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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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.
To monitor Medi-Cal managed care issues affecting San Diego County and to advise the Director, Health and Human Services Agency concerning those issues.
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.
Guiding Principle #1:
Integrate public/preventive health care with managed care
Plans – Development & Implementation of MOAs.
Carved Out Services
Guiding Principle #2:
Local involvement in oversight, development of local standards, monitoring of the quality of care and outcomes system-wide
Guiding Principle #3
Inclusion of health care providers who have
been serving the Medi-Cal population
Guiding Principle #4 -Consumer Choice in Selection of Health Plans
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.
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.”
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.
What Happens Next? – Major Initiatives