Accreditation of Medi-Cal, Healthy Kids and Healthy Families Program.

Transcription

1 Accreditation of Medi-Cal, Healthy Kids and Healthy Families Program. 1

2 Overview of Medi-Cal Expansion Transition of HWLA Members to Medi-Cal Key Changes for Transitioning Members Continuity of Care Protections During Transition Key Challenges in Transitioning Homeless Population L.A. Care Readiness Efforts 2

3 Three Key Programmatic Changes for January 1, 2014 More people will be covered under Medi-Cal Medi-Cal eligibility will be simplified based on income only Medi-Cal behavioral health benefits will be expanded

4 California poised for significant Medi-Cal expansion on January 1, 2014 California s Low Income Health Program (LIHP) facilitated early enrollment of prospective newly Medi-Cal eligible population Los Angeles County s LIHP is Healthy Way L.A. (HWLA) LIHP/HWLA (matched) program ends on December 31, 2013 pursuant to California s federal 1115 Waiver

5 State law allows active eligible HWLA members to transition to Medi-Cal coverage effective January 1, 2014 In L.A. County, about 300K HWLA members expected to transition to full scope benefit Medi-Cal coverage Transitioning HWLA members will receive Medi-Cal coverage through Medi-Cal managed care plan Transitioning members provided Medi-Cal Plan and PCP choice No choice members shall be defaulted to Medi-Cal Plan linked to member s prior HWLA medical home 3

6 Accreditation of Medi-Cal, Healthy Kids and Healthy Families Program. 1

7 L.A. Care HWLA / Medi Cal Enrollment L.A. Care Member Assignment Based on Member Choice or Prior HWLA Clinic Home LA Care IPA Network (Non DHS) LA Care/ DHS PPG IPAs Physician / Ancillary Services L.A. Care contracted hospitals outpatient / inpatient DHS clinic DHS hospitals 4

8 Access to L.A. Care s Member Services Department for coverage questions and assistance to navigate managed care system Access to full Medi-Cal benefits through L.A. Care s provider delivery system Access to expanded Pharmacy Network through L.A. Care 8

9 L.A. Care provides 24 hour toll-free member service assistance to members and their representatives Explain benefits Assist with access to health care services Assist with resolving delays in care Access grievances and appeals rights Navigator Program The LA Care Health Navigator serves as the bridge of communication among the member, providers, and health plan services addressing any barriers to accessing care. Member can change clinic home or medical group via L.A. Care Member Services every 30 days Do not hesitate to refer your L.A. Care patients to our Member Service department for assistance at (888) 4LA-CARE 9

10 HWLA benefits were Medi-Cal like Medi-Cal covers the following services not available today through HWLA Program: Lower Level of Care Services Home Health Hospice Skilled Nursing Facility Dialysis 12

11 Vision (VSP) Vision care services are covered by L.A. Care. Members may contact VSP at for vision care and lenses benefit information. To find out more about eye exams or vision care coverage, members can also call L.A. Care Member Services Dental Benefits are not covered under L.A. Care Carved out to the Medi-Cal Denti-Cal Program. To find a Denti-Cal dentist (MCLA members up through age 21) Denti-Cal # Online at 13

12 Expanded Behavioral Health Services Benefit Mental Health & Substance Abuse Non-specialty mental health services will be covered through L.A. Care Health Plan More substance use disorder benefits will be available through L.A. County Department of Public Health Screening and Brief Intervention (SBI) for substance (alcohol) use will be performed by primary care provider

13 L.A. Care Pharmacy Network L.A. Care partners with 1,400 pharmacies throughout Los Angeles, including Sav-On, CVS, Rite Aid and many neighborhood pharmacies. Member receives information about pharmacy network L.A. Care Formulary Broader formulary of covered medications Under Medi-Cal, non-prescription drugs or over-the-counter drugs (such as cough/cold syrups, cough drops or aspirin) prescribed by a physician are a covered benefit. 16

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15 *Pending final State DHCS guidance Members transitioning from HWLA to Medi-Cal or self-pay provider are afforded continuity of care provisions: Completion of services by non-participating providers (Refer to H&S Code for detailed timeframes) Covered services include: acute conditions, serious chronic condition, pregnancy, terminal illness, and authorized surgeries/procedures Twelve (12) months of continuity of care with a specialist or primary care provider without regard to the condition criteria, if an existing relationship can be demonstrated Continuity for medication until member can be seen by primary care provider Note: Medical exemption requests (MERs) are not applicable for the LIHP transition members 15

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17 HWLA members whom are homeless may not be aware of HWLA coverage nor impending Medi-Cal eligibility Limited data to identify HWLA members whom are homeless Reaching out and communicating with members can be difficult HWLA medical home data may not be reliable or updated for homeless population Proactive case management challenging to implement

18 Accreditation of Medi-Cal, Healthy Kids and Healthy Families Program. 1

19 L.A. Care working closely with LA County DHS to exchange clinical and patient data in connection with HWLA members moving to L.A. Care Some specialty physician appointment data Member historical data for last 12 months Members with ongoing lower level of care needs (e.g. Home health, DME) Tracking log of members in out-of-network (non-dhs) hospitals at time of transition Some pharmacy utilization data Some homeless indicator data Patient HWLA clinic home data 19

20 Purpose of TRU* Goal To assist PPGs, providers, members and their representatives in accessing needed care in a timely manner. To facilitate and coordinate transition of members between DHS and L.A. Care/ PPGs Dedicated Staff: nurses, auth techs, and phone techs Time limited: 90 days from start of transition PPGs are still expected to handle continuity of care requests, as required. The TRU is an additional support to PPGs, it does not take the place of your E-list. Phone number: (855) ; Fax number: (855)

21 Pending final guidance, Through First Quarter CY 2014 Currently, HWLA members receive prescription drugs through DHS or Community Partner pharmacies To facilitate continuity of care the required transitional fill period is: 30 day supply with one 30 day refill This is applicable to the following: Non-formulary drugs or situations where member s ability to get the drug is limited Applies to any network retail, home infusion, long-term care and mail-order pharmacies 21

22 Verify Eligibility Need to know which IPA is financially at risk Determines which providers a member can use (e.g. lab- HCLA IPA) Contact L.A. Care s Member Service department if member needs to change and be assigned to more appropriate clinic home Contact L.A. Care s Transitional Resource Unit if assistance is needed if member is having difficulty accessing previous providers for continuity of care Collaborate to determine better ways to identify homeless members Collaborate to determine effective ways to communicate and reach members 24

23 L.A. Care Member Services Phone: (888) 4LA - CARE ( ) TTY/TDD (866) LA Care Transition Resource Unit Phone: (855) Right Fax: (855)

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