Medi-Cal and the Safety Net California Association of Health Plans Seminar Series Medi-Cal at its Core August 3, 2017 Deborah Kelch Executive Director Insure the Uninsured Project 1
Safety-Net Definitions Safety-Net Population Uninsured or Enrolled in a Public Program Under 300 percent of the federal poverty level (FPL) Safety-Net Providers (Serve safety-net populations and provide services regardless of ability to pay) Hospitals Primarily County and UC Hospitals, Some district and private hospitals Community Clinics and Health Centers Federally-qualified health centers, FQHC look-alikes, rural health centers, and community, county, and free clinics 2
CA Safety Net Programs Medi-Cal Covers children up to 266% FPL, regardless of immigration status Covers pregnant women up to 322% FPL Covers most adults up to 138% FPL Programs for Remaining Uninsured Medically Indigent Adult (MIA) Programs Counties as the providers of last resort for those not eligible or enrolled in other coverage Federal Health Center 330 Grant Program Funding for uninsured and underserved populations Global Payment Program Statewide funding pool for public hospitals/health systems to care for the remaining uninsured State-only programs, such as Breast and Cervical Cancer Screening programs Covered California State Exchange Tax credits and cost sharing reduction subsidies for safety-net populations 3
Medi-Cal and the Safety Net Medi-Cal Programs for the Safety-Net Disproportionate Share Hospital (DSH) supplemental payments Presumptive Eligibility and Retroactive Enrollment FQHC/RHC Prospective Payment System (PPS) Medi-Cal, Safety-Net Populations and the Affordable Care Act ACA Medicaid Adult Expansion Expanded Medi-Cal to 3.9 M adults under 138% FPL (2017-18) Expansion for Former Foster Care Youth Expanded Medi-Cal to 18,823 young adults Parent and Caretaker Relative Expansion Expanded Medi-Cal to 1 M parents and adult caretaker relatives between 100 138% FPL 4
Medi-Cal and CA Counties California counties are integral to Medi-Cal and the state safety net Providers of last resort for those not eligible or enrolled in Medi-Cal or other coverage County facilities (hospitals, clinics) participate as Medi-Cal providers Counties administer Medi-Cal specialty mental health and behavioral health services Counties manage Medi-Cal eligibility 5
Coverage for Safety Net Populations Pre- and Post-ACA Insurance Status of Individuals with Incomes <300% FPL California, 2013 and 2015 40% 47% 32% 27% 21% 13% 14% 7% Uninsured Public Programs Medicare Private Insurance Primarily Medi-Cal Includes Medi-Cal Dual Eligibles 2013 2015 Source: Insure the Uninsured Project; California Health Care Foundation, January 2016 and California Health Interview Survey 6
Public Program Enrollment Pre- and Post-ACA Safety-Net Population (<300% FPL) Enrolled in Public Programs 2013 California, 2013 and 2015 2015 Other [VALUE] Other [VALUE] Medicare* [VALUE] Medicare* [VALUE] Uninsured [VALUE] Medi-Cal [VALUE] *Medicare includes Medi-Cal Dual Eligibles Uninsured [VALUE] Medi-Cal [VALUE] Source: Insure the Uninsured Project; California Health Care Foundation, January 2016 and California Health Interview Survey, 2015, UCLA Center for Health Policy Research 7
Community Clinics and Health Centers (CCHCs) 2013 CCHCs 2015 1,136 Sites 1,276 17.8 M Encounters 20 M 5.7 M Consumers/Patients 6.3 M 77% Patients <200% FPL 74% 41% % Uninsured 25.4% Source: Insure the Uninsured Project analysis of 2013 and 2015 Primary Care and Specialty Clinics Annual Utilization Data, Office of Statewide Planning and Development (OSHPD) www.oshpd.gov 8
Community Clinics and Health Centers (CCHCs) 2013 CCHCs and Medi-Cal 2015 38% % Medi-Cal Patients 56% 3.4 M Fee-for-Service (FFS) 4.1 M Medi-Cal Managed Care (MCMC) $624M FFS $623M MCMC Medi-Cal Encounters Net Revenue - Medi-Cal 53% Medi-Cal Net Revenue as a % of Total Net Revenue 4.2 M FFS 7.8 M MCMC $813M FFS $1.3B MCMC 66% Source: Insure the Uninsured Project analysis of 2013 and 2015 Primary Care and Specialty Clinics Annual Utilization Data, www.oshpd.gov 9
CA Public Hospital Systems California s Public Hospitals and Health Systems (PHs) 21 PHs including county-owned and operated facilities (16) and University of California medical centers (5) account for 6% of California hospitals Serve more than 2.85 M patients annually and provide 10.5 M outpatient visits at more than 200 clinic facilities Provide 35% of all hospital care to Medi-Cal beneficiaries Provide 34% of all hospital care to the remaining uninsured From 7/13 7/14, CA PHs provided $225 M in uncompensated care services Located in 15 counties where 80% of the state s population reside 10
CA Public Hospital Systems California PH Funding for Medicaid enrollees For state fiscal year 2013-14, approximately 17% of the non-federal share of Medicaid reimbursements to PHs was funded by state general fund match and the other 83% came from local matching sources (certified public expenditures (CPEs) and intergovernmental transfer IGTs) PH Net Patient Revenue Total Med-Cal Revenue 2013-2014 Revenue excludes local funding sources (CPEs and IGTs) Source: California Department of Health Care Services, Evaluation of Uncompensated Care Financing for California Designated Public Hospitals, Navigant, May 15, 2016, http://www.dhcs.ca.gov/provgovpart/documents/waiver%20renewal/ca_ucp_report_final.pdf Medi-Cal Revenue as % of Total Revenue $13.7 B $7.5 B 55% 11
CA Public Hospital Systems California PHs and the Affordable Care Act More than 560,000 people served by PHs gained Medi-Cal coverage through the ACA Because the ACA reduced the number of uninsured, the ACA significantly reduced Disproportionate Share Hospital funding Additional federal DSH funding reductions scheduled and pending According to the California Association for Public Hospitals and Health Systems, a repeal of the federal Medicaid adult expansion results in PHs losing $2.2 billion in revenue each year 12
Safety Net Funding Private hospitals are the safety net in many communities, especially in rural and remote areas Mission oriented, and/or Lack of public hospitals in the community Eligible and may receive DSH funding if serve a high number of Medi-Cal patients 13
Future of Medi-Cal and the Safety Net Safety net providers will continue to participate in and rely on Medi-Cal for patients and revenue Medi-Cal represents more than half of the funding for the safety net (66% for CCHCs) Safety net hospitals in Medicaid expansion states like California had twice the level of uncompensated care in 2015 than other hospitals Federal Medicaid and safety net funding will continue to be vulnerable Federal budget deliberations Medicaid reform proposals (presumptive eligibility, per-capita cap) Supplemental funding (DSH, 330 Grants) 14
Future Safety Net Risks DSH Program ACA anticipated phased cuts in DSH funding Delayed for 2018-2025 but now under consideration California could be disadvantaged because of Medi-Cal expansion and lower number of uninsured (7.1%) Health Center 330 Grants ACA created a trust fund for 330 federal grants to health centers with new funding The Trust Fund extended through September 30 Trust Fund equivalent to 20% of current health center funding ($3.6 billion) 2,800 health centers nationwide could close 15
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