Last month, state officials began informing more than 380,000 aged, blind and disabled Californians receiving subsidized health coverage that they need to choose a managed Medi-Cal plan in the coming months.
Mandatory managed care for this "high-touch" population of seniors and persons with disabilities (known as SPDs in the acronym-prone world of health care) is part of a sweeping Medicaid waiver negotiated last year between California and CMS. Called California's "Bridge to Reform," the waiver will bring about $10 billion in federal funds over the next five years to invest in the state's health delivery system and to help pay for changes required by federal health care reform.
Some of the money is aimed at changes designed to help slow the rate of growth in health care costs within the Medi-Cal program. State officials think shifting SPDs into managed care will save money and improve care simultaneously. They predict blind, disabled and frail elderly beneficiaries -- a needy population that accounts for a large portion of Medi-Cal's annual budget -- will receive improved care coordination, improved management of chronic conditions and overall better health outcomes through managed care. Ultimately, they hope those improvements will bring Medi-Cal's costs down.
When it was approved in November last year, California Department of Health Care Services spokesman Norman Williams said the waiver "allows us to completely restructure California's health care system, and to rein in costs in Medi-Cal."
Moving SPDs into managed care is California tugging at those reins.
The state estimates managed Medi-Cal will cost about 10% less than fee-for-service for this population.
Consumer Input Helped Shape Program
Much of the state's framework for this shift was built in conjunction with consumer groups and other stakeholders who participated in the state's preparations to negotiate the Medicaid waiver with CMS. A coalition of eight consumer groups last May issued a detailed list of recommendations for the state's move to making managed care mandatory for the SPD population. Many of those recommendations are included in the new requirements health plans now face.
"We certainly didn't get everything we wanted but I think we did get some important consumer protections included in the state's plans," said Elizabeth Landsberg, legislative advocate for Western Center on Law & Poverty.
"I think the department (of health care services) is working very hard and in good faith, but this is not an easy task, enrolling 380,000 people in a new program. There are a lot of moving pieces and we do continue to have some concerns."
The coalition -- which includes Alzheimer's Association, AARP, California Pan-Ethnic Health Network, Community Health Councils, Congress of California Seniors, Disability Rights Education and Defense Fund, Health Access California and Western Center on Law & Poverty -- is monitoring a couple of specific areas in the rollout: procedures and timeframe for enrollment and the state's efforts to make sure health plans are aware of special needs for individuals in a timely manner.
"There have already been some bumps in the road and we really haven't even gotten started yet so that raises some concerns," Landsberg said.
There is some confusion over the state's plans to notify affected beneficiaries. While most people expected the state to notify all 380,000 beneficiaries on March 1, only about 58,000 letters reportedly went out on that date.
DCHS plans what it's calling a "phased-in" enrollment process based on each individual's birth date. Each Medi-Cal beneficiary in the SPD classification will be mailed an enrollment packet 60 days prior to his or her birthday.
"Beneficiaries being phased in (currently in fee-for-service) will receive a 90/60/30-day notification," according to DHCS spokes person Anthony Cava. "This process is repeated monthly based upon the birth month of enrollees."
The coalition is also concerned about the state's timing for getting claims data to health plans for new enrollees.
"We've been told that in some cases a patient's history and specific needs might not be communicated to the new plan until seven days after they're enrolled," Landsberg said. "That could be a problem in some situations."
State officials acknowledge the situation and hope to work our wrinkles as the process unfolds.
"There are many activities that begin in the prior month, which take time, to ensure the information to be shared is complete and accurate" Cava said. "The anticipated period may be reduced once we begin the process and see if indeed it takes the anticipated time and/or if efficiencies can streamline. However, no plan can receive member information prior to the member’s first day of active enrollment," Cava said.
Landsberg and Anthony Wright, executive director of Health Access California, both lauded DCHS for its willingness to listen to and heed consumer input, but both also said consumers and consumer advocates need to stay aware and engaged in the coming months.
"We still need to be very diligent in our scrutiny of the process," Wright said. "We need to keep sight of the details about when people have to enroll and we have to keep our eyes on the big picture about how the state is going to make sure that these health plans are really prepared to do this.
"This is a big project involving some of the state's neediest, most vulnerable people," Wright said.
Health Plans Getting Ready
California health plans participating in managed Medi-Cal programs have been getting ready for the influx of SPD members since the waiver was approved six months ago. Health plans will have a whole new set of regulations and requirements to participate in the SPD shift.
"This is a more vulnerable, sicker population," said Lisa Rubino, president of Molina Healthcare of California. The group's needs and costs are generally greater than those of younger, more able-bodied Medi-Cal beneficiaries.
Many health plans in California, including Molina, are already serving the Medi-Cal SPD population but under the new waiver privisions they face greater numbers of enrollees and new oversight from the state.
"The state has set very rigorous requirements that we have had to meet," Rubino said. "They're not that much different than what we do today but there are a lot of readiness requirements around assessing network and assessing care management programs."
Some of the steps health plans are taking to get ready for the new wave of patients include:
- Expanding or solidifying network of providers to make sure state requirements are met;
- Assessing the adequacy of provider networks. Some health plans are checking clinics and physician offices for accessibility ramps, special parking and wide doorways;
- Increasing case management and social work staffs; and
- Offering training in dealing with SPD populations.
Changes Come With Bleak Budget Backdrop
Like all health care changes in California -- whether they arrive as a result of federal reform or the Medicaid waiver -- the promise of improvements is tempered by the reality of financial austerity.
"What folks need to be aware of is all this is happening at same time as have a fairly significant budget deficit," Rubino said. "As we're expanding care, we're also cutting back on Medi-Cal spending by 10%. That creates concern.
"We have a lot ot be mindful of over the coming months," Rubino said.