1115 waiver california s bridge to reform
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1115 WAIVER CALIFORNIA’S BRIDGE TO REFORM. Los Angeles County Implementation May 2011. Key Waiver Facts. ▪ Expands Medicaid Coverage through December 31, __ 2013 ▪ Establishes Delivery System Reform Incentive Pool

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1115 waiver california s bridge to reform


Los Angeles County


May 2011

Key waiver facts

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

Medicaid coverage expansion mce

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

Mce hwla enrollment

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

Mce network adequacy out of network emergency services

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

Mce network adequacy geographic access standards

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

  • Mce network adequacy timely access standards

    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

    Mce network adequacy timely access standards cont

    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

    Mce network adequacy timely access standards cont1

    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

    Mce behavioral health integration

    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

  • Mce due process requirements

    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

    Safety net care pool

    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

    Sncp delivery system reform incentive pool dsrip

    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

    Dsrip lac dhs proposal

    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

    Dsrip lac dhs proposal cont

    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)

    Managed care for seniors and persons with disabilities spds

    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

    Next steps waiver implementation

    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

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