This issue of the DREDF eNews examines a change in how California will provide health care services to many seniors and people with disabilities who are enrolled in Medi-Cal (called Medicaid federally and in other states). California is among many states that consider mandatory managed care a less costly option than providing fee-for-service (FFS) care for people with disabilities and chronic conditions. The state's move to establish mandatory managed care more widely will be closely watched across the country. This issue of the eNews presents the main issues that should concern people with disabilities who are Medicaid beneficiaries and provides further information sources for those who want greater detail.
In November 2010, the Federal Centers for Medicare and Medicaid Services approved a renewal for California's 1115(a) Demonstration Waiver Project under the Social Security Act.
What Does This Mean?
The 1115 Waiver affects Medi-Cal eligible seniors and people with disabilities in certain counties who currently receive health care services through FFS providers. These individuals, not including those who have any other kind of health coverage in addition to Medi-Cal, such as Medicare, will be required to enroll in one of the managed care plans that are available in their county in order to receive Medi-Cal services. The waiver will also affect how California is preparing to expand Medicaid, which will be required under the federal Affordable Care Act by 2014, and renews funding for the state's safety net hospitals.
Who Does This Affect?
The move to mandatory managed care will affect approximately 385,000 seniors and people with disabilities who live in the 16 California counties that are served by at least two managed care plans. These counties include the major urban counties of Los Angeles, San Diego, and San Francisco, as well as areas with a significant rural population, such as Sacramento, San Luis Obispo, and Tulare.
What Counties are Included?
Here is total list of the affected counties.
The California Department of Health Care Services (DHCS) has tried many times in the past to require more of the state's population of Medi-Cal-eligible people with disabilities to get their health care from managed care plans. Those efforts failed in large part because the disability community consistently joined to oppose them. The community has valued preserving full choice among those providers that accept Medi-Cal payments, including fee-for-service (FFS) providers.
The intensity of the ongoing budget crisis fueled this latest incorporation of mandatory managed care in the 1115 Waiver process. At the same time, the budget shortfall has motivated other severe threats to the health and well-being of people with disabilities, such as IHSS cuts, which have demanded much of the disability community's immediate attention. California anticipates that the latest waiver, including the move to mandatory managed care, will provide cost savings in the billions for the state's General Fund over the life of the five-year waiver.
How Mandatory Enrollment Will Work
DHCS plans to phase in managed care enrollment over a 12–month period. Beginning June 1, 2011, individuals will be enrolled based on their birth month. As of March, the department began to send advisory notices to the first group of Medi-Cal beneficiaries affected (those whose birthdays fall in June) to advise them that they will have to join a managed care health plan in order to receive Medi-Cal health care services.
DHCS is holding a community presentation in each of the 16 affected counties for Medi-Cal beneficiaries who are required to enroll in managed care. The DHCS website provides information about the enrollment process and related questions and answers.
Note: Medi-Cal beneficiaries who are already in a managed care plan and do not wish to make a change do not have to do anything.
DREDF continues to have concerns over the substance and process of the waiver, even though DHCS offers laudable goals for the change—"to achieve care coordination, better manage chronic conditions, and improve health outcomes" for seniors and people with disabilities. Our overarching concern is that the managed care plans vary widely in their level of experience with, and ability to actually provide and coordinate care for, people with disabilities. DHCS cannot simply assume that a managed care plan's experience with coordinating care for a primarily healthy working population will effectively translate into better care for people with disabilities. As a community, we certainly cannot gamble our health and lives on this assumption.
- It is very important for all of those affected by this change to get as much information as possible about the enrollment process.
- Write down your questions about whether and how you can continue to see and receive care from providers who are critical to the maintenance of your health and well-being, and document the answers that you receive.
- Ask your providers whether they are in a managed care network, and if so, which one.
- Contact your managed care plans and test their capacity to provide you with the disability accommodations you need. Ask whether they have information about the disability accessibility of their providers, and how soon you can actually get in to see the specialists you need to see.
- The managed care plans are required to assess all new enrollees on their care coordination. Many of us have complex chronic care, accessibility, and home-based care needs. The waiver terms and conditions indicate that "needs may be identified through the risk assessment process.Care shall be coordinated across all settings including services outside the provider network."
- Ask your potential plan(s) about when this assessment will occur and whether the initial "risk assessment" will include issues that are important to you (for example: DME; mental health services; non-emergency transportation assistance; language translation; home-based community services; accessible medical equipment in provider offices; and so on).
DHCS has asked each plan to develop its own risk assessment tool and give it to the state to review. If the state simply leaves the plans to themselves without informed guidance or standards, we anticipate risk assessment tools that will, for example, have few or no questions on issues as basic as the need for physical and programmatic accessibility.
- DREDF anticipates that continuity of care will be crucial to many in the disability community affected by the 1115 waiver. The policies and procedures must be clear about:
- How the application process will work
- Who gets to decide the application and on what grounds—for example, what if a plan cannot provide a beneficiary with a provider who has accessible equipment or trained lift assistance?
- Whether consumers can appeal the decisions and how
Many of the managed care plans indicate that they will be recruiting existing fee-for-service providers who already serve Medi-Cal-eligible people with disabilities. However, there has been very little information to date about how that attempt will interact with the state's exception process, especially in terms of timing.
- Access to specialist expertise is very important for many of the people affected by the move to mandatory managed care.
The waiver terms and conditions require the state to develop a process for establishing and monitoring the initial and ongoing network adequacy of the managed care plans. This process must include "minimum standards regarding access to specialty providers and their capacity to serve individuals."The State has a physical site review tool that plans are supposed to administer to their providers "that provide care to a high volume of seniors and persons with disabilities."However, at this point, the state has not defined how they designate someone as a specialist who provides care to a "high volume" of people with disabilities. Our community requires timely access to experienced providers who are geographically available as well as physically and programmatically accessible.
- It is critically important to ensure accountability and ongoing monitoring and assessment, including data collection and consumer satisfaction information from people with disabilities enrolled in managed care. While the waiver terms and conditions establish a contract requirement between DHCS and the managed care plans that mandates each plan to submit data for their enrollees, the community must advocate to ensure that the state collects disability-specific and accessibility-specific data from those affected by the waiver.
Receive e-mail updates from DHCS on the Section 1115 Waiver.