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Calitornia
J'
Association
ofHealthPions
1415lSTREETSUITE850SACRAMENTO.CA95814916.552.2910
P
9
6.443.1031
f
CALHEALTHPLANS.ORG
August19,2011JaneOgle,DeputyDirectorHealthCareDeliverySystemsDepartmentofHealthCareServices1501apitolAvenue,MS4000P.O..Box997413SacramentoCA
95814ViaEmail:Jane.ogle@dhcs.ca.govRe:TransitionofAdult
Day
HealthCareBeneficiariesintoMed-Cal.ManagedCare
DearMs.Ogle:TheCaliforniaAs
ociation
ofHealthPlansrepresents
39
public,non-profit,andcommercialKnox-KeenelicensedhealthplansinCalifornia..Wearewritingonbehalfofourmemberplans,whichservemorethan
4million
Medi-CalbeneficiariesintheTwo-Plan,GeographicManagedCare,andCountyOrganizedHealthSystemmodelsofMedi-CalManagedCaretoprovideyouwithourcommentsandquestionsregarding
th
transitionofAdultDayHealthCare(ADHC)beneficiariesintoMedi-CalManagedCare.WeappreciateDHCS'scontinuedpartnershipwiththehealthplansandarefullycommittedtoprovidinghighqualitycaretoMedi-Calbeneficiaries.Medi-CalManagedCarecanprovideamuchneededmedicalhomeforfee-for-servicebeneficiaries.ThetransitionofADHCbeneficiariesintoMedi-CalManagedCareposesawiderangeofquestionsandoperationalconcernsforthehealthplans.ResolutionoftheseissuespriortotheOctober
1
51
enrollmentdatewillhelpsmooththetransitionandeaseanyconcernsonthepartofthisfragilepopulation.Wehopethatinprovidingyouwiththisfeedbackwecanensurethesebeneficiarieshaveapositiveexperienceandreceivetheappropriatelevelofcare.Theissuesaredetailedbelow.
CommunicationwithADHC
Beneficiaries:I)DHCSshouldtemperbeneficiaries'expectationsbyprovidingADHCmembersalistofwhatbenefitscurrentlyprovidedbyADHCarerequiredMedi-Calmanagedcarebenefits.HealthplansmaychoosetocontractwithADHCcenter-stoprovidemedicalcareandcarecoordinationservices,butmanycurrentADHCbenefitsarenotcoveredunderMedi-CalManagedCare.Healthplanswillprovidemedicalmanagementcarecoordinationandappropriatemedicalservices.However,healthplansarenotresponsibleforprotectiesupervision,meals,socializationormaintenancetherapies.WeappreciatethatDHCSdid
 
JaneOgle,DeputyDirectorAdultDayHealthCareTransitionPage2of6
notusetheterm'ADHC-like"initslettertobeneficiariesandwouldrequestthat
it
nolongerbeusedtominimizeconfusion.2)DHCShouldclarifythatthe$60enhancementtothehealthplansreflectstheacuityoftheADHCpatientpopulationandnotanewenhancedbenefitpackage.TheMedi-CalManagedCarebenefitpackageissolelyrelatedtomedicalcareassetforthincontractandstatute.Ifahealthplanchoosestogobeyondtherequiredscopeofservicesthatisattheplansdiscretionbutnotalegalorcontractualobligation.3)DHCSshouldmakeitcleartobeneficiariesthathealthplansarenotfinanciallyresponsiblefortheservicesprovidedbyIn-HomeSupportServices(lHHS),Multi-PurposeSeniorServicesProgram(MP)oranyothersocial.serviceprogramastheyarenotcoveredbenefitsunderMedi-CalManagedCare.Whilehealthplanscanrefermemberstotheseprogramsandtrytopartnerwiththeorganizationstoprovidecoordination,healthplanscannotimpactenrollmentoravailabilityoftheseservices.Iftheervicesarenotavailable,healthplansshouldnotbeheldresponsiblefornon-healthcareserices.4)HealthplansrecommendthatDHCSissuealettercorrectingtheissuesnotedaboveinordertopreventconfusionamongbeneficiariesandADHCcenters.AmoredetailedcommunicationmayhelptomitigateanymisunderstandingontheavailablebenefitsunderMedi-Calmanagedcare.5)otificationofADHCbeneficiariesinCountyOrganizedHealthSystem(COHS)countiesabouttheeliminationofthebenefitshouldbeseparatefromtheothercounties.COHsalreadyhavethesemembersintheirhealthplans.ProvidingthesamenoticewillcausevastconfusionandpossibledisruptionsincarefortheCOHSmembers.
RateEnhancement:
1)Healthplanratesaregenerallydeterminedbasedoncostandutilizationdataprovidebytheplans;howeverADHCservicesandalargeportionofitsbeneficiariesarecarvedoutofMedi-CalManagedCare.WhatdatadidDHCSusetocalculatethe$60pmpmamount?2)IfDHCSusedCountyOrganized'ealthSystem(COHS)datawhereADHCbeneficiariesarecurrentlyenrolledinmanagedcare,didDHSCconsiderthepossibleincreasedacuitylevelassociatedwiththeeliminationoftheADHCbenefit?3)ADHCbeneficiariestendtohavehigherutilizationanddemandformedicalcarethanthepopulationscurrentlyenrolledinMedi-CalManagedCareinnon-COHScounties.Thepopulationisdistinctandshouldhavetwouniqueaidcodesandcapitationrates
-ADHCMedi-CalOnly
and
ADHCDuals.
DHCShasstatedthatthememberrecordswillbe'flaggd'forthehealthplansbutlabelingthesebeneficiariesassubpopulationswillmakeidentificationforassessmentandreportingpurposesdifficult.ThedevelopmentofaspecificaidcodesfortheADHCpopulationwillhelptheplansmoreeasilydelineate
 
JaneOgle,DeputyDirectorAdultDayHealthCareTransitionPage3of6
thesemembersfromtherestofthemembersinordertoimmediatelyseekoutandassesstheircareneedsuponplanenrollment.Separateaidcodeswillalsosimplifyreportingasplanswillbeabletocullthroughthepopulationdatamoreefficiently.4)DHCSshouldalsoprovideanactuariallysoundrateforthenewaidcodespopulation.Thispopulationhasuniquecharacteristicsandhealthcareneedsandanactuarialassessmentoftheestimated(oractual)healthcarecostsmustbeusedtoderiveanappropriateplanrate.UsinganexistingSPDaidcoderatemaynotbeappropriate,andattheveryleast,shouldbejustifiedbaseduponanactuarialassessmentofthissub-population.5)DHCShasstatedthatthe$60enhancementfortheADHCbeneficiariesisrelatedtothisincreasedlevelofneed.DHCSexpectsthattheenhancementisanaverageadditionalcostofthebeneficiariesandhealthplanswillpooltheriskinordertomeettheneedsofallmember.However,onceDHCiseliminated,nootherenrolleeswillbeprovidedtheadditionalenhancementeveniftheyhavethesamelevelofneedastheADHCbeneficiaries.Givenalikelyincreaseinthenumberofhighacuitybeneficiaries,DHCSshouldreiewthecurrentdualsandPDratescloselytoensureadequatepayment.6)Healthplanshavenotpreviouslybeenrequiredtocoordinatebeneficiarymedicalcarewithsocialservicesprograms.Thislevelofcarecoordination
will
resultinanadditionaladministrativeexpense.Doestheratecalculationincludeahigherlevelofreimbursementforincreasedcasemanagement?7)SincedualsarenotmandatedtoremaininMedi-CalManagedCare,adualcancycleinandoutoftheprogramonamonthlybasis,WillDHCSprovidethe$60enhancementinperpetuityforanADHCdualoronlfortheOctober1Medi-CalManagedCareenrollment?
Medicare/Medi-Cal
Eligible
Beneficiaries:
I)DHCSshouldnotholdthehealthplansliableforensuringthatbeneficiarieseligibleforbothMedi-CalandMedicare(duals)donottransitionintolong-termcareasMedi-CalManagedCaredoesnotprovidefullcoverageforduals.Medi-Cal.managedcareplansareonlyresponsibleforversmallportionofdualsrndicalcare.ThemajorityofservicesareproidedbyMedicare.Althoughaplanmaywanttocoordinateamembershealthcareservices,themembersMedicareproidersarenotcontractuallyobligatdtoworkwiththeMedii-Calplan.SomeplansmaybeabletomanagethewholepersonwithintheirMedi-CalandMedicareplans.However,themajorityofplanswillnoteitherbecausethebeneficiaryisinMedicarefee-for-sericeorbecausetheplan'sparentcompanymanagestheMedicareandMedi-Calpopulationsseparately.2)GiventhatMedi-CalManagedCaredoesnotprovidemostmedicalservicesforduals,willtheMedi-CalplansberequiredtoassignADHCdualstoaprimarycarephysician?
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