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Healthy San Diego Medi-Cal Managed Care. 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

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Healthy San Diego Medi-Cal Managed Care

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healthy san diego
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
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
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
a partnership
A Partnership
  • State
  • Health Plans
  • County Staff
  • Consumers/Professionals
hsd legal relationships
HSD Legal Relationships
  • Stateagrees to
  • participate in Joint
  • P&C Committee
  • Delegates enrollment
  • function
  • Allows other county roles
  • Requires plan
  • participation in Joint
  • P&C
  • Requires MOA’s




Joint Committee


Health Plans



healthy san diego consumer professional advisory committees
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.


Healthy San Diego Advisory Committee Structure

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 joint professional consumer advisory committee
Healthy San DiegoJoint Professional & Consumer Advisory Committee
  • Physician Organizations
  • Traditional Providers
  • Hospitals
  • Public Health
  • Community Clinics
  • Education Sector
  • Legal Profession
joint committee continued
Joint Committee (continued)
  • Mental Health
  • Optometry
  • Pharmacy
  • Podiatry
  • Dental
  • Health Plans (all)
  • Medi-Cal Beneficiaries
  • Consumer Representatives
joint committee continued11
Joint Committee (continued)
  • Business
  • Mental Health
  • Taxpayer Associations
  • Members at Large
  • Ethnic & Cultural Groups
healthy san diego health plans
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




-Foster Care/Adoptions

-Pregnant 21-65 not-linked

-American Indian

-Aged/Blind/Disabled (SSI)


-Long-term Care

-Share of Cost Medi-Cal

-Restricted Benefits Medi-Cal

-Full Coverage w/OHC

-Medicare HMO

Who is Eligible to Enroll in a Managed Care Plan?
medi cal in san diego county
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 diego15
Healthy San Diego

Guiding Principles:

  • Integration of public health/preventive health services with managed care plans
  • Local involvement in oversight, development of local standards, monitoring of the quality of care and outcomes system-wide
  • Opportunity for the inclusion of those health care providers who have traditionally served the Medi-Cal population
  • Consumer choice in the selection of health plans
healthy san diego16
Healthy San Diego

Guiding 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 diego17
Healthy San Diego

Carved Out Services

  • California Children’s Services
  • Dental Health
  • Mental Health
  • Alcohol & Drug Services
healthy san diego18
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
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 diego20
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 diego21
Healthy San Diego

Guiding 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 offices health care options
El Cajon

North Inland

Centre City

Kearny Mesa


Lemon Grove


North Coastal

South Bay

HHSA District OfficesHealth Care Options
health care options presentations
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
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
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
  • 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
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
  • 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
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
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
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.”

  • 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 diego32
Healthy San Diego

What Happens Next? – Major Initiatives

  • Continued Quality Improvement Activities
  • Coordination of Long Term Care Integration into a Managed Care Model