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
  • 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