Managed Long Term Care National Medicaid Congress June 14, 2011 Richard Chambers Chief Executive Officer
Overview CalOptima overview Medicaid managed care Orange County s experience Managed long term care initiatives MACPAC 1
Orange County, CA 3 million residents Urban, densely populated area Racially and ethnically diverse Mature managed care market 380,000 Medicaid beneficiaries 2
CalOptima County Organized Health System for Orange County Public agency authorized by federal, state and county Key features: Single plan responsible for providing Medicaid Mandatory enrollment of all full scope Medicaid beneficiaries Includes Seniors and Persons with Disabilities Includes Dual Eligibles Responsible for nearly all acute medical services Includes nursing home care (long term institutional care) Certain benefits still carved out (e.g., dental, behavioral, home and community-based) 3
CalOptima Programs Medi-Cal OneCare Healthy Families Program Multipurpose Senior Services Program Program Type Medicaid MA-SNP CHIP HCBS (1915c waiver) Enrollment 380,000 12,000 38,000 500 Eligibility Services TANF SPD Duals Health Rx Vision Duals Health Rx Vision Children under 250% FPL Health Rx Revenue (FY11) $1.1 B $148 M $40 M $2 M Medicaid eligible who is: 65+ Risk for nursing home placement Assessments Care planning Coordination In-home services In addition, the CalOptima Foundation operates the Orange County Regional Extension Center 4
CalOptima s Medicaid Membership TANF 71.0% Disabled 14.0 % Seniors 13.8 % LTC 1.2 % Non-Duals 35% Duals 65% 5
Medicaid Managed Care Today Focuses primarily on TANF populations Includes primary / acute services 6
Medicaid Managed Care Tomorrow Will likely include entire Medicaid population (duals) Will include all services, have fewer benefit carve-outs Will focus on coordinated care across the continuum Will increasingly need to be, or promote, fully integrated systems 7
Medicaid Managed Care Tomorrow: More Managed Long Term Care (MLTC) Go beyond acute services and silos of care delivery Align incentives to promote most effective care delivery Bring managed care principles to home and communitybased services (HCBS) 8
Medicaid Managed Care Tomorrow: Fully Integrated Systems for Duals 15 states will pilot fully integrated programs for duals Will focus on optimal program and financing models PACE is currently the only tested model 9
CalOptima 1998-2004 CalOptima responsible for primary/acute care, and institutional long term care (limited HCBS) State and County responsible for HCBS (personal care, adult day health care) via fee for service system 10
CalOptima 2005-2011 For Duals who are enrolled in CalOptima s D-SNP, CalOptima also provides Medicare primary/acute With exception of CalOptima s limited HCBS, duals also receive HCBS from State/County 11
CalOptima s Future PACE Medicaid MLTC Duals Integration 12
Current Initiative: PACE Program of All Inclusive Care for the Elderly Estimated 9,000 eligible in Orange County First site to open in Spring 2012 CalOptima to be a direct service provider at first site Unique model for health plan as a PACE provider Develop a PACE system for Orange County Meet community-specific needs Consider other delivery models (e.g., delegation) 13
Current Initiative: Medicaid Managed LTC Assume financial / administrative responsibility for community-based LTC services Develop global capitation rate Amend state s 1115 Waiver Ongoing engagement with local community Elimination of adult day health care benefit Further reductions in personal care benefit 14
Current Initiative: Full Medicare / Medicaid Integration California recently awarded CMS Duals Pilot contract States Awarded Contracts (# duals) California (982K) Minnesota (116K) South Carolina (129K) Colorado (69K) New York (643K) Tennessee (257K) Connecticut (83K) North Carolina (279K) Vermont (32K) Massachusetts (233K) Oklahoma (98K) Washington (136K) Michigan (229K) Oregon (82K) Wisconsin (161K) Legislative authority to contract with up to 4 pilot sites CalOptima applying to be a pilot site / contractor 15
Current Initiative: Full Medicare / Medicaid Integration California s timeline for duals integration pilot Timeframe June 1, 2011 Sept 1, 2011 Oct 31, 2011 Dec 22, 2011 March 2012 Nov-Dec 2012 Activity RFI responses due Submit plan for CMS approval Release RFP RFP responses due Announce pilot counties Begin operating pilots 16
Considerations for Integrated System Impact on delivery system More complex, higher acuity patients (e.g., duals) More financial risk for plans and providers Fundamental changes Risk distribution Contract arrangements Care management 17
MACPAC Presentation at the Medicaid Congress Richard Chambers June 14, 2011
MACPAC Statutory Charge Legislative History Established in February 2009 (CHIPRA) Expanded and funded in March 2010 (ACA) Commission Appointed by the Comptroller General of the United States to 3-year terms 17 Commissioners represent broad spectrum of interests and expertise on Medicaid and CHIP Goals Serve as a federal non-partisan and analytic resource on Medicaid and CHIP policy for the Congress Review federal and state Medicaid and CHIP policies and data sources 19
MACPAC Duties Review Medicaid and CHIP policy issues: Payment policies Access to care issues Eligibility Quality of care Interactions between Medicaid and Medicare Data policy analysis and program accountability Review and comment on Secretarial reports and regulations that relate to policies under Medicaid and CHIP Submit annual reports to the Congress in March and June Collaborate and consult with states, MedPAC, and the Medicare- Medicaid Coordination Office 20
Overview of MACPAC s March 2011 Report to the Congress Background and overview of Medicaid and CHIP Foundation for MACPAC s initial approach to addressing payment, access and data Evolving framework to guide the Commission s analytic approach and research on access to care in Medicaid and CHIP Initial approach for examining Medicaid provider fee-for-service payment policy across states and providers Outlines federal data sources, issues and potential areas for improvement for policy and accountability 21 Medicaid and CHIP Program Statistics (MACStats): original MACPAC data analysis of state-level and national Medicaid data on enrollment, spending, program design, budget share, etc.
Preview of the June 2011 Report Current, baseline information on Medicaid managed care: Medicaid managed care in the context of the U.S. health care system Populations enrolled in Medicaid managed care Managed care models Payment policies Access and quality Program accountability, integrity and data Future issues facing Medicaid managed care 22 June 2011 MACStats tables and figures will include: Trends in Medicaid enrollment and spending Current health characteristics, enrollment, and benefit spending among Medicaid populations Medicaid managed care enrollment
June 2011 Report Coming out June 15, 2011 www.macpac.gov 23