Healthy San DiegoMedi-Cal Managed Care

Healthy San Diego

Goal:

To establish a Medi-Cal managed care system that integrates public health functions and services of a local health department with private sector full-risk, full-service health plans.

Evolution of Healthy San Diego

Key Dates February, 1992 Commission on Health Care Reform

March, 1993 State Releases “Strategic Plan for Medi-Cal Managed Care”

October, 1993 Creation of Ad Hoc Governance Committee

October, 1994 Governor signs AB2176 “Healthy San Diego” Legislation

May, 1995 Creation of Healthy San Diego (HSD) Advisory Committees

April, 1996 Approval of HSD Contract Between State and County

Evolution (continued)

Key Dates January, 1997 Enrollment Presentations by County Staff

Begin April, 1998 CMAC Announces Recipients of HSD

Contracts October, 1998 Federal Waiver Approved November, 1998 Conversion to Mandatory Enrollment Begins July, 1999 New HSD Contract Approved August, 2000 New Health Plan Contracts Begin June, 2007 Current HSD Contract Expires

A Partnership

State Health Plans County Staff Consumers/Professionals

HSD Legal Relationships

Joint Committee

Health Plans

MOA’s

County

* *

*Contracts

•State agrees to participate in Joint P&C Committee•Delegates enrollment function•Allows other county roles

•Requires plan participation in Joint P&C•Requires MOA’s

State

Healthy San DiegoConsumer & Professional

Advisory Committees Purpose:

To monitor Medi-Cal managed care issues affecting San Diego County and to advise the Director, Health and Human Services Agency concerning those issues.

Subcommittees and Workgroups:Quality Improvement, Enrollment, Health Plan, Behavioral Health, Facility Site Review, Health Education and Cultural Linguistics, and QIP Task Force.

Purpose: The advisory committees were established in accordance with Welfare and Institutions Code Section 14089.05 to monitor Medi-Cal Managed Care issues or other issues concerning health care delivery that may impact upon this system and advise the Director, Health and Human Services Agency concerning those issues.

Healthy San Diego Advisory Committee Structure

H e a lth P lan W G B e h av io ra l H e a lth W G

F a c ilt iy S ite R e v ie w W G H E & CL W o rk G ro up

Q IP T a sk F o rce

Q I S u b co m m ittee

P ro vid e r E d u ca tion W G

E n ro llm en t S u b co m m ittee

Jo in t Co n sum e r & P ro fe ss io na l A dv iso ry C o m m ittee

D ire c to r H H S A

C h ie f A d m in istra tive O fficer

B o a rd o f S u p e rv iso rs

Healthy San DiegoJoint Professional &

Consumer Advisory Committee Physician Organizations Traditional Providers Hospitals Public Health Community Clinics Education Sector Legal Profession

Joint Committee (continued)

Mental Health Optometry Pharmacy Podiatry Dental Health Plans (all) Medi-Cal Beneficiaries Consumer Representatives

Joint Committee (continued)

Business Mental Health Taxpayer Associations Members at Large Ethnic & Cultural Groups

Healthy San Diego Health Plans

Blue Cross of California Care 1st Health Plan Community Health Group Health Net of California Kaiser Permanente Molina Healthcare of California

Who is Eligible to Enroll in a Managed Care Plan? Mandatory:

-CalWORKs

-Medi-Cal

Voluntary:-Foster Care/Adoptions

-Pregnant 21-65 not-linked

-American Indian

-Aged/Blind/Disabled (SSI)

Ineligible:-Long-term Care

-Share of Cost Medi-Cal

-Restricted Benefits Medi-Cal

-Full Coverage w/OHC

-Medicare HMO

Medi-Cal in San Diego County

Total Medi-Cal: 335,671 (5/06) Enrolled in Managed Care: 167,520 (5/06) Mandatory: 161,279 Voluntary: 93,540

Healthy San DiegoGuiding Principles:

1. Integration of public health/preventive health services with managed care plans

2. Local involvement in oversight, development of local standards, monitoring of the quality of care and outcomes system-wide

3. Opportunity for the inclusion of those health care providers who have traditionally served the Medi-Cal population

4. Consumer choice in the selection of health plans

Healthy San DiegoGuiding Principle #1: Integrate public/preventive health care with managed care Plans – Development & Implementation of MOAs. California Children’s Services Child Health & Disability Prevention (CHDP) Community Epidemiology Hansen’s Disease Immunization Program Maternal & Child Health Sexually Transmitted Disease Control Program Tuberculosis Control Program Children’s Emergency Shelter Care Facility (Polinsky Center) Office of Aids Coordination Mental Health Health Plan Site Review Health Education and Cultural Linguistics Refugee Health Assessment HIPAA Business Associate Provisions

Healthy San Diego

Carved Out Services

California Children’s Services Dental Health Mental Health Alcohol & Drug Services

Healthy San Diego

Guiding Principle #2:

Local involvement in oversight, development of local standards, monitoring of the quality of care and outcomes system-wide

HSD Quality Improvement Current Local Standards included in Exhibit A of HSD

Admin. Contract, i.e., membership of QI subcommittee, etc.

Access the Panorama data base Facility Evaluation Program. Establish and maintain a

collaborative process which decreases duplication while increasing compliance to regulatory and accrediting standards

Mental and Physical Health Coordination

Healthy San Diego

Guiding Principle #3

Inclusion of health care providers who have

been serving the Medi-Cal population

Safety Net Providers

Traditional Providers

Healthy San DiegoGuiding Principle #4 - Consumer Choice in Selection of Health Plans

Default Enrollment Enrollment/Disenrollment Exemptions Plan/Provider Choice – GeoAccess Education of Foster Parents on Their Options

for Healthcare (FFS vs. Managed Care) Community Presentations

HHSA District OfficesHealth Care Options

El Cajon North Inland Centre City Kearny Mesa Southeast

Lemon Grove Northeast North Coastal South Bay

Health Care Options Presentations

Specially-trained county staff Enrollment deadline is emphasized Individualized assistance available 892 is the average number of presentations

per month in 2006 3,450 people on average attend a

presentation each month

Health Care Options Presentations (continued) Provide answers to questions

• Enrollment packet described• Rights and responsibilities in Managed Care

explained• Default enrollment• Enrollment/Disenrollment • Exemptions • Plan/Provider choice - GeoAccess

Default Enrollment Process

30 days to choose Fill out the Medi-Cal Choice form Send to State HCO If no form is sent, the state selects the

health plan Beneficiary can change health plans at any

time for any reason

Disenrollment

Regular Disenrollment• Obtain, fill out and return Medi-Cal Choice

form• Need to choose another plan at time of

disenrollment• Change will be effective in 15-45 days• Beneficiary uses “old” plan until they receive a

notice from the State

Disenrollment (continued)

Emergency disenrollment• Have to request an “emergency disenrollment”• Provider needs to provide sufficient information

regarding medical emergency• If approved, disenrollment will take effect within 48-72

hours• If health plan provided services to beneficiary that

month, request may be denied• People not meeting emergency criteria need to follow

normal disenrollment process

Exemptions

Medical Exemptions• Pregnancy• Organ transplant• Needs skilled nursing services at home• Chronic renal dialysis RX• HIV+• Other complex or high-risk medical condition

To Apply for a Medical Exemption

The beneficiary’s doctor must complete the exemption form

The beneficiary must sign and date the form Fax form to State DHS

Healthy San Diego Evaluation

1. Independent Waiver Assessment of HSD GMC – Pacific Gateway Group – As required by the Center for Medicare & Medicaid Services (CMS), the State contracted with Pacific Gateway Group to conduct an Independent Analysis of the HSD 1915(b) waiver. This independent analysis indicated:

   a. Based on Pacific Gateway Group’s Independent Assessment, PGG

has determined that HSD is meeting and/or exceeding both its organizational goals and Medi-Cal managed care requirements set by the Center for Medicare & Medicaid Services (CMS), formerly HCFA, and DHS for healthcare access and quality.

 b. The San Diego Geographic Managed Care program for the waiver period of October 1998 through October 2000 was cost effective when compared to a comparable fee-for-service Medi-Cal population.

Healthy San Diego Evaluation (continued)

c. The assessment looked at the balance between the need to protect the liquidity of the health plans and to pay provider rates sufficient to maintain access. According to Pacific Gateway, “Based on the positive findings in the Independent Assessment on access and quality, this balance appears to have been successfully met during the waiver period.”

2. Enrollment Survey Task Force – Field Research Corporation – As required by AB 2780, which enacted W & I Code section 14016.55, the State contracted with Field Research Corporation to conduct a survey to determine reasons beneficiaries fail to choose a health plan. Comments and recommendations included in the report indicated the following:

a. Medi-Cal should consider adopting an approach similar to the one used in San Diego County, where presentations are built into the Medi-Cal program enrollment process and attendance is therefore nearly universal. If this is feasible, the presentations could provide the interpersonal assistance that many beneficiaries need and want.

Healthy San Diego

What Happens Next? – Major Initiatives• Continued Quality Improvement Activities • Coordination of Long Term Care

Integration into a Managed Care Model

Healthy San Diego

QUESTIONS?