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Medicaid Managed Care: Keeping your clients connected to care in a changing environment Lessons, advice, and warnings from California Vanessa Cajina, Legislative.

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Presentation on theme: "Medicaid Managed Care: Keeping your clients connected to care in a changing environment Lessons, advice, and warnings from California Vanessa Cajina, Legislative."— Presentation transcript:

1 Medicaid Managed Care: Keeping your clients connected to care in a changing environment Lessons, advice, and warnings from California Vanessa Cajina, Legislative Advocate Families USA, January 23, 2014 WESTERN CENTER ON LAW & POVERTY

2 We made it! Happy January 2014! First things first:

3  Roadmap for today:  California’s Medicaid program (Medi-Cal), and our historic managed care populations  Other California laws and protections for health care consumers  How our state managed to get pretty much all of our populations into managed care  How we fought back, and continue to do so: tips, tricks, and flashpoints  Resources and state laws and regulations Okay, now down to business:

4  Population-wise, the largest state in the nation: 38 million  We’re officially a “majority-minority” state: 2/3s people of color & almost 40% Latino in 2012  43% of us speak a language other than English at home  We have the highest poverty rate in the US - almost 25%  Our state budget: Back in black  We were the 1 st to start an Exchange, & one of the 1 st to enact the full Medicaid expansion A little background:

5  US’ largest Medicaid program: about 7.6 million people  Medi-Cal provides free, comprehensive coverage for:  1 in 5 Californians under age 65  1 in 3 of our kids  Most people living with AIDS  We also cover:  Low-income parents  People with disabilities  Pregnant women  Seniors about age 65  And we’re excited that we NOW cover childless adults from age 19 up to age 65! Medi-Cal: At a glance

6  1966 – California creates Medi-Cal following Title XIX of Social Security Act created Medicaid  1973 – first Medi-Cal managed care plans established  1982 – state creates 3 County Organized Health Systems (COHS). A COHS is the health plan for ALL Medi-Cal beneficiaries in that county; 3 more added in 1990  1992-96 – Additional managed care models adopted throughout California  1993 – State required most children and parents with Medi- Cal to enroll in managed care  2011 – Feds ok’d move of Seniors and Persons with Disabilities & Duals into managed care, expansion into rural areas A brief history of Medi-Cal

7  Managed care can be a good fit, particularly for people with lower health needs or those in good overall health  However, it can be very hard to navigate for people with multiple providers, specialists, subspecialists, or those who use non-medical services like durable medical equipment, pharmacies, other long-term services  These navigation problems are especially prevalent during transitions between traditional Medicaid to managed care  And what do provider contracts look like? How are your medical groups regulated – how much risk do they bear and does that impact treatment decisions?  Can the health plan guarantee that their networks are adequate for the population they serve, including specialist access, subspecialists, hospital contracts, etc… The pros & cons of managed care

8 From the County of Los Angeles, with a total population of 9.9 million *About 2.39 million Angelenos will be Medi-Cal-eligible with the ACA expansion

9 To Rural California For example, Mono County has a population of under 15,000 and a population density of 4 people per square mile

10 California currently has 6 models of managed care delivery, with each of 58 counties choosing which model to employ – each with its own regulations and sets of operations

11  Under CA law, most Medi-Cal managed care plans are treated like commercial managed care plans, meaning they have to follow certain laws in providing and helping patients access care Some of our tools include:  Knox-Keene Act – the granddaddy of California health consumer protections  Continuity of care  Medical Exemption Requests  Contract language, health plan oversight California Protections

12  The big law in California that regulates managed care plans, including most Medi-Cal plans  Passed in 1975 with subsequent amendments, includes:  Services covered  Access standards  Consumer protections  Quality assurance  Grievances & dispute resolution  Financial protections & solvency for plans, contracts & licensure Knox Keene – CA Health & Safety Code § 1340-1399.818

13  Since enacted, great provisions added on requiring plans to provide language assistance and interpretation to consumers  Provides for Continuity of Care – we’ll discuss in a moment  More information available at:   bin/calawquery?codesection=hsc&codebody=&hits=20 bin/calawquery?codesection=hsc&codebody=&hits=20 Knox Keene cont’d

14  An existing policy within our Medi-Cal program  The use of MERs was expanded when SPDs were required to enroll in managed care  Permits a beneficiary to opt out of managed care if s/he has a relationship with a doctor/nurse midwife/licensed midwife who is not part of a health plan  In California, this is a narrow document and the MER only lasts 12 months  When new populations are added to mandatory managed care, MERs are typically added to legislative language Medical Exemption Requests

15  Beneficiaries have the right to completion of certain covered services they were getting from a non- participating or terminated provider, under some conditions  Services for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, and some planned surgeries must be provided for up to 12 months  Medi-Cal enrollees newly enrolled in a plan can continue RX as long as RX was in effect when the beneficiary moved into the plan.  An underused protection, and subject to a health plan negotiation with the non-participating provider Continuity of Care

16 1.SPDs: FFS to managed care -Additional RX authorizations if their MER was denied, plus other protections. -New enrollees can request to see FFS provider for up to 12 months – must have seen the provider in the last 12 months – provider must accept the higher of the plan’s rate or the Medi-Cal FFS rate. Plan must notify SPD within 30 days of request. 2. Duals: FFS to managed care -Duals in certain counties may request treatment with out-of-network providers for 6 months if they have seen provider twice in last 12 months. 3.Children shifting from CHIP to Medi-Cal: managed care to managed care -Kids going to a new health plan will get preference in keeping their PCP -If child’s PCP isn’t in new plan, the child may keep that provider for 12 months Continuity of Care for special populations

17  Medi-Cal is administered by the state’s Department of Health Care Services, but participating plans are regulated by the Department of Managed Health Care  Demand that contracts be public, as well as correspondence and directives from the plan’s regulator or contract manager including subregulatory guidance  Establish relationships with health plans and provider organizations Administrative Advocacy

18  Draft and advocate for model language if the transition is a foregone conclusion – even piecemeal fixes can help  Start with gradual additions of types of beneficiaries – perhaps children & families, or adult expansion Medicaid population  Your state has a D majority? Talk to labor – some home care unions have found that managed care could be better for their members  Your state has an R majority? Pit health plans against providers and choose your friends and battles wisely Is your state considering expanding managed care?

19  Western Center on Law and Poverty –  National Health Law Program & care/continuity-of-care-in-medi-cal#.UtcYWLRXL5M For more information and model language:

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