Medicaid Managed Care: Keeping
your clients connected to care in a
changing environment
Lessons, advice, and warnings from
California
Vanessa Cajina, Legislative Advocate
Families USA, January 23, 2014
WESTERN CENTER ON LAW & POVERTY
First things first:
We made it! Happy January 2014!
Okay, now down to business:
 Roadmap for today:
 California’s Medicaid program (Medi-Cal), and our
historic managed care populations
 Other California laws and protections for health care
consumers
 How our state managed to get pretty much all of our
populations into managed care
 How we fought back, and continue to do so: tips, tricks,
and flashpoints
 Resources and state laws and regulations
A little background:
 Population-wise, the largest state in the nation: 38 million
 We’re officially a “majority-minority” state: 2/3s people of
color & almost 40% Latino in 2012
 43% of us speak a language other than English at home
 We have the highest poverty rate in the US - almost 25%
 Our state budget: Back in black
 We were the 1st to start an Exchange, & one of the 1st to
enact the full Medicaid expansion
Medi-Cal: At a glance
 US’ largest Medicaid program: about 7.6 million people
 Medi-Cal provides free, comprehensive coverage for:
 1 in 5 Californians under age 65
 1 in 3 of our kids
 Most people living with AIDS
 We also cover:
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Low-income parents
People with disabilities
Pregnant women
Seniors about age 65
 And we’re excited that we NOW cover childless adults
from age 19 up to age 65!
A brief history of Medi-Cal
 1966 – California creates Medi-Cal following Title XIX of
Social Security Act created Medicaid
 1973 – first Medi-Cal managed care plans established
 1982 – state creates 3 County Organized Health Systems
(COHS). A COHS is the health plan for ALL Medi-Cal
beneficiaries in that county; 3 more added in 1990
 1992-96 – Additional managed care models adopted
throughout California
 1993 – State required most children and parents with MediCal to enroll in managed care
 2011 – Feds ok’d move of Seniors and Persons with
Disabilities & Duals into managed care, expansion into rural
areas
The pros & cons of managed care
 Managed care can be a good fit, particularly for people
with lower health needs or those in good overall health
 However, it can be very hard to navigate for people with
multiple providers, specialists, subspecialists, or those who
use non-medical services like durable medical equipment,
pharmacies, other long-term services
 These navigation problems are especially prevalent during
transitions between traditional Medicaid to managed care
 And what do provider contracts look like? How are your
medical groups regulated – how much risk do they bear
and does that impact treatment decisions?
 Can the health plan guarantee that their networks are
adequate for the population they serve, including specialist
access, subspecialists, hospital contracts, etc…
From the County of Los Angeles, with a total
population of 9.9 million
*About 2.39 million Angelenos
will be Medi-Cal-eligible with
the ACA expansion
To Rural California
For example, Mono County has a population of under 15,000
and a population density of 4 people per square mile
California currently has
6 models of managed
care delivery, with
each of 58 counties
choosing which model
to employ – each with
its own regulations
and sets of operations
California Protections
 Under CA law, most Medi-Cal managed care plans are
treated like commercial managed care plans, meaning
they have to follow certain laws in providing and
helping patients access care
Some of our tools include:
 Knox-Keene Act – the granddaddy of California health
consumer protections
 Continuity of care
 Medical Exemption Requests
 Contract language, health plan oversight
Knox Keene – CA Health & Safety Code §
1340-1399.818
 The big law in California that regulates managed care
plans, including most Medi-Cal plans
 Passed in 1975 with subsequent amendments, includes:
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Services covered
Access standards
Consumer protections
Quality assurance
Grievances & dispute resolution
Financial protections & solvency for plans, contracts &
licensure
Knox Keene cont’d
 Since enacted, great provisions added on requiring
plans to provide language assistance and
interpretation to consumers
 Provides for Continuity of Care – we’ll discuss in a
moment
 More information available at:
 http://www.healthconsumer.org/cs016knoxkeene.pdf
 http://www.leginfo.ca.gov/cgibin/calawquery?codesection=hsc&codebody=&hits=20
Medical Exemption Requests
 An existing policy within our Medi-Cal program
 The use of MERs was expanded when SPDs were required
to enroll in managed care
 Permits a beneficiary to opt out of managed care if s/he
has a relationship with a doctor/nurse midwife/licensed
midwife who is not part of a health plan
 In California, this is a narrow document and the MER only
lasts 12 months
 When new populations are added to mandatory managed
care, MERs are typically added to legislative language
Continuity of Care
 Beneficiaries have the right to completion of certain
covered services they were getting from a nonparticipating or terminated provider, under some
conditions
 Services for an acute condition, serious chronic
condition, pregnancy, terminal illness, newborn care, and
some planned surgeries must be provided for up to 12
months
 Medi-Cal enrollees newly enrolled in a plan can continue
RX as long as RX was in effect when the beneficiary
moved into the plan.
 An underused protection, and subject to a health plan
negotiation with the non-participating provider
Continuity of Care for special populations
1.
SPDs: FFS to managed care
-Additional RX authorizations if their MER was denied, plus other
protections.
-New enrollees can request to see FFS provider for up to 12 months – must
have seen the provider in the last 12 months – provider must accept the
higher of the plan’s rate or the Medi-Cal FFS rate. Plan must notify SPD
within 30 days of request.
2.
Duals: FFS to managed care
-Duals in certain counties may request treatment with out-of-network
providers for 6 months if they have seen provider twice in last 12 months.
3.
Children shifting from CHIP to Medi-Cal: managed care to managed
care
-Kids going to a new health plan will get preference in keeping their PCP
-If child’s PCP isn’t in new plan, the child may keep that provider for 12
months
Administrative Advocacy
 Medi-Cal is administered by the state’s Department of
Health Care Services, but participating plans are
regulated by the Department of Managed Health Care
 Demand that contracts be public, as well as
correspondence and directives from the plan’s
regulator or contract manager including
subregulatory guidance
 Establish relationships with health plans and provider
organizations
Is your state considering
expanding managed care?
 Draft and advocate for model language if the transition is a
foregone conclusion – even piecemeal fixes can help
 Start with gradual additions of types of beneficiaries –
perhaps children & families, or adult expansion Medicaid
population
 Your state has a D majority? Talk to labor – some home
care unions have found that managed care could be better
for their members
 Your state has an R majority? Pit health plans against
providers and choose your friends and battles wisely
For more information and model
language:
 Western Center on Law and Poverty
www.wclp.org – vcajina@wclp.org
 National Health Law Program
www.healthlaw.org &
http://www.healthlaw.org/issues/medicaid/managedcare/continuity-of-care-in-medi-cal#.UtcYWLRXL5M