PACE organizations and counties include: PACE Organization AltaMed Senior BuenaCare Center for Elders' Independence Los Angeles County County Alameda, Contra Costa On Lok Lifeways Alameda, San Francisco, Santa Clara Sutter SeniorCare Community ElderCare of San Diego dba St. Paul's Sacramento County San Diego County 10 5

6 Strategic Initiatives in Seniors and Persons with Disabilities (SPD) transition 2. CCI / Duals Demonstration 3. Plan monitoring and oversight 4. Managed care expansion 5. Medi-Cal & California Health Benefit Exchange 6. Healthy Families (CHIP) transition 7. Low-Income Health Program (LIHP) 11 Population growth in Medi-Cal Managed Care SPD Transition ( ): 240,000 Coordinated Care Initiative (CCI) / Duals Demonstration (2013): 550,000 Managed care expansion (2013): 340,000 CHIP transition to Medi-Cal (2013): 875,000 Low-Income Health Program (2014): 460,

7 Strategic Initiative #1: Seniors & Persons w/ Disabilities (non-duals ABD) Part of 1115 Bridge to Reform waiver Transitioned 240,000 into managed care plans Transitioned by birth month, over one year Included additional notices to beneficiaries Conducted outreach activities Worked collaboratively with the plans on transition 13 Lessons from Seniors and Persons with Disabilities (SPD) Transition You can never do enough outreach Key lessons for current initiatives: Target providers In particular, target the physician community Engage in comprehensive beneficiary outreach effort Get de-identified data to plan as early as possible 14 7

8 Strategic Initiative #2: Duals Demonstration Medi-Cal Services not covered by Medicare (i.e. transportation, vision, dental, mental health services) Medicare cost-sharing Long-term skilled nursing Personal care services, and other home-based services Lack of Coordinated Care Siloed Programs Misaligned Incentives Medicare Hospital services Physician services Temporary skilled nursing facility Rehabilitation services Home health services Dialysis Durable medical equipment Prescription drugs Hospice 15 Duals Demonstration Goals Coordinate benefits and access to care, improve continuity of care and services. Maximize the ability of dual eligibles to remain in their homes and communities with appropriate services and supports in lieu of institutional care. Increase availability and access to home- and community-based alternatives. 16 8

9 Duals Demonstration Goals Preserve and enhance the ability for consumers to self-direct their care and receive high quality care. Improve health and satisfaction with care. Optimize the use of Medicare, Medi-Cal and other State/County resources. 17 Duals Demonstration Timelines 2011 Spring: DHCS released an Request for Information (RFI) August: RFI Conference in Sacramento Fall & Winter: Stakeholder outreach; 3 public meetings 2012 January: DHCS releases Request for Solutions (RFS) to select counties with qualifying health plans May: Demonstration Proposal to CMS June: CCI Trailer Bill passes (SB 1008) Ongoing stakeholder involvement at local and state levels Q4-2012: MOU/Contract development and health plan readiness review process 2013 Q1-2013: State, CMS, and health plans sign 3-way contracts Q2-2013: Enrollment in the Demonstration begins 18 9

10 Proposed Demonstration Model Benefits: Medicare Part C & D and Medicaid, plus LTSS integration IHSS and other HCBS, nursing homes will be contracted with the managed care plan Behavioral health integration Goal is to include mental health and substance use as managed care benefits by 2015 Care Coordination required and essential benefit; State developing standards Supplementary benefits Dental, vision, etc, strongly encouraged Consumer Protections DHCS will work with CMS and stakeholders to develop: Beneficiary notifications, Network adequacy, Appeals process 19 Strategic Initiative #3: Plan Monitoring & Oversight State as a purchaser will increase quality of its oversight Key activities: Encounter reporting Health Plan dashboards Visual depiction of monitoring next slide 20 10

11 Plan Monitoring 21 Strategic Initiative #4: Managed Care Expansion Into 28 remaining FFS counties (mostly rural) Key activities: Robust stakeholder process Input on procurement and model of managed care Provider and consumer engagement 22 11

12 Strategic Initiative #5: Medi-Cal & California Health Benefit Exchange Working very closely to implement ACA Considering how to maximize purchasing power: Coordinated contract elements Shared monitoring & oversight Shared quality metrics Issues to address for consumers: Mixed eligibility status families Plan and provider network overlap 23 Strategic Initiative #6: Healthy Families (CHIP) Transition 875,000 children to be transitioned 2013 Transition to occur in four phases January 2013 April 2013 August 2013 September 2013 DHCS anticipates significant provider overlap 24 12

13 Strategic Initiative #6: Low-Income Health Program Part of 1115 Bridge to Reform waiver Early expansion of new Medicaid coverage group County run and financed Over 400,000 enrollees; 500,000 by 2014 Plan for transitioning to managed care plans (2013) 25 Managing Changes & Growth As delivery system transitions to managed care and more fully integrated managed care, DHCS will undergo transitions Key transitions: Emphasis on plan oversight and monitoring Emphasis on fully integrating care across continuum Increased emphasis on matrix departmental structure 26 13