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Rural Health Clinics Medi-Cal Managed Care

STATE HEALTH PROGRAMS. Rural Health Clinics Medi-Cal Managed Care. and. Janice Milligan, Director Public Health Programs Eric Villegas, Senior Public Health Administrator December 5, 2007. STATE/LOCAL SPONSORED HEALTH COVERAGE. MEDI-CAL FEE FOR SERVICE INDIGENT CARE CHDP FAMILY PACT

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Rural Health Clinics Medi-Cal Managed Care

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  1. STATE HEALTH PROGRAMS Rural Health Clinics Medi-Cal Managed Care and Janice Milligan, Director Public Health Programs Eric Villegas, Senior Public Health Administrator December 5, 2007

  2. STATE/LOCAL SPONSORED HEALTH COVERAGE • MEDI-CAL FEE FOR SERVICE • INDIGENT CARE • CHDP • FAMILY PACT • MANAGED CARE (GMC/2 PLAN) • HEALTHY FAMILIES • HEALTHY KIDS

  3. RURAL HEALTH CLINIC SCOPE OF SERVICES • MENTAL HEALTH • DENTAL • WIC SERVICES • GATEWAY • FAMILY PLANNING • TARGETED CASE MANAGEMENT • INDIGENT CARE • LAB • RADIOLOGY • HEALTH EDUCATION • TRANSPORTATION • IMMUNIZATION • PHARMACY • PRIMARY CARE

  4. CONTRACT ISSUES / MANAGED CARE PRIMARY CARE (HCFA 1500) • PM 160 PROCESS • DENTAL SERVICES • HEALTH EDUCATION • MENTAL HEALTH • TRANSPORTATION • SPECIALTY ACCESS • WIC SITES

  5. CONTRACT DEVELOPMENT Health Net’s goal is to create/provide a medical home for our members. • Primary Care Provider (PCP): Directs all care • Medical Home • “A Medical Home is not a building, house or a doctor’s office. It is a health care provider that knows their patients and the community in which they live.” • PCP Standard Contract Model: • Needs re-design • Needs out-of-the-box thinking and creative solutions • Commitment to change

  6. RURAL HEALTH SPECIALTY ACCESS • Lack of Specialty Providers in rural areas • Access is further limited by plan/networks • Specialists limiting access based on referral/payer source mix • Health Plan referral management practices/prior authorization • Further complicated by specialty-ancillary relationships (i.e. lab, radiology, etc.)

  7. GETTING OUT OF THE BOX Health Net’s Next Steps…

  8. CONTRACTING • Would a different contracting methodology be better? • Examples: Capitation, Budget Contracting, Fee for Service w/ quality bonus, per diem, utilization? • Does it make sense to develop a contract methodology with incentives for wrap-around services provided by your facility, including dental, mental health, health education, etc? • Would a contract arrangement around primary care services that involves care management of patients/member make sense?

  9. HEALTH NET CONTACTS • Northern San Joaquin Valley/Sac Sierra • Ellen Brown (916) 935-1438 • Terri Howell (209) 556-1402 • Merced, Madera, Fresno, Tulare County • Eric Villegas (559) 447-6122 • Eloisa Estrada (559) 447-6124 • Kern, Kings County • Alexis Esparza (661) 321-3914 • Heather West (661) 321-3904 • SouthernCalifornia • Rogelio Lopez (619) 521-4916

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