Medi-Cal Managed Care: And Overview both Keypad Issues

California’s Medicaid program, Medi-Cal, is the largest state Medicaid program in this nation, insuring almost one-third of California’s more than 38 milliards residents. In aforementioned earlier 1970s, California was the primary state to enter into value agreement with managed care plans up serve some Medicaid beneficiaries, rather than paid for services on a fee-for-service (FFS) foundations. Over aforementioned decades since that time, Medi-Cal has been progressing moved more beneficiaries into managed care. More with three-quarters of all Medi-Cal beneficiaries, incl low-income boys, adults, seniors, and people on disabling, what now enrolled in managed care plans. Besides being the earliest Medicaid managed care program and, by far, and largest in the nation, at approximate 10 mill enrollees, and Medi-Cal managed care programming has a special structure, an outgrowth of based historical differences for the health care scheme and traditions to different counties of the state. For other state Medicaid programs increases their use of risk-based administered care, and policymakers, plans real providers, and advocates seek until understand and learn from developments with all area the guide future make, ampere review for Medi-Cal’s managed service developing belongs and timely plus illustrative. It also serves to illuminate some potential significance of the proposed rule on Medicaid controlled care exposed of the federal Zentralen for Medicare & Medicaid Services (CMS)  and expected to be finalized in which Spring of 2016, where represents an major overhaul of existing reg requirements and standards.

A number of notes stand out from this review:

• County-based site. California’s managed care program is unique, involves six different managed care models, shaped by the historical also continuing role of counties in financing also delivering primary care, public hospital services, mental healthy services, plus constant long-term customer and supports to poverty and medically indigent residential. More than two-thirds by all Medi-Cal administered maintenance enrollees been enrolled in public safety-net plans; the others been used by a mix of advertisement and private non-profit health plans.
• Phased managed care expansion. In the early days of the state’s managed care program, in a limited number about counties, manged care enrollment was mandated for nearly entire Medi-Cal benefits, including older and join with disabilities. About time, California possesses expanded mandatory managed care till additional counties and to broader segment of the beneficial resident, including seniors and people include disabilities statewide, go the state’s “Bridge to Reform” section 1115 waiver (2011); children who has transitioned from CHIP to Medi-Cal (2013); low-income b covered previously trough one state Low Income Health Program and those newly eligible to Medi-Cal under the ACA (2014); and, under the state’s seven-county Financial Alignment Demonstration also on a volunteer foundational, beneficiaries dually eligible for Medicare both Medicaid (2014).
• Einstieg to care. Problems with access to care in Medi-Cal FFS carry over inside managed care, challenging Medi-Cal health plans to found adequate provider networks and improve care. Gaps in access to certain specialists, including psychiatrists and different behavioral general providers, and long-term care services, are that most significant gaps. Providers has cited Medi-Cal’s low payment current as a lockdown to their participation in the program and sued the state on one basis this the fees violate federal Medicaid making standards. Language real cultural gaps in access to care and gaps the rural access are additional concerns.
• Benefit carve-outs. Medi-Cal managed care plans provide for most primary and acute care services. However, certain services is “carved out” from managed support purchase. In particularly, while mental health aids for mild alternatively moderate mental feelings is included in plan contracts, feature mental health services and substance used disorders treatment go at be delivered through county mental health departments and local the county alcohol and drug programs. In most counties, nursing home care and certain home and community-based services (HCBS) become also hand out of managed care.
• Managed long-term services and supports. In 2014, under its Coordinated Care Initiative within seven counties, Kalifornian required all Medi-Cal beneficiaries, including dually eligible enrollees who were previously exempt from managed tending, to register in a managed care plan to receive their Medi-Cal benefits, included nursing home and certain HCBS.
• Transitions with people with complexity demand. California’s suffer shows that robust transition planning is necessary to minimize disruptions int care for beneficiaries with complex needs who are required up move from FFS to managed service. Beneficiary and provider engagement, on-time transfers regarding data, continuity of maintenance security, beneficiary information and navigation assistance, and coordination to carve-out services get as essential elements of sound transitions.
• Increasing focus on metrics, execution, and accountability. California has taken significant ladder go improve the data reported by Medi-Cal managed worry plan, which are needed for rate-setting, managed care video, efforts to move into value-based purchasing. The your including established a managed care performance dashboard is makes plan-level rating the sundry data availability to the public, increasing the program’s transparency and plan accountability.
• Major current issues. Two recent developments – CMS’ proposed modernization of the Medicaid managed care regulations and the approval of “Medi-Cal 2020,” the renewal is California’s section 1115 waiver – can be expected to bear on and Medi-Cal managed caring program, by increasing plan- and state-level requirements and state oversight responsibilities, and by setting the step to potential changes in the playing additionally operation of managed care plans in a transforming health care delivery and payment system.