RURAL EXPANSION Amber Cutler, Staff Attorney Abbi Coursolle, Staff - - PowerPoint PPT Presentation

MEDI-CAL MANAGED CARE RURAL EXPANSION

Amber Cutler, Staff Attorney Abbi Coursolle, Staff Attorney National Senior Citizens Law Center National Health Law Program

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National Senior Citizens Law Center

The National Senior Citizens Law Center is a non-profit

• rganization whose principal mission is to protect the rights
• f low-income older adults. Through advocacy, litigation,

and the education and counseling of local advocates, we seek to ensure the health and economic security of those with limited income and resources, and access to the courts for all. For more information, visit our website at www.NSCLC.org.

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The National Health Law Program

Founded in 1969, the National Health Law Program protects and advances the health rights of low income and underserved individuals. The oldest non-profit of its kind, NHeLP advocates, educates and litigates at the federal and state level.

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Glossary

County Organized Health System (COHS) Dual Eligibles (Duals or Medi Medis) Fee-for-service (FFS) Imperial Model Long-Term Services and Supports (LTSS)

 Community Based Adult Services (CBAS)  In-Home Supportive Services (IHSS)  Multi-Purpose Senior Services Program (MSSP)  Nursing Facility Care

Regional Model San Benito Model Seniors & Persons with Disabilities (SPDs)

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Senior/Person with Disability Provider DHCS & Medicare Provider Provider $$ Health Plan DHCS & Medicare $$

More Managed Care

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Rural Expansion: Where

Where: 28 Rural Counties

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Rural Expansion: COHS Counties

Partnership HealthPlan of California

 September 1, 2013  8 Counties (Del Norte,

Humbolt, Lake, Lassen Modoc, Shasta, Siskiyou, Trinity)

 SPDs (18, 464) & Duals (21,577)

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September

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Rural Expansion: Regional Counties

Anthem Blue Cross & California Health and Wellness

 December 1, 2014  18 Counties (Alpine, Amador, Butte, Calaveras, Colusa,

El Dorado, Glenn, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Tuolumne, Yuba)

 SPDs Mandatory (28, 946)  Duals Voluntary** (36, 180)

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December

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Regional County Notices 60 Day

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Regional County Notices 30 Day

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Rural Expansion: Imperial County

California Health & Wellness & Molina Healthcare

 December 1, 2014  Imperial  SPDs Mandatory (5,429)  Duals Voluntary** (11,527)

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December

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Imperial County Notices 60 Day

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Imperial County Notices 30 Day

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Rural Expansion: Regional Counties

EXCLUSIONS

 Other Health Coverage  Share of Cost  Nursing Facility Residents  ICF/DD Residents

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Rural Expansion: San Benito County

Anthem Blue Cross

 December 1, 2014  San Benito  SPDs Voluntary** (676)  Duals Voluntary** (1,154)

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December

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San Benito County Notices 60 Day

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San Benito County Notices 30 Day

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Rural Expansion: Covered Benefits

Medi-Cal benefits will be provided through a managed care plan.

• Includes MOST benefits currently covered by Medi-Cal FFS
• Carved-Out Benefits
• LTSS**, HCBS waivers, specialty mental health, etc.

http://www.dhcs.ca.gov/provgovpart/Documents/MMCDExpansion/ Rural/CarvedOutServices.pdf

**CBAS – now a managed care benefit. Must join Medi-Cal plan to receive CBAS.

• Dental – through Denti-Cal

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Rural Expansion: Medical Exemption Request (MER)

 Exemption from enrollment into a Medi-Cal plan  Available only in Regional Model counties including Imperial County  Provider has to be out-of-network (not contracting with either Medi-

Cal plan)

 Beneficiary is receiving treatment for a complex medical condition

(e.g., pregnant, organ transplant, dialysis, awaiting surgery, etc.)

 Temporary – up to 12 months, then must renew  Submit to Health Care Options:

http://www.healthcareoptions.dhcs.ca.gov/HCOCSP/Enrollment/content/en/for ms/MU_0003383.pdf

 22 CCR § 53887

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Rural Expansion: Continuity of Care

• 12 months - keep seeing current providers and maintain service

authorizations & receive services set to occur within 180 days of enrollment.

• Must have an “existing relationship”
• Seen the provider at least once within 12 months (from date of plan

enrollment)

• Provider must accept plan reimbursement rate
• Provider must meet quality of care standards
• Continuity may be available for longer periods for individuals with terminal

illnesses or on hospice

• Does not extend to durable medical equipment, medical supplies,

transportation, or other ancillary services

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Rural Expansion: Continuity of Care

• Prescription drugs
• Can continue to receive single source drug as part of

prescribed therapy until beneficiary is seen by a plan doctor to establish a careplan.

• For multi-source drug, plan will notify Pharmacy that

prior authorization and plan will require medical justification from provider and must make a decision within 24 hours

• Plan must provide 3-day supply in cases of an emergency

until prior authorization is complete

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Rural Expansion: Appeals

• Available when a plan denies, delays, or modifies a

requested service, or reduces or terminates an existing service.

• Plan must provide a notice of action.
• Enrollees entitled to aid paid pending when an existing

service is reduced or terminated if request fair hearing or grievance within 10 days of the proposed action.

• Internal plan grievance – must file within 90 days, plan

must make a decision within 30 days.

• All grievances and appeals may be expedited.

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Rural Expansion: Appeals

• External review:
• Medi-Cal state fair hearing – available for any action; must

request within 90 days, state must make a decision within 90 days.

• **Independent Medical Review (IMR) – available for certain cases

involving medical necessity. Must request within 6 months, IMR entity decides within 30 days. Must complete internal grievance

• first. No IMR allowed if enrollee has gone to fair hearing.
• **DHMC Complaint – available for cases not eligible for IMR.

Department makes a decision within 30 days. Must complete internal grievance first. **Not available in to COHS enrollees.

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Rural Expansion: Network Adequacy

• Geographic access: Plans must provide primary care within 10 miles
• r 30 minutes. Other services within a “reasonable” distance.
• Timely access:
• Urgent care: 48 hours / 96 hours if prior authorization required
• Primary care: 10 business days
• Specialty care: 15 days
• Mental health: 10 business days
• Ancillary care: 15 business days
• Dental: urgent – 72 hours, routine – 36 days, preventive – 40 days
• 24/7 emergency care
• Access to care out-of-network:
• In cases of emergency
• For reproductive health and family planning services
• When a service is not available in the plan’s network

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Rural Expansion: Transportation

• Plans must cover:
• Emergency transportation
• Non-emergency medical transportation (NEMT)
• Transportation for children under 21
• Plans may cover:
• Non-emergency, non-medical transportation.

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Rural Expansion: CBAS

• CBAS will be a managed care benefit
• To continue receving CBAS, you must join a Medi-Cal plan (applies

to duals and SPDs)

• Medicare doctors may refuse to see dual because of Medi-Cal plan

enrollment due to confusion or they may try to bill dual for Medi- Cal portion.

• FACT SHEET: http://www.calduals.org/wp-

content/uploads/2014/09/PhysToolkit_FFS-Medicare-for-Duals-in- Medi-Cal-Plans_09.18.14.pdf

• BALANCE BILLING IS PROHIBITED:

http://dualsdemoadvocacy.org/wp- content/uploads/2014/10/Balance-Billing-in-California-2.pdf

THANK YOU!

27 Amber Cutler, Staff Attorney Abbi Coursolle, Staff Attorney National Senior Citizens Law Center National Health Law Program aculter@nsclc.org coursolle@healthlaw.org

Department of Health Care Services Medi-Cal Managed Care Expansion

http://www.dhcs.ca.gov/provgovpart/Pages/Medi-CalManagedCareExpansion.aspx