+

Making the ACA

Work for Clients &
Communities

September 18, 2013

Barbara DiPietro
Director of Policy
National HCH Council
+
Agenda for the Day
Part 1: Outreach & Enrollment

National Goals & Issues

Barbara DiPietro

SAMHSA Perspectives &
Resources

David Dickinson

CA Primary Care Association

Beth Malinowski

Insured the Uninsured Project

Kandis Driscoll

Discussion
Part 2: Delivery of Care & Access

National Goals & Issues

Barbara DiPietro

Medicaid Managed Care &
Californias Bridge to Reform

Ilia Rolon

Anthony Rose

Communities of Color & Other
Subpopulations: Orange County
Asian and Pacific Islander
Community Alliance, Inc.

Mary Ann Foo

Discussion
Health Care & Housing Are Human Rights
+
Care Delivery Models

Renewed focus on coordination and integration of
services, working as teams

Ultimate goals:

Improve access

Increase quality

Decrease cost

Integrated care

Access

Services

Funding

Evidence-based practices

Data
Health Care & Housing Are Human Rights
+ Models of Care

Patient-centered medical homes, CCEs, ACOs, etc.

Integrated, team-based care (mental health, addictions, medical)

Internal and/or external

Focus on quality and outcomes, not
quantity of procedures

Electronic health records

Coordinated care across multiple venues

Collect data, eliminate disparities

Coordinated care entities/accountable care organizations,
etc.

Health care viewed in a wider perspective

Renewed attention to social determinants of health
+
Identify Key Service Needs

Primary care

Oral health

Addictions

Mental health

Outreach

Specialty care

Housing (full continuum)

Medical respite care

Employment

Transportation
+
Identify Key Relationships

Local hospital

Discharge planning sources

Referral sources

Jail administrators

Political leaders

Shelter and housing providers

All health care providers

Business community

Emergency responders police & fire

Continuum of Care

Local health officer/social services director
+
Match Resources to Needs

Who provides the services in each area of identified
need, and how will health care reform impact them?

How will the state of the current economy impact any of
these service providers?

What are the greatest service gaps?

What is your role in filling them?

What collaborations/partnerships are possible?

How are needs being communicated to state/county

policymakers?
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Workforce Development

$1.5 billion for National Health Service Corps (over 5 years)

Scholarships, loan repayments

Primary care physicians, family nurse practitioners, certified
nurse midwives, physician assistants, dentists, dental
hygienists, and certain mental health clinicians

http://nhsc.hrsa.gov/

Also impacted by budget cuts (FY13 = $285M)

Health Center-based residency programs (e.g., teaching health
centers)

Increases to Medicaid provider payments:

2013-2014, raise to Medicare rate level
+ Workforce Challenges

7,200 new primary care providers needed (2.5% of the

current supply)

Geographic disparities in level of disruption

44 million (14%) live in areas where 5%+ increase in demand

7 million (2%) live in areas where 10%+ increase in demand
Source: Huang and Finegold. (March 2013.) Seven Million Americans Live in Areas Where Demand
For Primary Care May Exceed Supply by More than 10%. Health Affairs.
http://content.healthaffairs.org/content/early/2013/02/19/hlthaff.2012.0913.full.pdf+html.

96% physician practices accepting new patients

31% unwilling to accept Medicaid

Increases in reimbursements help
Source: Decker, S. (August 2012). In 2011, Nearly One-Third of Physicians Said They Would Not
Accept New Medicaid Patients, But Rising Fees May Help. Health Affairs 31 (8): 1673-1679.
+
State Level Actions
Part I

Consider Medicaid options

Health Homes

Waivers to target benefit packages to specific groups

Billable providers

Create incentives for quality (not quantity) of care

Re-assess scope of practice laws, data sharing limitations

Actively participate in system of change, check/prevent
abuses

Include housing as a health care intervention in state plans
(track homeless measures in health system)
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State Level Actions
Part II

Maximize relationships between Medicaid directors and

health centers (& other health providers)

Link objectives and goals to larger community health
initiatives

Facilitate data availability and exchange

Negotiate rates using broad range of factors

Social determinants of health

Health status

Quality outcomes

Facilitate new partnerships where possible
+ State Level Actions
Part III

Ensuring sufficient providers of primary care & behavioral

health services

New opportunities for criminal justice population

Staffing case managers & benefits coordinators

Training (and revitalizing) burned out workforce

EBPs, new approaches to care

Treating intense needs

Absorbing local gaps in care

Recruiting/retaining best skills

Adapting clinical curricula to include social determinants of
health, working with homeless population
+ State Level Actions
Part IV

Budget for case managers and benefit coordinators at

CBOs

Allow funding to be flexible

Not diagnosis-specific

Provides for practical items & incentives

Use peer-to-peer models, community health workers

Provide personal assistance/enabling services

Enrollment/navigation

Transportation, translation, etc.

Ensure Medicaid application works for special populations

Homeless, returning citizens, those with disabilities

Enrollment in health plan simultaneous to eligibility screening
+ State Level Actions
Part V

Reduce Medicaid administrative barriers for providers and

patients

Suspend, not terminate, benefits during institutionalization

Minimize authorizations, reimbursement time, empanelment delays &
related complexities

Reduce/eliminate co-pays and other out of pocket costs for services &
prescriptions

Maximize EHR to share patient info across service sectors

Ensure resources to fill gaps

Ongoing need for block grants, Ryan White, PATH, etc.

Ensure services for those remaining uninsured

Continue to pursue eligibility expansions
+
OPPORTUNITIES RISKS

Improved individual & public
Fail to reach newly eligible
health (lack of outreach)

Reduced personal bankruptcy
Continued barriers to
& poverty enrollment

Increased individual & family
Inability to find provider(s)
stability

Difficulty engaging in care

Increased employment &

Ongoing housing instability
productivity
risks engagement in care

Reduced recidivism to criminal

Poor transition to exchange
justice
jeopardizes gains in health,

Preventing & ending income
homelessness

Ongoing homelessness & poor
health
 Medi-Cal Expansion

Ilia Rolon, MPH

Director, Strategic Development

16
 New Landscape in 2014
Affordable Care Act brings two new health care coverage
options to increase access for about 44 million nationally
and more than 250,000 in Orange County
Health Benefit Exchange
Medicaid expansion

17
 Medi-Cal Expansion Overview
Medi-Cal (Medicaid) will be expanded to include
individuals between the ages of 19 and 65 with incomes
up to 138% of the federal poverty level (FPL) effective
January 1, 2014
Approximately $15,000 for an individual and $32,000 for a family
of four

Impact to CalOptima is significant

Brings about change in our overall population, adding more than
56,000 new members
Adds a new demographic to CalOptimas membership mix, which
has traditionally been women, children and seniors

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 Medi-Cal Expansion Population
In Orange County, the Medi-Cal expansion population
falls into two broad categories:

Low-Income Health Program (LIHP) members Countys

safety net program for the uninsured today, known as the Medical
Services Initiative (MSI)
 Currently provides medical services to individuals with incomes at or below
200% FPL
 Approximately 46,000 will be eligible for Medi-Cal expansion
 Will transition to CalOptima on January 1, 2014

Newly eligible people

 Low-income childless adults who are not elderly or disabled

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 Medi-Cal Before and After ACA

Before Affordable Care Act After Affordable Care Act

Today, individuals must meet Higher income threshold

financial criteria (income No longer need to be
level, asset test) AND also be categorically eligible,
categorically eligible: although categories will
remain to qualify others
Families with children Elimination of asset test
Pregnancy
Disability
Seniors
Children in foster care
People with specific diseases
(i.e., breast cancer and HIV)

20
 Medi-Cal Benefit Package
ACA defines certain categories of benefits as Essential
Health Benefits
Essential Health Benefits
Ambulatory patient services (doctor visits)
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral
health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care

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 Income Guidelines for ACA Programs
IF YOU ARE YOU QUALIFY FOR
AN INDIVIDUAL
making less than $15,415 Medi-Cal

making $15,415 to $27,935 Help in paying out-of-pocket costs like deductibles and co-pays. You
also qualify for a tax credit that will lower the amount of your monthly
premium
making $27,935 to $44,680 A tax credit that will lower the amount of your monthly premium

making over $44,680 No government assistance but are eligible to buy health insurance
through Covered California
A FAMILY OF FOUR
making less than $31,810 Medi-Cal

making $31,810 to $57,635 Help in paying out-of-pocket costs like deductibles and co-pays. You
also qualify for a tax credit that will lower the amount of your monthly
premium
making $57,635 to $92,200 A tax credit that will lower the amount of your monthly premium

making over $92,200 No government assistance but are eligible to buy health insurance
through Covered California

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 MSI Program Overview
Anthony Rose
Administrator, Medical Services Initiative
Orange County Health Care Agency

23
 About the MSI Program
Mandated under Californias Welfare and Institutions
Code 17000

Serves as the countys safety-net program for the

uninsured

Expanded under 1115 Medicaid Waiver Low-Income

Health Plan (LIHP)
November 2010 to December 2013
Approximately $50 million each year to continue primary and
preventive care, and expand membership for ACA
implementation in January 2014

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 Who Qualifies for MSI Now?
Ages 19 to 64

Income at or below 200% Federal Poverty Level

$1,915/month for individual

U.S. citizen or legal permanent resident

Orange County resident

Not eligible for Medi-Cal

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 LIHP Population Demographics
Diverse population
Slight majority of females (52.7%)
More than half are age 50+
Slight majority of Asian/Pacific Islanders, with Latinos as the next
largest group
English is preferred language among members who stated a
preference (66.7%)
More complex needs than current Medi-Cal population
Half have a chronic disease, with hypertension as the top
condition
Nearly 5% are homeless
Approximately 500 have HIV

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 MSI Membership Trends
Steady growth from 2010 to present

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 MSI Transition
Member Income: 0% to 138% of FPL
Will be transferred to Medi-Cal expansion under CalOptima
45,650* MSI members, or 83% of existing group
MSI began to pre-enroll members into Medi-Cal expansion
starting May 1, 2013
DHCS to notify members of their eligibility in October 2013
Member Income: 138.1% to 200% of FPL
Eligible to purchase subsidized coverage from Covered California
9,350* MSI members, or 17% of existing group
Includes legal residents of less than 5 years, regardless of
income level
Open enrollment period: October 1, 2013, to March 31, 2014
*Membership figures as of July 2013

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 MSI Post Transition
MSI to resume its role as the countys safety net program
Serving people with incomes of 138.1% to 200% of FPL who
have not enrolled in a plan through Covered California
Will need urgent or emergent condition to enroll
Reduced scope of benefits and smaller network of providers
Co-pays similar to the Bronze Plans in Covered California
All enrollees will be encouraged to apply for coverage during
Covered Californias open enrollment period
Smaller network of providers
Estimated annual enrollment less than 6,000

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 Newly Eligible

Ilia Rolon
Director, Strategic Development

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 Medi-Cal Expansion Population Mix

31
 Newly Eligible Population
Eligibility determinations remain with the Social Services
Agency

CalOptima is collaborating with the community on

outreach and education
Covered OC
Town Halls
CalOptima Community Alliances Forum (September 18)
CalOptima Informational Series (September 27)

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 Expected Enrollment Patterns

Young and healthy newly eligible are

one of the most difficult populations to
reach
May not be motivated to enroll due to good
health status
May not be aware that they qualify for free
or low-cost coverage
Many young adults under age 26 can be
covered under their parents plan

CalOptima expects about 8,600

newly eligible to enroll in FY14

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 CalOptima Preparations

Ilia Rolon, MPH

Director, Strategic Development

34
 Preparations
Gearing up for increased volume
Assessing resources
Budget
Staffing
Workspace
Participating with the state
Developing communications strategy
Preparing for the transition of LIHP members to Medi-Cal

35
 LIHP Transition Planning
MSI to CalOptima transition planning began in 2011

Analysis of MSI and CalOptima networks

Over 98% of MSI primary care providers are CalOptima providers
CalOptima actively recruiting MSI providers not already affiliated
with Medi-Cal

36
 LIHP Transition Overview
State-mandated and state-led transition process
Department of Health Care Services is lead agency
Monthly DHCS teleconferences with LIHP plans
Draft transition plan released in August

Transition requirements
Continuity of care
Member/PCP assignment
Special populations requiring additional assistance
 Beneficiaries receiving mental health services
 Ryan White beneficiaries
 Homeless beneficiaries
 Beneficiaries with open treatment authorizations

37
 LIHP Transition Timeline
October 2013
 CalOptima prepares systems, develops policies and procedures

November 2013
 CalOptima receives utilization management data
 LIHP members begin to receive DHCS notices

December 2013
 By December 30, CalOptima receives enrollment data from DHCS
 CalOptima receives PCP companion files for continuity of care

January 2014
 CalOptima sends welcome packet to new Medi-Cal members by January 10

LIHP still enrolling through the end of the year

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 LIHP Impact on CalOptima
Provider Network Capacity
Strong likelihood of continuity of care
Increased demand for behavioral health services due to needs of
population and new legislation
Increased Volume
Call center, claims, utilization management and case management
New member packets, provider directories and standard
communications
Fiscal Considerations
Full-scope benefits
Rate for expansion population pending

39
 Benefits and Contracting
Benefits for Medi-Cal expansion population
Requires 10 essential benefits
May be different than existing Medi-Cal population
 Excludes Long-Term Services and Supports, unless the state gets
permission from CMS to apply the asset test

Contracting is CalOptima Medi-Cal

CalOptima is not taking over MSI contracts

Provider outreach efforts

Will provide education and information

40
 Upcoming Events
CalOptima Informational Series:
Affordable Care Act and Its Impact on
Vulnerable Populations in OC

Friday, September 27, Noon to 2:30 p.m.

41
MAKING THE ACA WORK
FOR CLIENTS AND
COMMUNITIES
LESSONS LEARNED RELATED TO THE DELIVERY OF CARE AND
ACCESS TO SERVICES

Mary Anne Foo, MPH

Orange County Asian and Pacific
Islander Community Alliance
Challenges Accessing Care for Diverse
Communities
 As a small business owner Im scared that I will lose my business because this new
insurance will cost too much.

 Im going to reduce my employees time and the number of employees so I dont have
to pay for this.

 Im very excited I can now have health insurance but I dont know where to go, who to
choose, and how to find the right hospital or clinic.

 I want to choose the clinic and hospital near me, but they dont have anyone that
speaks my language or have anything in my language.

 I want to go to a provider or place that looks like me, speaks like me, and understands
me.

 Even if I get the insurance Ill still go through emergency because I will be seen faster
instead of waiting weeks to see a doctor.
Partnering with community
organizations and providers
 Ethnic Chambers of Commerce can reach out to all the small business owners

 Ethnic media and community leadership can give tours of the facility, introduce
them to your leadership, help them understand how your health system will be
improving access to care and addressing an increase in patients

 Can partner with community organizations who can help on patient navigation
medical interpreting, making appointments, navigation through the health system,
improving patient-provider communications, building trust for the health care system
will lead to improved patient compliance and increase HEDIS scores for managed
care institutions and cost effectiveness

 Can partner with community organizations, churches, temples, school districts to

reach homeless community members to have services in the community or more
accessible
Partnering with community
organizations and providers
 Language and cultural competency work with a small group of community
organizations and leaders on translations and cultural competency

 Community competency work with community resources to understand how

to increase access in the health care system for special populations

 Color code or use visuals for community members with higher illiteracy

 Work with community organizations and leaders on helping patients to

understand all the paperwork, HIPAA, patient rights and responsibilities,
etc.

 Work with community partners and leaders in teams or through Advisory

Committees tumor board, going on rounds, trainings for providers and
administrators, ACOs, CCEs, case management, etc.
Translations

Dont send to
Asia to be
done

Dont use
google
translate

Dont do literal
word for word
translations

Do check for
regional,
generational,
and gender
When is the best time to have
differences
relations (sex) with you?