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1115 WAIVER CALIFORNIA’S BRIDGE TO REFORM Los Angeles County Implementation May 2011.

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Presentation on theme: "1115 WAIVER CALIFORNIA’S BRIDGE TO REFORM Los Angeles County Implementation May 2011."— Presentation transcript:

1 1115 WAIVER CALIFORNIA’S BRIDGE TO REFORM Los Angeles County Implementation May 2011

2 Key Waiver Facts ▪ Expands Medicaid Coverage through December 31, __2013 ▪Establishes Delivery System Reform Incentive Pool ▪Implements Managed Care for Seniors and Persons with Disabilities (ongoing)  Continues Safety Net Care Pool funding ▪New Waiver funding will partially address the __Department's budget gap 2

3 Medicaid Coverage Expansion (MCE)  Builds on current Coverage Initiative (HWLA)  Funded by 50% County and 50% Federal funds  Adults ages 19-64 years with incomes of 133% or less of the Federal Poverty Level, citizen/legal permanent residents 5+ years  New program start date: July 1, 2011 3

4 MCE (HWLA) Enrollment  Approximately 60,000 current HWLA members will be “grandfathered in” to the new program  Initial focus on enrolling existing DHS/PPP patients (150,000 potentially eligible)  DHS/PPP patients on General Relief (50,000+)  Patients using both DHS and DMH services (8,000)  Next enrollment wave to target homeless, General Relief, and DMH high utilizers not currently using DHS/PPP  Ultimate goal to enroll all eligible LA County residents 4

5 MCE Network Adequacy: Out-of-Network Emergency Services ▪ Coverage for out-of-network ED and post-stabilization care ▪ Coverage only for "true" emergencies ▪ Private EDs will receive payment for previously uncompensated care to the MCE population ▪ Patients cannot be billed for emergency services 5

6 MCE Network Adequacy: Geographic Access Standards  Non-DHS hospitals (or transportation) will be required in three areas:  Antelope Valley  West LA  San Gabriel Valley  Public Private Partner (PPP) community clinics will help ensure primary care coverage 6

7 MCE Network Adequacy: Timely Access Standards  Primary care appointments within 30 business days initially, reducing to 20 days from 7/1/12 to 12/31/13  Urgent care appointments within 48 hours  Specialty care appointments within 30 business days  After-hours consultation available 24/7 7

8 MCE Network Adequacy: Timely Access Standards (cont.)  Primary care access  Empanel patients with primary care teams (6 pilots started late February)  New county personnel item: Certified Medical Assistant -- will allow other staff to work at “top of license”  Conduct staff trainings on medical home model and registry use  Implement Disease Management Registry in primary care medical homes 8

9 MCE Network Adequacy: Timely Access Standards (cont.)  Specialty care decompression  Identify patients no longer requiring specialty care, and hand off to medical home provider  Develop standardized referral guidelines  Move to centralized referral process for more timely processing  Expand alternatives to face-to-face visits (e.g., telemedicine, telephone/email consults, etc.)  Work with affiliated medical schools to ensure DHS specialty care priorities are met 9

10 MCE Behavioral Health Integration:  Co-locate mental health services with primary care in DHS facilities  3 sites already implemented; 3 more scheduled  Implement depression screening and treatment by primary care providers in DHS facilities  Additional integrated services under development 10

11 MCE Due Process Requirements:  Applicants can appeal eligibility denials  Members can file grievances regarding access to care, etc.  Members have right to appeal grievance findings and right to hearing 11

12 Safety Net Care Pool ▶ New Waiver continues SNCP funding for public hospitals‘ uncompensated care ▶South Los Angeles Preservation fund will be covered through the CI (Medicaid expansion) and the SNCP ▶State will also claim from the SNCP for State general fund relief ▶If certain State and County commitments are not accomplished, the SNCP will be reduced 12

13 SNCP Delivery System Reform Incentive Pool (DSRIP) ▪ Approximately $200M to LAC DHS in first year, approx. $230M in years 3 to 5 of Waiver; plan approved by CMS ▪ Receipt of funds conditional on achievement of milestones and Waiver goals: - Improving patient care experience - Improving population health - Reducing per capita health care costs ▪ Four general project areas eligible for funding: - Infrastructure Development - Innovation and Redesign - Population-Focused Improvement - Urgent Improvement in Care 13

14 DSRIP: LAC DHS Proposal  Infrastructure Development  Expand Disease Management Registry utilization  Expand access and utilization of nurse advice line  Enhance coding and documentation  Enhance performance improvement and reporting capacity  Innovation and Redesign  Expand medical homes  Expand chronic care management models  Integrate physical and behavioral health care 14

15 DSRIP: LAC DHS Proposal (cont.)  Population-Focused Improvement (measurement)  Patient and caregiver experience  Care coordination  Patient Safety  Preventive Health  At-risk populations  Urgent Improvement in Care (inpatient)  Improve outcomes for patients with sepsis  Prevent central line bloodstream infections  Reduce surgical site infections  Prevent and treat venous thromboembolism (VTE) 15

16 Managed Care for Seniors and Persons with Disabilities (SPDs) ▪ One year phase-in of SPDs to Medi-Cal managed care based on month of birth starting June 2011 ▪ Default assignments will be based on previous providers and utilization history; may also consider plan quality and whether safety net providers are included in plan network ▪ Knox-Keene requirements, including adequate network and timely access, must be met ▪ County will be assigned lives through LA Care and will work to assure adequate numbers are assigned to DHS 16

17 Next Steps - Waiver Implementation ▪ Proceed with implementation of ambulatory care restructuring and MCE requirements ▪ Assess need for other internal restructuring and process changes to ensure achievement of milestones ▪ Develop retention strategy for SPDs and new Medicaid enrollees ▪ Restructure relationships with PPPs to meet Waiver requirements and system goals ▪ Continue working with DMH and DPH to integrate _behavioral health services 17

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