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1115 WAIVER CALIFORNIAS BRIDGE TO REFORM Los Angeles County Implementation May 2011 Slide 2 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 2 Slide 3 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 3 Slide 4 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 4 Slide 5 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 5 Slide 6 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 6 Slide 7 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 7 Slide 8 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 8 Slide 9 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 9 Slide 10 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 10 Slide 11 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 11 Slide 12 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 12 Slide 13 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 13 Slide 14 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 14 Slide 15 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) 15 Slide 16 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 16 Slide 17 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 17