Federal lawmakers passed a historic federal healthcare reform bill. On March 23, 2010 President Obama Signed thePPACA (Patient Protection and Affordable Health Care Act) into law. This set in motion some major changes
in the state’s healthcare industry. The PPACA (Patient Protection and Affordable Care Act), a majority of which goes into effect in 2014 includes
provisions banning health plans from denying health insurance to consumers because of pre-existing conditions and changes that
will make it easier for low-income patients to qualify for Medicaid. Since passage California has taken a leadership role in implementing some key reform goals. In October of 2010, legislators approved a bill that made California the first state to create a Health Insurance Exchange, which will provide
consumers with a place to buy health insurance and receive information on subsidies. In November, the state moved ahead with a plan that will allow California to receive up to $10 billion in federal funds over a five-year period to implement healthcare reform goals.
Enter the California Section 1115 Medicaid Demonstration Waiver (i) . This waiver will serve as our “Bridge to Reform”. It will provide $3.9 billion to supplement coverage of uncompensated care for public hospitals, invest $3.3 billion to improve safety net hospitals, and use $2.9 million to expand healthcare coverage to low-income adults. “Through the Section 1115 Waiver, California will receive approximately $10 billion in federal funds to invest in our healthcare system to prepare for national healthcare reform,” said David Maxwell-Jolly, director of the California Department of Health Care Services.
Section 1115 of the Social Security Act allows the Secretary of Health and Human Services to authorize pilot or demonstration projects that can help promote the objectives of the Medicaid programs. Section 1115 waivers are generally used to allow states to institute demonstration projects and provide federal funding that would not normally be eligible under federal law. To avoid Congressional approval, these waivers must be "BUDGET NEUTRAL" over the life of the waiver, meaning that they cannot cost the federal government more than it would normally pay under Medicaid in the absence of the waiver. All waivers are subject to approval by the CMS (Centers for Medicare and Medicaid Services) (x) , the Office of Management and Budget and the Department of Health and Human Services.
By January 1, 2014, California (xi) will have made significant strides in implementing key components of H.R.3590 - Patient Protection and Affordable Care Act (PPACA) aka Obamacare including coverage expansion to the newly eligible Medicaid populations, expansion of Medicaid benefits for new and existing populations, delivery system reform, administration simplification, and payment reform.
Previously we collectively went about understanding what the H.R.3590 - Patient Protection and Affordable Care Act aka Obamacare was / meant & how it will effect us one 'Quickbite' at a time. I now ask that you allow me to take you on a journey to "Bridge the Information Gap" one 'Snapshot' (BIGS) at a time, as it relates to how California's Section 1115 Medicaid Demonstration Waiver (ii) shall implement the mechanisms, initiatives & provide the funding to meet the deadline(s) & mandate(s) set forth within the new legislation (PPACA).
All of this in an effort to prepare California (iii) for the additional numbers of people who will have access to health care once H.R.3590 - (PPACA) Patient Protection and Affordable Care Act aka Obamacare is fully implemented.
You will recall that H.R.3590 - Patient Protection and Affordable Care Act (PPACA) aka Obamacare had four (4) major tenets:
Increase Access to Affordable Care Improving Quality & lowering Cost New Consumer Protections Holding Insurance Companies Accountable
Bridge the Information Gap Snapshot(s) Section 1115 Waiver intends to prepare California to meet these tenets using four (4) key principles of its own:
Medicaid Coverage Eligibility Expansion (MCE) Improve Care Coordination for Vulnerable Populations Safety Net Delivery Systems Promotes Public Hospital Delivery System Transformation
Please Click HERE to Commence the Journey to BRIDGE the Gap of Information on Health Care Reform via the 1115 Waiver
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #01 - Medicaid Coverage Eligibility Expansion (MCE)
Mandatory Enrollment of SPD (Seniors and Persons with Disabilities)
by January 2011
The waiver requires mandatory enrollment of SPD (Seniors and Persons with Disabilities) into Medi Cal managed care. The waiver also includes a pilot program for the California Children’s Services (CCS) program. The mandatory enrollment of SPD (Seniors and Persons with Disabilities) individuals will apply to new or existing Medi Cal when the plan or plans in the geographic area have been determined by the State to meet certain readiness and network requirements and require plans to ensure sufficient access, quality of care, and care coordination for beneficiaries established by the State, as required by 42 CFR 438 and approved by CMS (Centers for Medicare and Medicaid Services) (x) . The State will provide updates through its regular meetings with CMS and submit regular documentation requested of its Readiness Review status. (Please see pg. #33 of 1115ANALYSIS.pdf for additional information)
BILLS SIGNED BY GOVERNOR SCHWARZENEGGER TO IMPLEMENT PROVISIONS OF THE WAIVER:
Senate Bill (SB) 208 / Steinberg/Alquist
Assembly Bill (AB) 342 / John Pérez
Download 1115Fact Sheet (Please Click HERE to DOWNLOAD Reports)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #02 - Improve Care Coordination for Vulnerable Populations
SPD (Seniors and Persons with Disabilities) Specific Progress Reports
due 60 days after the end of each quarter
During the first year of implementation of the mandatory enrollment of SPDs (Seniors and Persons w/ Disability), the State will submit regular progress updates to CMS (Centers for Medicare and Medicaid Services). After the first year of the waiver, the State will submit quarterly progress reports that are due 60 days after the end of each quarter. The fourth quarterly report of every calendar year will include an overview of the past year as well as the last quarter, and will serve as the annual progress report.(Please see pg. #07 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #03 - Safety Net Delivery Systems
DSRIP (Delivery System Reform Incentive Pool)
Effective Throughout Waiver Lifespan
The waiver includes the potential for $3.3 billion in federal funds over five years for public hospitals through the DSRIP (Delivery System Reform Incentive Pool) This funding will be contingent upon public hospitals’ achievement of specific milestones and deliverables related to infrastructure development, innovation and redesign, population focused improvements and urgent improvement in care. The waiver provides the possibility that portions of these funds could be used for incentive payments to private or district Disproportionate Share Hospitals (DSH) if such a program is developed at the State level.
Download 1115EXPENDITURE_AUTHORITY (Please Click HERE to DOWNLOAD Reports)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #04 - Promotes Public Hospital Delivery System Transformation
Redistribution of SNCP (Safety Net Care Pool) Funds
Effective Throughout Waiver Lifespan
A Safety Net Care Pool is continued under the new waiver, with a series of components, including partial reimbursements to public hospitals for uncompensated uninsured care costs; the DSRIP (Delivery System Reform Incentive Pool) and federal match for designated state programs, for which the state can access up to $400 million annually. (Please see pg. #19 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #05 - Medicaid Coverage Eligibility Expansion (MCE)
Coverage Initiative(s) and Expansion(s)
Effective Throughout Waiver Lifespan
The waiver builds on the existing county Coverage Initiatives and expands them to all counties that wish to participate, with new standards and requirements for each program. While the terms and conditions (the legal document governing the waiver) uses different names for coverage of adults with incomes between 0% - 133% and 134% - 200% of the Federal Poverty Level (FPL)
It appears the state will be using the term Coverage Expansion and Enrollment Demonstration (CEED) to describe the projects going forward. As part of the Coverage Expansion and Enrollment Demonstration (CEED) projects, counties may enroll persons in state prisons and county jails for inpatient hospital services. Essentially, inmates who leave the grounds of the prison or county jail for an inpatient stay at a community hospital would become eligible for Medi Cal or a Coverage Expansion and Enrollment Demonstration (CEED) project. (Please see 1115OVERVIEW.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #06 - Medicaid Coverage Eligibility Expansion (MCE)
Coverage Expansion and Enrollment Demonstration (CEED)
Effective Throughout Waiver Lifespan
The waiver increases and expands health care coverage to as many as 500,000 low-income uninsured residents by taking advantage of the Coverage Expansion and Enrollment Demonstration (CEED) offered in the Patient Protection and Affordable Care Act. (Please see 1115FACTSHEET.pdf for additional information) Eligible adults enrolled in a Coverage Expansion and Enrollment Demonstration (CEED) project will be enrolled in a Medical Home and receive a core set of services, including inpatient and outpatient services, prescription drugs, mental health, and other Medically necessary services.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #07 - Medicaid Coverage Eligibility Expansion (MCE)
Coverage Initiatives
Effective Throughout Waiver Lifespan
Continues the funding streams from the 2005 waiver for public hospitals:
Medi Cal FFS. Provides funding for inpatient services provided to Medi Cal patients enrolled on a fee for service basis. Public hospitals draw down the federal matching funds using Certified Public Expenditures (CPE's). As more patients move from fee for service into managed care, this funding stream will decline.
Medi Cal Inpatient Fee for Service Physician Services. Provides funding for professional physician services provided to Medi Cal patients. CMS (Centers for Medicare and Medicaid Services) specified that physician services are not included in the regular Medi Cal inpatient FFS reimbursement. Public hospitals draw down the federal matching funds using Certified Public Expenditures (CPE's). As more patients move from FFS into managed care, this funding stream will decline.
Disproportionate Share Hospital (DSH). Provides funding for hospital based services – inpatient and outpatient – to uninsured patients, including undocumented immigrants. Public hospitals use a combination of Intergovernmental Transfers (IGTs) and Certified Public Expenditures (CPE's) to draw down DSH payments.
Safety Net Care Pool Uncompensated Uninsured Care. Provides funding for inpatient, physician and hospital and non hospital based outpatient and other services provided to uninsured patients. However, this pool excludes undocumented immigrants.
$180 million a year, for three years, was included in the 2005 waiver to create health coverage initiatives. This funding is included in the Safety Net Care Pool. Ten counties created these programs. The counties provide the match to draw down the California State Association of Counties federal funds using Certified Public Expenditures (CPE's). The ten programs have expanded coverage to more than 100,000 adults with incomes up to 200 percent FPL (Federal Poverty Level).
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #08 - Medicaid Coverage Eligibility Expansion (MCE)
PPACA Expands Mandatory Medicaid
Effective Throughout Waiver Lifespan
California will build on its current county-based Health Care Coverage Initiative (HCCI) so that in 2014, this population can become fully enrolled in Medi Cal statewide. California estimates that approximately 851,000 currently uninsured children and adults will become eligible for Medicaid coverage through the expansion of Medicaid eligibility to 133% of the federal poverty level (FPL) in 2014. (Please see 1115VISION.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #09 - Medicaid Coverage Eligibility Expansion (MCE)
Prepare the HCCI Population for Medi Cal or for coverage in the Health Insurance Exchange in 2014
Effective Throughout Waiver Lifespan
California proposes to establish a minimum Health Care Coverage Initiative (HCCI) benefits package, for which California seeks designation by the Secretary of Health and Human Services as a benchmark-equivalent plan as defined in Section 1937 of the Social Security Act for implementation. (Please see 1115VISION.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #10 - Improve Care Coordination for Vulnerable Populations
Medical Homes and Care Coordination
Reform by 2014
Under the waiver, Medical Home services will be expanded to all SPD (Seniors and Persons with Disabilities) enrolled in organized delivery systems of care, dual eligibles, and all newly eligible individuals enrolled in Health Care Coverage Initiative (HCCI)' s. Accordingly, Medical Homes and care coordination will be hallmarks of the HCCI programs and Medi Cal managed care plans as well as any County Alternative Options (CAO) developed under the waiver. (Please see pg. #02 of 1115VISION.pdf for additional information)
California envisions that, by 2014, it will significantly expand access to Medical Homes and care coordination to populations that are currently served in the unmanaged fee-for-service system. Likely lead to more expansive delivery system reform by 2014 as it will drive Medi Cal managed care plans and providers to incorporate the use of Medical Homes into their delivery of care for existing Medi Cal managed care members, newly eligible Medicaid beneficiaries (e.g. childless adults), and their commercial insurance market members. Ultimately in theory would better position the State to implement more systematic efforts to improve the quality and reduce the cost of health care.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #11 - Promotes Public Hospital Delivery System Transformation
Payment to the DSRIP (Delivery System Reform Incentive Pool)
Reform by 2014
The State will work with public hospital system to develop and monitor plan-specific milestones and deliverables to ensure that DSRIP payments result in improved systems of care during the transition to Medi Cal expansion in 2014. Under the DSRIP, each public hospital system will be held accountable to those milestones, returning federal funds if they are not achieved. (Please see pg. #04 of 1115VISION.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #12 - Safety Net Delivery Systems
VBP (Value Based Purchasing)
by the end of waiver year 1
California seeks the opportunity to pilot methods of incorporating value based purchasing into safety net provider-based coverage through the Health Care Coverage Initiative (HCCI). The State will develop methods of creating incentives for providers to improve process and health outcomes; patient and provider satisfaction; and greater integration and efficiencies. The value-based purchasing component will be developed and implemented by the end of waiver year 1. (Please see pg. #05 of 1115VISION.pdf for additional information)
In order to help transition local safety net systems to health care reform, California proposes to consider a shift in reimbursement structure for the Health Care Coverage Initiative (HCCI) from the current direct CPE (Certified Public Expenditure) structure to an actuarial-based payment method. This structure would introduce an element of financial risk to the Health Care Coverage Initiative (HCCI) and provide further incentives to ensure appropriate use of services.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #13 - Medicaid Coverage Eligibility Expansion (MCE)
LIHP (Low Income Health Program)
Effective Throughout Waiver Lifespan
The LIHP (Low Income Health Program) is a county-based elective program that consists of two components, the Medicaid Coverage Expansion (MCE) and Health Care Coverage Initiative (HCCI). The MCE is not subject to a cap on federal funding, and provides a broader range of Medi Cal assistance than the HCCI, which is subject to a cap on federal funding within the limited amounts available for the SNCP. (Please see pg. #16 of 1115ANALYSIS.pdf for additional information)
Download 1115AUTHORITY (Please Click HERE to DOWNLOAD Report(s)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #14 - Medicaid Coverage Eligibility Expansion (MCE)
Mental Health Benefits for MCE enrollees
Effective Throughout Waiver Lifespan
The State must offer a minimum evidence-based benefits package for mental health services under the Demonstration, to promote services in community-based settings with an emphasis on prevention and early intervention. (Please see pg. #29 of 1115ANALYSIS.pdf for additional information)
Minimum Benefits Package - Each county will provide the minimum level of mental health benefits to enrollees:
Up to 10 days per year of acute inpatient hospitalization in an acute care hospital, psychiatric hospital, or psychiatric health facility.
Psychiatric pharmaceuticals.
Up to 12 outpatient encounters per year. Outpatient encounters include assessment, individual or group therapy, crisis intervention, medication support and assessment. If a Medically necessary need to extend treatment to an enrollee exists, the plan will optionally expand the service(s).
Download 1115APPROVAL (Please Click HERE to DOWNLOAD Report(s)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #15 - Improve Care Coordination for Vulnerable Populations
Initial Behavioral Health Services Needs Assessment
No later than March 1, 2012
The State will submit to CMS a comprehensive assessment, developed collaboratively with the State Departments of Mental Health and Alcohol and Drug Programs, of its current behavioral health system, anticipated growth needs to meet all Medicaid needs by 2014, including mental health and substance use services system. This assessment shall also include information on available service delivery infrastructure, information system infrastructure/capacity, provider capacity, utilization patterns and requirements (i.e., prior authorization) current levels of behavioral health and physical health integration and other information necessary to determine the current state of behavioral service delivery in California. (Please see pg. #30 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #16 - Medicaid Coverage Eligibility Expansion (MCE)
Cost Sharing Parameters for the LIHP (Low Income Health Program) Population
Effective Throughout Waiver Lifespan
MCE related enrollment fees and premiums must be discontinued for enrollees with family income at or below133 percent of the FPL and newly participating MCE program counties must comply with Medicaid cost sharing limits for MCE and HCCI populations.
Effective July 1, 2011. All cost-sharing must be in compliance with Medicaid requirements for State plan populations that are set forth in statute, regulation and policies and all HCCI enrollees must be limited to a 5% aggregate cost sharing limit per family.(Please see pg. #30 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #17 - Safety Net Delivery Systems
Network Adequacy and Access Requirements for the LIHP (Low Income Health Program) Population
Effective Throughout Waiver Lifespan
The State must ensure that any managed care entity complies with network adequacy and access requirements, including that services are delivered in a culturally competent manner that is sufficient to provide access to covered services to the low-income population. Providers must meet standards for timely access to care and services, considering the urgency of the service needed. (Please see pg. #31 of 1115ANALYSIS.pdf for additional information)
Accessibility to primary health care services will be provided at a location within 60 minutes or 30 miles from each enrollees place of residence.
Primary care appointments will be made available within 30 business days of request during the period of the Demonstration term through June 30, 2012 and within 20 business days during the Demonstration term from July 1, 2012 through December 31, 2013.
Urgent primary care appointments will be provided within 48 hours (or 96 hours if prior authorization is required) of request.
Specialty care access will be provided at a minimum within 30 business days of request.
Network providers must offer office hours at least equal to those offered to the health plans commercial line of business enrollees or Medicaid fee-for-service participants. Services under the contract must be made available 24 hours per day, seven days per week when Medically necessary.
The State will establish alternative primary and specialty access standards for rural areas, service areas within a county with a population of 500,000 or fewer, other areas within a county that are sparsely populated, or other circumstances in which the standards are unreasonably restrictive.
In an area of Los Angeles County where an uneven distribution of population resides across a large geographic area, the County shall, in instances where there is no network participation by other designated public hospitals or non-designated public hospitals, include coverage of inpatient hospital services at the nearest network hospital through the provision of appropriate transportation that is commensurate with patient need, is required for obtaining Medi Cal care and is provided at the lowest cost mode available.
A plan will not be found to be in violation of 1902(a)(10)(A) with respect to the provision of federally-qualified health center services as long as it contracts with or otherwise offers services through at least one such health center.
Penalty Provisions Related to Network Readiness and Adequacy. Failure to implement or operationalize the provisions listed in this STC's (Special Terms and Conditions) will result in the loss of a percentage of the expenditure cap applicable to Safety Net Care Pool (SNCP) expenditures cap (not including HCCI expenditures) under the expenditure authorities.
If the State fails to meet a provision, related to Network Adequacy and Access Requirements for the LIHP Population ,the annual expenditure authority cap will be reduced by the amount(s) listed in the table below for SNCP expenditures other than those reserved for the HCCI.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #18 - Medicaid Coverage Eligibility Expansion (MCE)
SPD Benefit Package
Effective Throughout Waiver Lifespan
SPDs mandatorily enrolled in any managed care program within the State will receive from the managed care program the benefits as identified in Attachment M – Capitated Services List/Managed Care Benefit Package.
Any addition or subtraction in Medicaid program benefits, such as home and community based services (HCBS), for any specific population added to the established benefit package will require an amendment to the Demonstration. Attachment M must also be updated and submitted when such a change is proposed. (Please see pg. #33& 34 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #19 - Improve Care Coordination for Vulnerable Populations
Consumer Assistance - Initial Outreach and Communication Strategy
By December 2010
The State shall develop, and CMS (Centers for Medicare and Medicaid Services) shall review, an outreach and education strategy to explain the changes to individuals to be impacted by mandatory enrollment. The strategy shall describe the State's planned approach for advising individuals regarding health care options utilizing an array of outreach techniques (including in person as needed) to meet the wide spectrum of needs identified within the specific population. (Please see pg. #34 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #20 - Medicaid Coverage Eligibility Expansion (MCE)
California Children’s Services (CCS) - Pilot Programs Approval
from the Date of CMS approval through December 31, 2015
With at least 180 days-notice and after CMS approval the State may submit a plan to test up to four health care delivery models for children enrolled in the California Children's Services (CCS) Program. The plan shall include provisions to ensure adequate protections for the population served, including a sufficient network of appropriate providers and timely access to out of network care. The plan shall also include specific criteria for evaluating the models. (Please see pg. #42 - #43 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #21 - Safety Net Delivery Systems
Medicaid Management Information System (MMIS)
by January 1, 2012 and October 1, 2013, respectively
In accordance with Title II (Administrative Simplification) provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the State must adopt the American Standards Committee X12 Group Version 5010 standard electronic transaction format and the International Classification of Diseases, 10th Revision (ICD-10) standard electronic code set as a condition of the State continuing to receive 90% and 75% Federal financial participation for the design, development, implementation, and operations of the State's new Medicaid Management Information System (MMIS) (Please see pg. #43 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #22 - Improve Care Coordination for Vulnerable Populations
CCS Pilot Program Protocol
Effective Throughout Waiver Lifespan
The goal of the CCS (California Children Services) pilot project is for the State to identify the model or models of health care delivery for the CCS (California Children Services) population that results in achieving the desired outcomes related to timely access to care, improved coordination of care, promotion of community-based services, improved satisfaction with care, improved health outcomes and greater cost-effectiveness. CMS (Centers for Medicare and Medicaid Services) will evaluate the submitted pilot projects based on the criteria included in the plans and the following(Please see pg. #43 of 1115ANALYSIS.pdf for additional information):
A Program Description – inclusive of eligibility, benefits, cost sharing
Demonstration Program Requirements - inclusive of eligibility, enrollment, benefits, and cost-sharing
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #23 - Safety Net Delivery Systems
Health Home Service Delivery Model
Effective Throughout Waiver Lifespan
The State will ensure that any health home delivery model developed through the Demonstration will comport with Section 1945 of the Social Security Act (the Act), and any applicable Federal future regulation or guidance on its implementation (Please see pg. #41 of 1115ANALYSIS.pdf for additional information).
Enhanced FMAP (Federal Medical Assistance Percentages) for health home services will only be available through the Demonstration, including for the LIHP (Low Income Health Program), if the program design meets all applicable requirements of Section 1945 of the Act.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #24 - Safety Net Delivery Systems
Information Technology
Effective April 1, 2011
The State will submit a plan to CMS to ensure that the State has information technology available and operational that can meet all requirements set forth in these SPD (Seniors and Persons with Disabilities) STC's (Special Terms and Conditions). (Please see pg. #40 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #25 - Improve Care Coordination for Vulnerable Populations
Plan Readiness / Care Coordination
by March 1, 2011
The State shall submit to CMS (Centers for Medicare and Medicaid Services) their procedures for ensuring that each plan has sufficient resources available to provide the full range of care coordination for individuals with disabilities, multiple and chronic conditions, and individuals who are aging. Care coordination capacity should reflect demonstrated knowledge and capacity to address the unique needs (Medi Cal, support and communication) of individuals in the SPD (Seniors and Persons with Disabilities) population and include capacity to provide linkages to other necessary supports outside of each plans benefit package (e.g., mental health and behavioral health services above and beyond the benefits covered within the plan, personal care, housing, home delivered meals, energy assistance programs, services for individuals with intellectual and developmental disabilities and other supports necessary) (Please see pg. #37 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #26 - Improve Care Coordination for Vulnerable Populations
Care Continuity – Initial and Ongoing
by May 1, 2011
The State shall ensure that the plans have mechanisms to provide continuity of care to SPD (Seniors and Persons with Disabilities) enrolled individuals in order to furnish seamless care with existing providers for a period of at least 12 months after enrollment and established procedures to bring providers into network. The State shall submit to CMS (Centers for Medicare and Medicaid Services) the policies and procedures that will establish and maintain a statewide, standardized exception process for an extended period of care continuity for individuals with significant, complex or chronic Medi Cal conditions.(Please see pg. #38 - "iii" of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #27 - Safety Net Delivery Systems
Geographic Accessibility
Effective Throughout Waiver Lifespan
The State shall ensure that each plan has an accessible network (including specialty providers) with reasonable geographic proximity to the individuals enrolled as required by State statute and regulations, including the Knox Keene Act, (Please see pg. #38 - "vi" of 1115ANALYSIS.pdf for additional information) taking into account the location of FFS providers, means of transportation ordinarily used by SPD (Seniors and Persons with Disabilities) enrollees, and taking into consideration community standards as necessary, including time and distance standards.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #28 - Safety Net Delivery Systems
Specialty Healthcare Sufficient Provider Pool
Effective Throughout Waiver Lifespan
The State shall ensure that each plan has a sufficient supply and continuum of providers to meet the unique needs of the population to be served as required by 42 CFR 438..206-207, the Knox Keene Act (xvi) and other applicable state law and regulation. Such adequacy analysis can be based upon COHS (County Operated Health Systems) plans data.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #29 - Medicaid Coverage Eligibility Expansion (MCE)
Transition into Mandatory Managed Care and Enrollment Strategies
Beginning June 1, 2011
The State will implement mandatory managed care for all SPD (Seniors and Persons with Disabilities) populations affected by the Demonstration in (Please see pg. #35 of 1115ANALYSIS.pdf for additional information):
Any non- County Organized Health System (COHS) participating county by assuring that at least 2 plans are meeting the readiness requirements by June 1, 2011.
Any new non-COHS county cannot implement mandatory managed care for SPDs until the designated plan meets the same readiness requirements.
SPD (Seniors and Persons with Disabilities) individuals in each county will be enrolled on a rolling basis over a 12 month period based on the date of their birth.
Through the outreach, enrollment and education strategy the State will articulate and establish clear methods for affirmative choice for individuals (e.g., online, in person, in writing, verbal with signature confirmation, by proxy or surrogate decision-maker, etc.).
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #30 - Medicaid Coverage Eligibility Expansion (MCE)
Demonstration LIHP (Low Income Health Program) - Affected Populations MCE
Eligible individuals who meet county residency requirements of a participating county, immigration status, are not eligible for Medicaid or CHIP, are not pregnant, and are within the following population
Medicaid Coverage Expansion (MCE) Population - Adults between 19 and 64 years of age who have family incomes at or below 133 percent of the FPL (less based on participating county income standards) - (Please see pg. #21 of 1115ANALYSIS.pdf for additional information):
New MCE Recipients - Adults between 19 and 64 years of age who have family incomes at or below 133 percent of the FPL (or less based on participating county standards) and who have been determined to be eligible for enrollment into a participating county program after the Demonstration approval date; and
Existing MCE Recipients - Includes certain adults who have family income at or below 133 percent FPL, and who were enrolled in the “Medi Cal Hospital/Uninsured Care Waiver,” HCCI in their county of residence on the effective date of this Demonstration approval;
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #31 - Medicaid Coverage Eligibility Expansion (MCE)
Demonstration LIHP (Low Income Health Program) - Affected Populations HCCI
Eligible individuals who meet county residency requirements of a participating county, immigration status, are not eligible for Medicaid or CHIP, are not pregnant, and are within the following population
Health Care Coverage Initiative (HCCI) Population – Adults between 19 and 64 years of age who have family incomes above 133 percent through 200 percent FPL (or less based on participating county income standards) - (Please see pg. #21 of 1115ANALYSIS.pdf for additional information):
New HCCI Recipients - Adults between 19 and 64 years of age who have family incomes above 133 through 200 percent of the FPL (or less based on participating county standards) and who have been determined to be eligible for enrollment into a participating county program after the Demonstration approval date; and
Existing HCCI Recipients - Includes certain adults who have family income above 133 through 200 percent of the FPL, who were enrolled in the “Medi Cal Hospital/Uninsured Care Waiver,” in their county of residence on the effective date of this Demonstration approval.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #32 - Medicaid Coverage Eligibility Expansion (MCE)
Demonstration LIHP (Low Income Health Program) - Affected Populations CCS
Eligible individuals who meet county residency requirements of a participating county, immigration status, are not eligible for Medicaid or CHIP, are not pregnant, and are within the following population
State Plan California Children’s Services (CCS) Affected by the Demonstration - Are those children with Special Health Care Needs who are - (Please see pg. #21 of 1115ANALYSIS.pdf for additional information):
Under 21 years of age; and
Meet the Medi Cal eligibility criteria as defined in the California Code of Regulations such as congenital anomalies, cerebral palsy, hearing loss, cancer and diabetes; and
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #33 - Medicaid Coverage Eligibility Expansion (MCE)
Demonstration LIHP (Low Income Health Program) - Affected Populations SPD
Eligible individuals who meet county residency requirements of a participating county, immigration status, are not eligible for Medicaid or CHIP, are not pregnant, and are within the following population
State Plan Seniors and Persons with Disabilities (SPD) - Are those persons who derive their eligibility from the Medicaid State Plan and are either aged, blind, or disabled - (Please see pg. #21 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #34 - Safety Net Delivery Systems
SNCP Delivery System Reform Incentive Payments
Effective Throughout Waiver Lifespan
Within the SNCP (Safety Net Care Pool), a Delivery System Reform Incentive Pool (DSRIP) is available to for the development a program of activity that supports California's public hospitals efforts in meaningfully enhancing the quality of care and the health of the patients and families they serve. The program of activity funded by the DSRIP shall be foundational, ambitious, sustainable and directly sensitive to the needs and characteristics of an individual hospital's population, and the hospital's particular circumstances. (Please see pg. #14 - #15 of 1115ANALYSIS.pdf for additional information) There are 4 areas for which funding is available under the DSRIP, each of which has explicit connection to the achievement of three aims:
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #35 - Improve Care Coordination for Vulnerable Populations
Affordable Care Act Transition Plan
By July 1, 2012
The State must submit to CMS for review and approval an initial transition plan, consistent with the provisions of the Affordable Care Act for all individuals enrolled in the Demonstration, The plan must outline how the State will begin transition activities (Please see pg. #08 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #36 - Improve Care Coordination for Vulnerable Populations
Access Report and Plan
By July 1, 2012
The State will submit to CMS an assessment of access to care for the populations currently enrolled in Medicaid through the state plan or under this Demonstration. This assessment will measure access to primary care services and specialty care, including access by major type of specialty provider. This assessment will also identify variations in access in the various counties participating in the Demonstration including differences in access to care that exist between urban and rural areas. (Please see pg. #08 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #37 - Improve Care Coordination for Vulnerable Populations
Behavioral Health Services Assessment
By March 1, 2012
The State will submit to CMS for approval an assessment that shall include information on available mental health and substance use service delivery infrastructure, information system infrastructure/capacity, provider capacity, utilization patterns and requirements (i.e., prior authorization), current levels of behavioral health and physical health integration and other information necessary to determine the current state of behavioral service delivery in California. (Please see pg. #08 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #38 - Improve Care Coordination for Vulnerable Populations
Behavioral Health Services Plan
By October 1, 2012
The State will submit to CMS for approval a detailed plan, including how the State will coordinate with the Department of Mental Health and Alcohol and Drug Programs outlining the steps and infrastructure necessary to meet requirements of a benchmark plan no later than 2014. (Please see pg. #08 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #39 - Medicaid Coverage Eligibility Expansion (MCE)
Implementation
By July 1, 2013
The State must begin implementation of a simplified, streamlined process for transitioning eligible enrollees from the Demonstration to Medicaid or the Exchange in 2014 without need for additional determinations of enrollees eligibility. (Please see pg. #33 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #40 - Improve Care Coordination for Vulnerable Populations
Penalty - Failure to implement or operationalize the milestones
TBD
Failure to implement or operationalize the milestones listed in this STC's (Special Terms and Conditions) will result in the loss of a percentage of the expenditure cap applicable to Safety Net Care Pool (SNCP) expenditures cap (not including HCCI expenditures) under the expenditure authorities. If the State fails to meet a milestone, the annual expenditure authority cap will be reduced by the amount(s) listed in the table below for SNCP expenditures other than those reserved for the HCCI. (Please see pg. #08 of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #41 - Improve Care Coordination for Vulnerable Populations
Reporting Requirements
Effective Throughout Waiver Lifespan
A key component which will allow for the improvement of Care Coordination would be the reporting requirement related to sustaining 'Budget Neutrality'. Reporting Requirements Relating to Budget Neutrality. The State will comply with all reporting requirements for monitoring budget neutrality set forth in these Special Terms and Conditions (STCs). (Please see pg. 5 section VI. of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #42 - Improve Care Coordination for Vulnerable Populations
Reporting Requirements
Effective Throughout Waiver Lifespan
Reports on ongoing data collection and analysis of required measurement elements, including HEDIS (Healthcare Effectiveness Data and Information Set) and other measurement (xvii) ; AND...
Problems/issues that were identified, steps taken to correct them, how they were solved, and if any progress has occurred in the resolution of the issue. (Please see pg. 7 section 21. - g. & h. of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #43 - Medicaid Coverage Eligibility Expansion (MCE)
Transition Plan
State Is Required to meet SPECIFIED transition milestones
This Demonstration will not be extended by CMS (Centers for Medicare and Medicaid Services) beyond December 31, 2013 for the MCE (Medicaid Coverage Expansion) and the HCCI (Health Care Coverage Initiative) Demonstration populations. The State is required to prepare, and incrementally revise, a transition plan consistent with the provisions of the Affordable Care Act for individuals enrolled in these Demonstration
populations, including details on how the State plans to coordinate the transition of these individuals to a coverage option available under the Affordable Care Act without interruption in coverage to the maximum extent possible. Reference BIGS (Bridge the Information Gap Snapshot(s)) #23 & #35 - #38 for more details. (Please see pg. 8 section 23. of 1115ANALYSIS.pdf for additional information)
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #44 - Promotes Public Hospital Delivery System Transformation
Financial Requirements
Payment to Contracted Hospital(s)
With the exception of payments for ER hospital services, base payments to hospitals that contract with the State under the Inpatient Hospital component will be limited to rates determined through negotiations with California Medical Assistance Commission (CMAC) (xviii) and shall follow the following principles. (Please see pg. #10 - #11 of 1115ANALYSIS.pdf for additional information)
The negotiated reimbursement rates to hospitals shall be on a per diem or other basis, and may include supplemental payments, but in no case shall such reimbursement exceed, in the aggregate, the upper payment limit for private hospitals established under CMS (Centers for Medicare and Medicaid Services) regulations. Should CMS promulgate new regulations governing hospital reimbursement, the reimbursement rates must reflect such new regulations as of the effective date of the new regulations.
The non-Federal share of payments to private hospitals may be funded by transfers from units of local government, at their option, to the State. Any payments funded by IGT (Intergovernmental Transfers) shall remain with the hospital and shall not be transferred back to any unit of government.
The State will inform CMS (Centers for Medicare and Medicaid Services) of the funding of all Medicaid payments to these hospitals through the quarterly payment report currently submitted to the Regional Office. This report has been modified to accommodate the identification of funding sources associated with each type of Medicaid payment received by each hospital.
For a discussion of Payment to 'Non - Government Operated Hospital(s) Finanacial Requirements please reference pg. #11. Section #.31 of 1115ANALYSIS.pdf. On the surface they would appear to match Financial Reuirement(s) of the aforementioned 'Contracted Hospital(s)'.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #45 - Safety Net Delivery Systems
SNCP (Safety Net Care Pool) Transition Period
From Approval Through July 1, 2011
From the period of 1115 Medicaid Waiver approval through July 1, 2011 counties currently participating in the Health Care Coverage Initiative (HCCI) may claim FFP (Federal Financial Participation) subject to the SNCP limits for qualifying payments for enrollees with family incomes from 0-200 percent FPL (Federal Poverty Level) as the counties implement the new MCE (Medicaid Coverage Eligibility Expansion) coverage requirements. By January 1, 2011, the State will submit to CMS (Centers for Medicare and Medicaid Services) a plan identifying: (Please see pg. #12 - #13 of 1115ANALYSIS.pdf for additional information)
Which counties intend to offer Medicaid expansion coverage;
The upper income levels and benefit packages that the county will cover for both MCE and HCCI coverage during DY 6;
The countiesplans for implementing the new MCE coverage requirements, including the counties plans to meet any requirements not enumerated in the Demonstration waiver and payment authorities that MCE requirements are fully achieved by July 1, 2011.
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By July 1, 2011, the state will demonstrate to CMS that counties meet the new MCE coverage requirements and that the expenditures related to this coverage can be claimed as FFP under the MCE EG (hypothetical). For those counties meeting this timeframe, FFP claimed from the date of Demonstration approval will be treated as MCE expenditures.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #46 - Medicaid Coverage Eligibility Expansion (MCE)
Demonstration Delivery System - Capitation Payments
By Compliance Date of January 01, 2012
The State must ensure that regular capitation payments made to the Medicaid health plans that are covered under this Demonstration are done through an automated process that is compliant with the standard HIPAA (Health Insurance Portability and Accountability Act) ANSI X12 820 electronic transaction format. (Please see pg. #23 section 55. of 1115ANALYSIS.pdf for additional information)
The State must transition to utilizing Version 5010 of the 834 standard transaction by the compliance date of January 1, 2012. FFP (Federal financial participation) under this Demonstration may be at risk if these electronic standards are not implemented by the HIPAA (Health Insurance Portability and Accountability Act) - mandated compliance date.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #47 - Improve Care Coordination for Vulnerable Populations
Demonstration Delivery System - Network Adequacy
No later than 30 days prior to enrollment of Demonstration populations
The State must ensure that each managed care entity has a provider network that is sufficient to provide access to all covered services in the contract covered for the Demonstration populations identified in STC 47. b., c., and d. The State must provide to CMS for review and approval the following (Please see pg. 23 section 56. of 1115ANALYSIS.pdf for additional information):
The anticipated Demonstration population enrollment;
Expected service utilization based on the Demonstration population's characteristics and health care needs;
The number and types of primary care and specialty providers needed to provide covered services to the Demonstration population;
The number of network providers accepting the new Demonstration population; and
The geographic location of providers and Demonstration population, considering distance, travel time, transportation, and disability access.
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #48 - Safety Net Delivery Systems
Demonstration Delivery System - Network Requirements
Effective Throughout Waiver Lifespan
The State must through its health plans deliver adequate primary care, including care that is delivered in a culturally competent manner that is sufficient to provide access to covered services to the low-income population, and coordinate health care services for Demonstration populations. (Please see pg. #23 - #24 section #57. of 1115ANALYSIS.pdf for additional information):
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #49 - Medicaid Coverage Eligibility Expansion (MCE)
Core Benefits
Effective Throughout Waiver Lifespan
MCE (Medicaid Coverage Eligibility Expansion) & HCCI population core benefits to the extent available under the California State Plan(Please see pg. #27 - #28 section #63. of 1115ANALYSIS.pdf for additional information on the subject of core benefits as well as 'Excluded Benefits' & "'Enhancement to Core Benefits'):
Medical equipment and supplies;
Emergency Care Services (including transportation);
Acute Inpatient Hospital Services;
Laboratory Services;
Mental health benefits as described in STCs 64 and 65;
Prior-authorized Non-Emergency Medical
Outpatient Hospital Services;
Physical Therapy;
Physician services;
Podiatry;
Prescription and limited non-Rx medications;
Prosthetic and orthotic appliances and devices; and
Bridge the Information Gap Snapshot(s) Section 1115 Waiver #50 - Improve Care Coordination for Vulnerable Populations
Budget Neutrality Enforcement
Over the life of the Demonstration as adjusted November 1, 2010(Please see pg. #49 section #112. of 1115ANALYSIS.pdf for additional information):
By July 15, 2012 California must submit to CMS (Centers for Medicare and Medicaid Services) an analysis of actual enrollment in the Mandatory SPD EG. If total member months in the Mandatory SPD EG fall below final enrollment projections for the 12 months of DY 7 as determined in the final budget neutrality projections in Attachment K by more than 10% for the period ending June 30, 2012
By January 15, 2013 California must submit to CMS (Centers for Medicare and Medicaid Services) an analysis of actual enrollment in the Mandatory SPD EG.
California must provide a savings analysis associated with State plan EGs by July 31, 2012.
If California must submit a corrective action plan, CMS will monitor budget savings on July 1, 2013, January 1, 2014, July 1, 2014 and January 1, 2015 to ensure that the Demonstration will be budget neutral by the end of DY 10.
If actual enrollment and expenditures for EG in DY 8 or 9 produces savings that demonstrate that California is within 5% of their projected budget neutrality savings, California may submit an amendment seeking to restore SNCP spending authority as long as the amendment demonstrates that the State will be budget neutral by the end of DY 10.
Increase Access to Affordable Care
