California’s Coordinated Care InitiativeDepartment of Health Care Services

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Overview of today’s discussion regarding Coordinated Care

• Movement toward Coordinated Care and Managed Care

• Coordinated Care Initiative:• Goals• Components• Planning

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PART 1: AN OVERVIEW OF MEDI-CAL MANAGED

CARE

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What is Managed Care – in general

• Medicaid managed care provides for the delivery of Medicaid health benefits and additional services in the United States through an arrangement between a state Medicaid agency and managed care organizations (MCOs) that accept a set payment – “capitation” – for these services.

• There are two main forms of Medicaid managed care,

“risk-based MCOs” and “primary care case management (PCCM).”

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Medi-Cal Managed Care Models

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Part 2: California’s Coordinated Care Initiative

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Why Coordinated Care?• Some people with multiple chronic conditions see an

average of 14 different doctors and fill 50 prescriptions a year.

• This is common among people with both Medicare and Medicaid, referred to as “dual eligibles,” who often are sicker and poorer than other beneficiaries.

• Today’s care delivery system is fragmented and doesn’t provide the care coordination dual eligibles need. This fragmentation leads to increased risk of admission to the hospital or nursing home.

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State Efforts to Coordinate CareCalifornia is on the forefront of the movement toward coordinated care.

1. Seniors and Persons with Disabilities transition into Medi-Cal managed Care

2. Community-Based Adult Services (CBAS) as a managed care benefit

3. Expansion of managed care in rural counties4. Coordinated Care Initiative (CCI), including

the Duals Demonstration

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CA’s Coordinated Care Initiative (CCI)

• Building on many years of stakeholder discussions, the CCI was enacted in July 2012 to expand coordinated care to Medi-Cal beneficiaries in eight counties.

• CCI will start no sooner than April 2014.

Two Parts1.Medi-Cal Managed Long-Term Services and Supports (MLTSS)

• Mandatory enrollment into a Medi-Cal health plan for all Medi-Cal benefits, including LTSS and Medicare wrap-around benefits.

• Who: Nearly all Medi-Cal beneficiaries, including dual eligibles

2.Cal MediConnect - Duals Demonstration• Optional enrollment into three-year demonstration program for coordinated

Medicare and Medi-Cal benefits through a single organized delivery system.

• Who: About 456,000 full benefit duals are eligible to participate

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8 CCI Counties• Los Angeles

• Health Net and LA Care (MLTSS)• Health Net, LA Care, Molina, Care1st and Care

More• Orange

• CalOptima (MLTSS) • San Diego

• Molina, Care 1st, Community Health Group, Health Net

• San Mateo • Health Plan of San Mateo

• Alameda • Alameda Alliance & Anthem Blue Cross

• Santa Clara • Santa Clara Family Health Plan & Anthem Blue

Cross• San Bernardino

• Inland Empire Health Plan & Molina• Riverside

• Inland Empire Health Plan & Molina

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CCI: One person, one plan, all benefits

• Brand new opportunity to coordinate care:• Medical care• Integrated long-term services and supports (LTSS):

• In-Home Supportive Services (IHSS)• Community Based Adult Services (CBAS)• Multipurpose Senior Services Program (MSSP)• Nursing home care

• Coordination county mental health and substance use programs

• CCI Goals:• Empower people to achieve their health goals.• Help people stay in their homes -- and stay out of the hospital and nursing

home.• Improve care coordination across all health care and social services.• Bend the health care cost curve.

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Why integrate Medicare and Medi-Cal?

• Medicare cost sharing• Long-term nursing

home (after Medicare benefits are exhausted)

• Long-term services and supports (LTSS) (including CBAS, MSSP, IHSS, HCBS waivers)

• Prescriptions and durable medical equipment not covered by Medicare

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• Hospital Care• Physician & ancillary

services• Short-term skilled

nursing facility care• Home health care• Hospice• Prescription drugs• Durable medical

equipment

Medi-Cal Medicare

• Lack of Coordinated Care

• Programs in silos

• Misaligned Incentives

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Cal MediConnect: What are my choices?1. Get your Medicare and Medi-Cal benefits together in one

health plan. • You can enroll in a single health plan for all of your health care services.

Joining one of these plans is voluntary.

OR2. Get ONLY your Medi-Cal benefits in a health plan.

• You can keep your Medicare benefits like they are today, but you still must enroll in a health plan for your Medi-Cal benefits. (long-term care services and extra Medicare cost-sharing)

• Note: Enrolling in a health plan for Medi-Cal benefits only won’t change or affect your Medicare services. You can still see your Medicare doctors.

OR3. Get your Medicare and Medi-Cal benefits in a PACE plan.

• You can enroll in the Program of All-Inclusive Care for the Elderly – called PACE – if you meet certain criteria.

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Long-Term Services and Supports in Managed Care• In-Home Supportive Services (IHSS) is personal care for people

who need help to live safely at home. In a health plan, you will keep your IHSS providers and can still hire, fire, and manage them. The county IHSS social worker will still assess your needs and approve your IHSS hours. Your rights to appeal will stay the same.

• Community Based Adult Services (CBAS) is adult day health care provided at special centers. Your health plan will work with you and your physician if you need this service.

• Multipurpose Senior Services Program (MSSP) provides social and health care coordination services for people 65 and older. Your health plan will work with MSSP providers to provide this service.

• Nursing home care is long-term care provided in a facility. Your health plan will work with your doctor and nursing home to make sure your medical and long-term care needs are met

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Coordinated Care Initiative Protections•Meaningful Information of Beneficiary Rights and Choices

• Notices sent at least 90, 60 and 30 days prior to enrollment.

•Continuity of Care• People can continue to see their Medi-Cal providers for 12

months and Medicare doctors for 6 months.•Self-Directed Care

• People will have the choice to self‐direct their care, including being able to hire, fire, and manage their IHSS workers.

•Appeals & Grievances• DHCS is working with CMS on a coordinated appeals

process.• Strong Oversight & Monitoring• Evaluation Coordinated with DHCS and CMS.

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Timeline• March 2013: MOU was signed.• August 2013: State and Federal governments will conduct

a readiness review of the health plans. • December 2013: Three-way contracts between the health

plans, CMS and the State established.• 2013 and 2014: Development and release of notices to

beneficiaries • April 2014: CCI begins• Ongoing: Beneficiary and provider outreach

Key Focus Areas for CCI Implementation• Enrollment – clear communication, broad outreach

• Sufficient provider participation – engagement, and collaboration will be critical for success

• Rate Development – aims to 1) align fiscal and quality incentives; 2) adequate for demo services; 3) slow cost growth

• Data Sharing – critical for success prior to enrollment between state and plans and after implementation between local partners

• County Coordination for delivery of IHSS and behavioral health services

• Encounter data – reliable data will be needed for quality monitoring & evaluation

• HCBS Universal Assessment – development began 2013 and implementation in 2015, California will use a Universal HCBS Assessment tool, built on IHSS Uniform Assessment, Hourly Task Guidelines and other appropriate HCBS assessment tools.

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What do these changes mean for beneficiaries?• More fully integrated care

• “One-stop shopping”

• Choices with regard to plan selection

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What do these changes mean for providers?• A system that connects supportive services to acute care

services

• Better outcomes for patients

• Potentially new ways of doing business with health plans

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Key Things to Remember about the CCI• People can keep the Medicare and Medi-Cal benefits they

have today.• For dual eligibles, Medicare coverage and rules will

remain primary • People with IHSS will continue self-directing their care.

Counties will decide hours.• Care coordination will help people stay in their homes and

stay out of the hospital and nursing home.• People’s needs and preferences will drive the care

they get.

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Stay Informed

Website: www.CalDuals.orgEmail: info@CalDuals.org

Twitter: @CalDuals

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