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Medi-Cal Waiver
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> Medi-Cal Waiver
Current as of July 26, 2010 Background A state has the option of making small changes or placing their entire Medicaid program under a waiver, with the primary benefit being the opportunity to receive federal matching funds for costs not otherwise matchable. However, the catch is that the state must ensure the package of programs and services as a whole is budget neutral to the federal government over the five year life of the waiver. In essence, the amount of new spending allowed by the federal government must be directly proportional to the amount of cost savings a state can prove it will achieve by instituting various program reforms. The State will submit a concept paper to the Centers for Medicare and Medicaid Services (CMS) on California’s proposal for its next 1115 waiver by the end of 2009 to initiate discussion on the design of the next waiver. The State will work with stakeholders and CMS over the subsequent 10 months to develop and secure approval of the waiver application. Waiver Initiatives Promoting Organized Delivery Systems As a key component of the waiver, the State seeks to offer organized systems of care that better coordinate care for Medi-Cal beneficiaries who now access care through the fee-for-service system. Target populations include: seniors and persons with disabilities, children and family in rural counties, children in the California Children’s Services program, Medi-Cal/Medicare dual eligibles, and adults with severe mental illness. The key elements of these systems of care will be consistent across the targeted populations, but the type of delivery system the State uses may vary by population and/or geographic region from existing managed care models to newly developed enhanced medical home models. These systems will include the following major components:
Strengthening the Safety Net
Implement Value-Based Purchasing Strategies Strategies may include:
Enhance the Delivery System for Uninsured to Prepare for National Health Care Reform The current 1115 waiver funds the Health Care Coverage Initiative (HCCI) in 10 counties to expand services to low-income uninsured adults not otherwise eligible for Medi-Cal. Under the new waiver, the State proposes to build upon the foundation of the current pilot programs to:
CPCA Meeting with DHCS Director on Medi-Cal Waiver On June 14, CPCA met with Department of Health Care Services Director (DHCS), David Maxwell-Jolly, to discuss the Section 1115 Medicaid Waiver proposal California recently submitted to the Centers for Medicare and Medicaid Services. CPCA members in attendance included Cathy Frey, Harry Foster, Roberto Juarez, Steve O’Kane, and Ralph Silber. CPCA expressed that our primary goal is to see that this waiver truly strengthens and builds upon the existing safety net in preparation for health care reform by including community clinics and health centers in the provider networks developed for the Seniors and Persons with Disabilities and the Health Care Coverage Initiative. At the request of the Director to better understand why CPCA is pursuing contracting protections for clinics under the new waiver, members spoke to the challenges they have faced in the past in successfully working with their county and/or health plans. CPCA acknowledged that we had reviewed the legislative language DHCS has drafted to enact the waiver, and shared the amendments we will be seeking through the legislative process expected to begin shortly. CPCA Comments on DHCS Waiver Implementation Plan On May 25, the California Primary Care Association submitted comments on the California Section 1115 Comprehensive Demonstration Project Waiver Implementation Plan, prepared by the Department of Health Care Services. CPCA commends the State for using the waiver renewal as an opportunity to lay the foundation for effective implementation of federal health care reform in California and looks forward to working with the State and fellow stakeholders to realize this vision. To read the comments click here.Behavioral Health Waiver Workgroup: Final Report and Recommendations The Department of Health Care Services has released the Final Report and Recommendations developed by the Behavioral Health Technical Workgroup on the Medi-Cal waiver. This report will inform the development of the behavioral health pilots planned under the new waiver. CPCA is pleased to see many of the comments we submitted incorporated into the document, particularly on pages 6-7 where our recommendations on financial barriers to integrated care that must be addressed are included. DHCS Convenes Third Stakeholder Advisory Committee On May 13, the third meeting of the 1115 Wavier Stakeholder Advisory Committee (SAC) was held in Sacramento. The purpose of the meeting was to review the newly released Department of Health Care Services (DHCS) 1115 Waiver Implementation Plan. DHCS Director Maxwell-Jolly presented a summary of the plan and fielded questions from SAC members. The members were then broken into small groups to discuss different pieces of the plan in more detail. DHCS acknowledged that the document presents a general plan and timelines but lacks many of the details that must be worked out between now and September (when the current waiver ends) or over the waiver’s five year implementation span. The SAC will meet again on June 10 via webinar, as well as July 22 and September 29 in-person. To view the materials from this meeting, including the plan and summary presentation, go to: http://www.dhcs.ca.gov/Pages/SACMeetings.aspx CPCA Comments on Behavioral Health Integration & the Next Medi-Cal Waiver In response to the work of the Department of Health Care Services Behavioral Health Integration Technical Workgroup, CPCA worked with the Mental Health Task Force and Waiver Workgroup to create comments titled California’s 1115 Medicaid Waiver Renewal: Behavioral Health Integration Opportunities. This paper discusses integration within community clinics and health centers and through partnerships with the county mental health system, as well as provides recommendations based on the technical workgroup’s pilot proposal for the next 1115 waiver.DHCS Announces New Waiver Workgroup on the Dual Eligibles Four Department of Health Care Services’ Medi-Cal Waiver Technical Workgroups have been underway since February and will wrap up in May. The topics include: Seniors and Persons with Disabilities, California Children’s Services Program, Health Care Coverage Initiatives, and Behavioral Health Integration. At the end of April, DHCS will convene a fifth workgroup focused on the Dual Eligibles (those eligible for both Medi-Cal and Medicare). Community clinic and health center representatives include Marty Lynch from LifeLong Medical Care and Jennifer Spalding from AltaMed Health Services. For more information, please see the DHCS Duals waiver web page. CPCA will be coordinating between the individuals in the DHCS workgroup and CPCA’s Waiver Workgroup to share information and provide feedback the representatives will carry forward at DHCS workgroup meetings. CPCA Comments on DHCS Approach to SPDs Aside from continuing to stabilize safety net hospital financing, DHCS has made clear their top priority for the new waiver is transitioning seniors and persons with disabilities (SPDs) from fee-for-service into organized systems of care that will better coordinate their care and reduce costs. In counties where Medi-Cal managed care exists, DHCS seeks to enroll SPDs into existing health plans on a mandatory basis starting in the first year of the new waiver. Counties have also been given the option to develop an alternative delivery system that SPDs could choose to enroll in, in lieu of existing managed care plans. Planning is already underway at the county level to prepare for the SPD transition into managed care and in some places to develop alternative models, so it is critical that community clinics and health centers (CCHCs) are at the table to secure a place in the new networks being developed. CPCA is working at the state level to obtain as much contracting protection as possible, but ultimately CCHC inclusion may play out differently county by county.
To read the DHCS concept paper released in March that lays out their plans for the SPD populations, click here. To read the comments CPCA has provided to DHCS seeking the CCHC protections mentioned above, click here. CPCA Releases Medical Home Waiver Concept Paper Working with CPCA’s Waiver Workgroup and Deborah Kelch Associates, CPCA has developed a demonstration proposal for the new Medicaid waiver, Community Clinics and Health Centers: Developing an Enhanced Primary Care Medical Home. We will be sharing this proposal with the Department of Health Care Services and other stakeholders for consideration, while we continue to refine the concept internally through member feedback. CPCA has released this concept paper in support of a meaningful and vigorous demonstration of the medical home concept in California’s next 1115 Medicaid waiver. Around the country, community clinics and health centers (CCHCs) are at the center of many of the existing medical home demonstrations, including the demonstration announced by CMS at the end of 2009 for FQHCs and Medicare. California’s CCHCs are one of the logical partners for a medical home demonstration and CPCA believes that the new waiver offers the opportunity to model and refine medical home concepts with existing safety net providers who are the primary providers of services for Medi-Cal beneficiaries. The Medicaid waiver is an opportunity to model medical homes that reflect the specific and diverse needs of subgroups of the Medi-Cal population, including the various categories of seniors and persons with disabilities with chronic illnesses and special needs. State Convenes Second Medi-Cal Waiver Stakeholder Committee On March 10, the second meeting of the 1115 Waiver Stakeholder Advisory Committee (SAC) was held in Sacramento. CPCA Board members Herrmann Spetzler and Marty Lynch participated. The agenda included an update from Director David Maxwell-Jolly on the Department of Health Care Services strategy for waiver renewal, and reports from each of the four technical workgroups that are convening to focus on the following areas: California Children’s Services, seniors and persons with disabilities, behavioral health integration, and the Health Care Coverage Initiative. Preliminary plans for stakeholder engagement on the topic of dual eligible beneficiaries were announced. DHCS plans to convene a webinar on the recommendations they have received from the Center for Health Care Strategies at the end of March and pursue further stakeholder engagement in April. The remaining SAC meetings are scheduled for May, June, and July. All meeting materials, including agendas and meeting notes, can be found at DHCS’s Waiver Renewal website. DHCS Convenes Medi-Cal Waiver Workgroups The Department of Health Care Services’ Medi-Cal Waiver Technical Workgroups are underway as of early February and will run through May. The four workgroup topics include: Seniors and Persons with Disabilities, California Children’s Services Program, Health Care Coverage Initiatives, and Behavioral Health Integration.These meetings will be open to the public and a listen-only conference line will be provided. For membership lists, materials and all other details go to: http://www.dhcs.ca.gov/provgovpart/Pages/WaiverRenewal.aspx. CPCA is pleased to see community clinics and health centers represented on each of the workgroups and will be coordinating between those individuals and CPCA’s Waiver Workgroup to share information and provide feedback the representatives will carry forward at DHCS workgroup meetings. CPCA has begun distributing two advocacy documents, prepared with member support from CPCA’s Waiver Workgroup, to DHCS, representatives from the Legislature, and various stakeholder groups.
On November 2, 2009 DHCS hosted a public meeting regarding their draft concept paper for California’s proposed section 1115 Medicaid waiver renewal. CPCA President and CEO, Carmela Castellano-Garcia, was in attendance to testify on behalf of community clinics and health centers. To read comments, click here. On November 18, 2009 Senate Health Committee held an informational hearing regarding the new waiver titled, Redesigning California’s Medi-Cal Program: Examining the Potential for Cost Savings and Program Improvements. Marty Lynch, LifeLong CEO and CPCA Board Member, participated to represent the community clinic voice on the stakeholder panel; to read his testimony, click here. On December 16, 2009 the State released their revised concept paper for the Section 1115 Medicaid waiver renewal, which they will be sending to the Centers for Medicare and Medicaid Services. They also announced the membership of the Stakeholder Advisory Committee. Among the 38 names are Marty Lynch from LifeLong Medical Care and Herrmann Spetzler from Open Door Community Health Centers. The first meeting will be held in Sacramento on January 7, and will be open to the public. Overall, the changes to the draft were relatively minor. However, CPCA is pleased to see that the role of community clinics and health centers is now referenced three times within the document, as opposed to zero in the original draft. California Section 1115 Comprehensive Demonstration Project Waiver Proposal—submitted by the State of California in June 2010 to the Centers for Medicare and Medicaid Services. DHCS Medical Home Webinar Recording Now Available On February 26, as part of the planning underway for the new Medi-Cal waiver, the Department of Health Care Services held a webinar titled Patient-Centered Medical Home for Vulnerable Populations. The presentation was developed to help participants understand the core elements of a patient centered medical home, and gain practical information from the experience of different clinical settings. Brenda Goldstein, Psychosocial Services Director at LifeLong Medical Care, was one of the exceptional panelists. To watch/listen to the recording, please click here. Additional Resources:
If you have any questions, would like more information, or are interested in joining CPCA’s Waiver Workgroup, please contact Allison Homewood at ahomewood@cpca.org. Government Programs Committee Updates - Members only If you have any questions, or need more information, please contact Allison Homewood at ahomewood@cpca.org.
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