Duals Demonstration. An Overview for Home Medical Equipment Providers

Transcription

1 Duals Demonstration An Overview for Home Medical Equipment Providers

2 Overview Background Medi-Cal Delivery Models State Budget Coordinated Care Initiative Duals Demonstration Overview Goals Population Coordinated Care CalOptima-HME Partnership and Contracting Timeline 2

3 Background

4 Background: Delivery Models Medi-Cal Managed Care Models Geographic Managed Care: State contracts with various commercial plans Two-Plan: State contracts with a local public plan and commercial plan County Organized Health Systems (COHS): State contracts with a local public plan Fee-for-Service (FFS) Fee-for-Service: State contracts with individual providers 4

5 Background: State Budget State budgeted to spend $91.3 billion through 6/30/13 There was a $15.7 billion shortfall State came up with $16.6 billion in solutions that includes: $8.1 billion in spending reductions $6 billion in revenues $2.5 billion in other solutions Part of the $8.1 billion in spending reductions includes $1.8 billion in spending reductions to the Medi-Cal program State options for Medi-Cal savings 1. Lower enrollment by changing eligibility criteria Federal law prohibits states from changing Medicaid eligibility 2. Lower provider payments 3. Eliminate optional benefits 4. Change health care delivery system High risk for litigation; already among lowest in the country High risk for litigation; 9 benefits previously eliminated Better coordination of services 5

6 Background: CCI June 2012 Passage of Coordinated Care Initiative (CCI) is a step toward more coordinated and integrated delivery models Major components: Integration of Long-Term Services and Supports (LTSS) Long-Term Institutional Care Multipurpose Senior Services Program (MSSP) Community-Based Adult Services (CBAS) In-Home Supportive Services (IHSS) Timeline: March 2013 Duals Demonstration Integration of Medicare and Medi-Cal Services Timeline: June

7 Duals Demonstration

8 Duals Demonstration Overview National pilot program: For people who have Medicare and Medi-Cal ( Medi-Medi or dual ) Focuses on making it easier to get available services by combining Medicare and Medi-Cal into a single health plan and creating one accountable entity to coordinate care Jointly run by CMS and the states: California applied and was one of 15 states chosen Coordinated Care Initiative gives California authority to participate in pilot California selected demonstration sites based on: Experience in providing services to dual eligibles Well-established partnerships among county agencies, providers and health plan Demonstrated ability to create an integrated and coordinated system of care 8

9 Duals Demonstration Overview Orange County selected as a demonstration site: CalOptima Board of Directors gave authority to proceed with application process Board asked staff to collaborate with Provider Advisory Committee and Member Advisory Committee to seek input and recommendations from stakeholders Provider Stakeholder Workgroup: Open to any provider stakeholder Member Stakeholder Workgroup: Open to any member stakeholder Behavioral Health Workgroup: Orange County Health Care Agency and CalOptima IHSS Workgroup: Social Services Agency, Public Authority and CalOptima Board will make final decision to participate in Duals Demonstration when final program details are released 9

10 Duals Demonstration Goals Coordinate Medicare and Medi-Cal benefits Ensure access to care across all settings, including home care and long-term care as appropriate Maximize the ability of duals to remain in their homes and community Increase availability, access and coordination of home- and community-based alternatives Preserve and enhance the ability for members to self-direct their care in a compassionate environment 10

11 Dual Eligible Population About 1.1 million duals live in California 66% are 65 and older 50% live on <$10,000/year 74,000 live in Orange County; 6.7% of total Many duals have complex needs Have multiple health conditions, see several providers and take a lot of medication Average member has 8 conditions, sees up to 15 providers and takes 10 medications May be culturally isolated or have language barriers In Orange County, 25% speak Vietnamese, 15% speak Spanish and 10% speak other languages Struggle to access health care because of challenging financial and social issues Have difficulty navigating through a complex system of disconnected programs Duals account for disproportionate share of health care spending 11

12 Duals Enrollment vs. Spending Medicare-Medicaid Enrollees Other Medicare Beneficiaries 12

13 Duals Case Studies Earsy, 77, is a dual eligible because she is elderly and has a low income. Diane, 59, is a dual eligible because of a disabling mental health condition. She has high blood pressure and diabetes, which led to a stroke 12 years ago that left her paralyzed on her right side. She uses a wheelchair and relies on caregivers through the state s IHSS program to assist with activities of daily living, such as getting in and out of bed, bathing, dressing, and meal preparation. For years, she has struggled with her disability and accessing medical care. She has had long stretches with no access to a psychiatrist. She went four years without going to the dentist or visiting an optometrist. For Diane, psychiatric services are crucial. She s been looking for a therapist and a doctor to monitor her medications. Source: CalDuals.org 13

14 Medicare Benefits and Services HOSPITAL SERVICES PRIMARY CARE SPECIALIST CARE Medicare is the primary payer Orange County s 74,000 duals receive Medicare in different ways: 19% are in OneCare (HMO SNP) 13% are in other managed care plans 68% are in fee-for-service Medicare SHORT-TERM SKILLED NURSING MENTAL HEALTH REHAB HOME HEALTH DIALYSIS DURABLE MEDICAL EQUIPMENT PHARMACY HOSPICE 14

15 Medi-Cal Benefits and Services LONG-TERM SKILLED NURSING Medi-Cal services wrap around Medicare services Orange County s 74,000 duals receive Medi-Cal from CalOptima SPECIALTY MENTAL HEALTH SOME DURABLE MEDICAL EQUIPMENT COMMUNITY-BASED ADULT SERVICES IN-HOME SUPPORTIVE SERVICES SOME SUPPLEMENTAL BENEFITS 15

16 Combining Separate Systems HOSPITAL SERVICES PRIMARY CARE SPECIALIST CARE SHORT-TERM SKILLED NURSING MENTAL HEALTH REHAB HOME HEALTH DIALYSIS DURABLE MEDICAL EQUIPMENT PHARMACY HOSPICE Duals Demonstration LONG-TERM SKILLED NURSING SPECIALTY MENTAL HEALTH SOME DURABLE MEDICAL EQUIPMENT COMMUNITY-BASED ADULT SERVICES IN-HOME SUPPORTIVE SERVICES SOME SUPPLEMENTAL BENEFITS 16

17 Coordinated Care Rehab Mental Health Specialist Care Hospital Services Member Primary Care Short-Term Skilled Nursing Home Health Dialysis Hospice Pharmacy Specialty Mental Health In-Home Supportive Services Durable Medical Equipment Durable Medical Equipment Community- Based Adult Services Supplemental Benefits Supplemental Benefits Flexible Coordination Dental Services Long-Term Skilled Nursing 17

18 Program Advantages The right service At the right time In the right place Members will get access to quality health care in a compassionate manner 18

19 CalOptima CalOptima Largest County Organized Health System Second largest health plan in Orange County 1 in 7 residents 1 in 5 seniors 1 in 3 children CalOptima Healthy Families Program Largest Children s Health Insurance Plan in Orange County; 40% market share Community Provider Plan for 15 years One of only three plans in the state honored for Superior Performance three years in a row, CalOptima OneCare (HMO SNP) 14,000-member Medicare Advantage Special Needs Plan 4-star plan in Medicare Star Quality Rating System CalOptima Medi-Cal Fifth largest Medi-Cal managed care plan in California Larger than 18 state Medicaid programs Ranked in the top 10 for quality among Medi-Cal plans for past five years NCQA accredited with commendable status 19

20 CalOptima Programs Medi-Cal OneCare Multipurpose Senior Services Program CalOptima Kids Logo Program Contractor/ Regulator California s Medicaid program California Department of Health Care Services (DHCS) Medicare Advantage Special Needs Plan (HMO SNP) Centers for Medicare & Medicaid Services (CMS) Medi-Cal home- and community-based services (HCBS) program California Department of Aging (CDA) Healthy Families Program (California s CHIP) Managed Risk Medical Insurance Board (MRMIB) Enrollment 382,339 14,126* 465* 35,639 Eligibility Services Low-income individuals Families with children Seniors People with disabilities Comprehensive health Prescriptions Vision Medi-Cal member who also has Medicare Comprehensive health Comprehensive dental Prescriptions Vision Medi-Cal member who is: Over 65; and At risk for nursing home placement Assessments Care planning Coordination of care In-home services Child who is: Age 0 to 19 Income < 250% FPL Comprehensive health Prescriptions (vision and dental provided by MRMIB) Budget FY12 13 $1.2 billion $200.9 million $1.9 million $37.9 million Source: CalOptima Fast Facts, October 2012 * Membership already accounted for in total Medi-Cal membership 20

21 CalOptima Delivery Model CalOptima Delegated Direct Shared Risk: Medical group responsible for medical services; CalOptima responsible for facility services CalOptima Direct Administrative: Administratively complex members, e.g., fee-for-service duals or Share of Cost members Physician-Hospital Consortia: Medical group and hospital responsible for all services CalOptima Care Network: Medically and administratively complex members, e.g., transplant or end-stage renal disease patients HMO: Health maintenance organization responsible for all services 21

22 HME in the Demonstration CalOptima-HME Partnership We can t do this demonstration without you We understand your role in the current continuum of care We recognize that the demonstration encourages home-based care We are considering our contracting options to ensure we can serve members well Currently, we are asking interested providers to send a Letter of Interest with details about your company s services Shared Goals Providing the best, most appropriate care for duals and future members of our growing senior population 22

23 Contracting Questions Exclusivity Current State: Direct Contracting CalOptima has 20 Medi-Cal and 15 OneCare contracted providers for basic HME CalOptima used RFP process to select three medical supply vendors for incontinence supplies Current State: Delegated Contracting Our medical groups and health networks may hold the risk for HME and in those cases will contract with HME providers (OneCare DOFRs can vary) Continuity of Care Demonstration priority is to maintain patient-provider relationships Contracting models for the demonstration are not yet determined 23

24 CalOptima-HME Engagement How CalOptima will engage you Provider stakeholder workgroup Outreach and education forums in the community Informational tools (print and electronic) Online resources on the homepage at How you can engage with CalOptima Get involved in the stakeholder workgroup or community forums Send a Letter of Interest to our Contracting department Provider Relations at providerservicesinbox@caloptima.org Call Provider Relations at

25 Tentative Timeline OCT NOV DEC JAN FEB MAR APR MAY JUNE Members receive notices about demo Board of Directors makes decision about demo Regulators check CalOptima s readiness LTSS Integration: CalOptima begins to manage IHSS Demo Starts CalOptima continues preparing 25

26 CalOptima s Mission To provide members with access to quality health care services delivered in a cost-effective and compassionate manner 26