Medi-Cal Managed Care: An Overview and Key Issues
Cite to new SHFO CPS data once posted.
Most of the state’s Medi-Cal managed care programs were included in the California “Bridge to Reform” Section 1115 waiver amendment effective for the 2010 – 2015 time period. The waiver amendment also expanded the managed care programs to include seniors and persons with disabilities, expanded managed care to additional counties, and added benefits. California Bridge to Reform Section 1115 Demonstration Fact Sheet, Updated August 2015. Accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ca/ca-bridge-to-health-reform-fs.pdf
Medi-Cal Managed Care Enrollment Report, October 2015, available at http://www.dhcs.ca.gov/dataandstats/reports/Documents/MMCD_Enrollment_Reports/MMCEnrollRptOct2015.pdf
Medi-Cal Managed Care, Medi-Cal Facts No. 8, March 2000, Medi-Cal Policy Institute, a project of the California Health Care Foundation. Accessed at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20M/PDF%20mmc2.pdf
California’s 12 public hospital health system counties are: Alameda, Contra Costa, Kern, Los Angeles, Monterey, Riverside, San Bernardino, San Francisco, San Joaquin, San Mateo, Santa Clara, and Ventura. All Plan Letter 13-022, California Department of Health Care Services, July 25, 2014, available at http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2013/APL13-022.pdf. These 12 counties are served under the Two Plan Model, except for Monterey, San Mateo, and Ventura counties, which are served by COHS plans. .
L.A. Care Health Plan website, Plan Partners page. Accessed at http://www.lacare.org/health-plans/medi-cal/plan-partners
As of August 2015, there are four plan choices in Sacramento County and five in San Diego County. Medi-Cal Managed Care Enrollment Report, August 2015. Accessed at http://www.dhcs.ca.gov/dataandstats/reports/Pages/MMCDMonthlyEnrollment.aspx
Medi-Cal Update, Part 1 – Program and Eligibility, October 2013. Accessed at http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/part1201310.asp
California Department of Health Care Services, Medi-Cal Managed Care Program Fact Sheet – Managed Care Models, November 2014. Accessed at http://www.dhcs.ca.gov/provgovpart/Documents/MMCDModelFactSheet.pdf; Medi-Cal Managed Care Enrollment Report, August 2015. Accessed at http://www.dhcs.ca.gov/dataandstats/reports/Pages/MMCDMonthlyEnrollment.aspx
California’s 12 public hospital health system counties are: Alameda, Contra Costa, Kern, Los Angeles, Monterey, Riverside, San Bernardino, San Francisco, San Joaquin, San Mateo, Santa Clara, and Ventura. See All Plan Letter 13-022, op. cit.
California’s “Bridge to Reform” section 1115 waiver, approved in November 2010, created the Low Income Health Program (LIHP), which allowed counties to receive federal Medicaid reimbursement for providing health services through the LIHP to residents who would become newly eligible for coverage under the ACA Medicaid expansion in 2014.
All Plan Letter 13-022, op. cit.
MCOs can avoid oversight action associated with not meeting the 75% auto-assignment standard if they demonstrate that they have attempted to meet it but are constrained by regulatory geographic access standards.
Knox-Keene Health Care Service Plan Act of 1975, §1367.03, and Title 28, California Code of Regulations §1300.51 and §1300.67.2.
Bridge to Reform Waiver Resources, California Department of Health Care Services, available at http://www.dhcs.ca.gov/provgovpart/Pages/1115-Bridge-to-Reform.aspx
SPDs in an additional 19 rural counties (Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Imperial, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Tuolumne, and Yuba) began to transition to mandatory enrollment in Medi-Cal managed care in December 2014.
Medi-Cal Managed Care Performance Dashboard, , California Department of Health Care Services, accessed at: http://www.dhcs.ca.gov/services/Documents/MMCD/20150305MMCPDashboard.pdf
2012-2013 Governor’s Budget Highlights Department of Health Care Services, January 6, 2012, available at http://www.dhcs.ca.gov/Documents/2012-13%20Budget%20Highlights.pdf
The 2012-13 Budget: Analysis of the Governor's Healthy Families Program Proposal, Legislative Analyst’s Office, February 17, 2012. Accessed at http://www.lao.ca.gov/analysis/2012/health/healthy-families-021712.aspx
California Department of Health Care Services, Healthy Families Program Transition to Medi-Cal: Final Comprehensive Report, February 4, 2014. Accessed at http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/AppendixCHFP.PDF
Legislative Analyst’s Office, Recent History of Adult Day Health Care and Transition of Seniors and Persons With Disabilities Into Managed Care, March 7, 2012. Accessed at http://www.lao.ca.gov/handouts/Health/2012/Recent_History_ADHC_3_7_12.pdf
California Demonstration to Integrate Care for Dual Eligible Beneficiaries, May 31, 2012, Proposal to CMS. Accessed at https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid-coordination-office/downloads/caproposal.pdf
Senate Bill (SB) 1008 (Chapter 33, Statutes of 2012); SB 1036 (Chapter 45, Statutes of 2012); and SB 94 (Chapter 37, Statutes of 2013).
Memorandum of Understanding (MOU) Between CMS and The State of California Regarding a Federal-State Partnership to Test a Capitated Financial Alignment Model for Medicare- Medicaid Enrollees, California Demonstration to Integrate Care for Dual Eligible Beneficiaries (2013). Accessed at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/CAMOU.pdf
Cal MediConnect Monthly Enrollment Dashboard as of October 1, 2015, California Department of Health Care Services. Accessed at http://www.calduals.org/wp-content/uploads/2015/10/CMC-Enrollment-Dashboard-October-Final-102015.pdf
S. Zuckerman, A. Williams, and K. Stockley (Urban Institute), Medi-Cal Physician and Dentist Fees: A Comparison to Other Medicaid Programs and Medicare , California Healthcare Foundation, April 2009; accessed at http://www.chcf.org/publications/2009/04/medical-physician-and-dentist-fees-a-comparison-to-other-medicaid-programs-and-medicare
S. Decker, “In 2011, Nearly One-Third Of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help,” Health Affairs, 31, no.8, available at http://content.healthaffairs.org/content/31/8/1673.full.pdf+html
P. Cunningham and L. Nichols, “The Effects of Medicaid Reimbursement on the Access to Care of Medicaid Enrollees: A Community Perspective,” Medical Care and Research Review 62, no. 6(2005), available at http://mcr.sagepub.com/content/62/6/676.abstract
D. Polsky, M. Richards, S. Basseyn, D.Wissoker, G. Kenney, S. Zuckerman, and K. Rhodes, “Appointment Availability after Increases in Medicaid Payments for Primary Care,” New England Journal of Medicine, February 5, 2015, accessed at: http://www.nejm.org/doi/full/10.1056/NEJMsa1413299
Douglas, Director, California Department of Health Care Services v. Independent Living Center of Southern California, Inc., et al., available at http://www.supremecourt.gov/opinions/11pdf/09-958.pdf
S. Rosenbaum, Medicaid Payment Rate Lawsuits: Evolving Court Views Mean Uncertain Future for Medi-Cal, California Health Care Foundation, October 2009, available at http://www.chcf.org/publications/2009/10/medicaid-payment-rate-lawsuits-evolving-court-views-mean-uncertain-future-for-medical
42 U.S.C. §1396a(a)(30)(A).
Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability: Proposed Rules, Federal Register, Vol. 80, No. 104, June 1, 2015, https://www.federalregister.gov/articles/2015/06/01/2015-12965/medicaid-and-childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered
Medi-Cal at a Crossroads: What Enrollees Say about the Program, California HealthCare Foundation, May 2012, available at http://www.chcf.org/publications/2012/05/medical-crossroads-what-enrollees-say
Monitoring Access to Care for MediCal Enrollees in a Time of Change: CHCF Sacramento Briefing, October 16, 2014, California HealthCare Foundation, accessed at: http://www.chcf.org/events/2014/briefing-medical-access
Centers for Disease Control and Prevention, National Center for Health Statistics, “Acceptance of New Patients With Public and Private Insurance by Office-based Physicians: United States, 2013,” NCHS Data Brief, No. 195, March 2015; accessed at http://www.cdc.gov/nchs/data/databriefs/db195.pdf
J. Coffman, D. Hulett, M. Fix, and A. Bindman, Physician Participation in Medi-Cal: Ready for the Enrollment Boom? California HealthCare Foundation, August 2014, available at http://www.chcf.org/publications/2014/08/physician-participation-medical
California Department of Health Care Services: Improved Monitoring of Medi-Cal Managed Care Health Plans Is Necessary to Better Ensure Access to Care, Report 2014-134, California State Auditor, June 2015, available at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20P/PDF%20PhysicianParticipationMediCalEnrollmentBoom.pdf
Frequency of Threshold Language Speakers in the Medi-Cal Population by County for December 2013,” Medi-Cal Statistical Brief, California Department of Health Care Services Research and Analytic Studies Division, , “May 2014, available at http://www.dhcs.ca.gov/dataandstats/statistics/Documents/RASB_Issue_Brief_Annual_Threshold_Language_Report.pdf
G. Sánchez, T. Nevarez, W. Schink, and D. Hayes-Bautista, “Latino Physicians in the United States, 1980–2010: A Thirty-Year Overview From the Censuses,” Academic Medicine 90:7, July 2015, available at: http://journals.lww.com/academicmedicine/Citation/2015/07000/Latino_Physicians_in_the_United_States,_1980_2010_.20.aspx
On the Frontier: Medi-Cal Brings Managed Care to California’s Counties, California Healthcare Foundation, March 2015, available a http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20F/PDF%20FrontierMediCalMgdCareRural.pdf
C. Graham, E. Kurtovich, S. Taube, and R. Arguello, Transitioning Beneficiaries with Complex Care Needs to Medicaid Managed Care: Insights from California, Kaiser Commission on Medicaid and the Uninsured, July 2013, available at https://www.kff.org/search/?s=Transitioning+Beneficiaries+with+Complex+Care+Needs+to+Medicaid+Managed+Care:+Insights+from+California
D. Gorn, “Medi-Cal Transition ‘Lessons Learned,’” California Healthline, October 24, 2013, available at http://www.californiahealthline.org/capitol-desk/2013/10/lessons-learned-from-medical-transitions
Extended Continuity of Care for SPDs Transitioning to Mandatory Managed Care, News Release, Department of Health Care Services, November 4, 2011, available at http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_20066.asp
C. Graham, E. Kurtovich, S. Taube and R. Arguello, op. cit.
J. Paradise and M. Musumeci, Proposed Rule on Medicaid Managed Care: A Summary of Major Provisions, Kaiser Commission on Medicaid and the Uninsured, July 23, 2015, available at https://www.kff.org/medicaid/issue-brief/proposed-rule-on-medicaid-managed-care-a-summary-of-major-provisions/
California Hospital Association comment letter to the Centers for Medicare & Medicaid Services, available at http://www.regulations.gov/#!documentDetail;D=CMS-2015-0068-0570
Medi-Cal 2020 Waiver Resources, California Department of Health Care Services, available at http://www.dhcs.ca.gov/provgovpart/Pages/medi-cal-2020-waiver.aspx