Medicaid Managed Care: Keeping your clients connected to care in a changing environment

Lessons, advice, and warnings from CaliforniaVanessa Cajina, Legislative AdvocateFamilies USA, January 23, 2014

WESTERN CENTER ON LAW & POVERTY

We made it! Happy January 2014!

First things first:

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:

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 1st to start an Exchange, & one of the 1st to

enact the full Medicaid expansion

A little background:

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

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

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

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

To Rural California

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

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

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

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

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: http

://www.healthconsumer.org/cs016knoxkeene.pdf http

://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=hsc&codebody=&hits=20

Knox Keene cont’d

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

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

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

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

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?

Western Center on Law and Povertywww.wclp.org – vcajina@wclp.org

National Health Law Programwww.healthlaw.org &http://www.healthlaw.org/issues/medicaid/managed-care/continuity-of-care-in-medi-cal#.UtcYWLRXL5M

For more information and model language: