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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
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