Managed Long Term CareNational Medicaid CongressJune 14, 2011

Richard ChambersChief Executive Officer

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Overview

• CalOptima overview

• Medicaid managed care Orange County’s experienceManaged long term care initiatives

• MACPAC

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Orange County, CA

• 3 million residents

• Urban, densely populated area

• Racially and ethnically diverse

• Mature managed care market

• 380,000 Medicaid beneficiaries

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CalOptima

• County Organized Health System for Orange County

• Public agency authorized by federal, state and county

• Key features:Single plan responsible for providing MedicaidMandatory enrollment of all full scope Medicaid beneficiaries

Includes Seniors and Persons with DisabilitiesIncludes Dual Eligibles

Responsible for nearly all acute medical servicesIncludes nursing home care (long term institutional care)Certain benefits still carved out (e.g., dental, behavioral, home and community-based)

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CalOptima ProgramsMedi-Cal OneCare Healthy Families

ProgramMultipurpose

Senior Services Program

Program Type Medicaid MA-SNP CHIP HCBS (1915c waiver)

Enrollment 380,000 12,000 38,000 500

Eligibility TANFSPDDuals

Duals Children under 250% FPL

Medicaid eligible who is:•65+•Risk for nursing home placement

Services • Health• Rx• Vision

• Health• Rx• Vision

• Health• Rx

• Assessments• Care planning• Coordination• In-home services

Revenue (FY11) $1.1 B $148 M $40 M $2 M

• In addition, the CalOptima Foundation operates the Orange County Regional Extension Center

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CalOptima’s Medicaid Membership

Non-Duals35%

Duals65%

Disabled14.0 %

Seniors13.8 %

LTC 1.2 %

TANF 71.0%

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Medicaid Managed Care Today

• Focuses primarily on TANF populations• Includes primary / acute services

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Medicaid Managed Care Tomorrow

• Will likely include entire Medicaid population (duals)

• Will include all services, have fewer benefit carve-outs

• Will focus on coordinated care across the continuum

• Will increasingly need to be, or promote, fully integrated systems

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Medicaid Managed Care Tomorrow: More Managed Long Term Care (MLTC)

• Go beyond acute services and ‘silos’ of care delivery

• Align incentives to promote most effective care delivery

• Bring managed care principles to home and community- based services (HCBS)

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Medicaid Managed Care Tomorrow: Fully Integrated Systems for Duals

• 15 states will pilot fully integrated programs for duals

• Will focus on optimal program and financing models

• PACE is currently the only tested model

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CalOptima 1998-2004

• CalOptima responsible for primary/acute care, and institutional long term care (limited HCBS)

• State and County responsible for HCBS (personal care, adult day health care) via fee for service system

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CalOptima 2005-2011

• For Duals who are enrolled in CalOptima’s D-SNP, CalOptima also provides Medicare primary/acute

• With exception of CalOptima’s limited HCBS, duals also receive HCBS from State/County

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CalOptima’s Future

PACE

Medicaid MLTC

Duals Integration

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Current Initiative: PACE

• Program of All Inclusive Care for the ElderlyEstimated 9,000 eligible in Orange County

• First site to open in Spring 2012CalOptima to be a direct service provider at first siteUnique model for health plan as a PACE provider

• Develop a PACE system for Orange CountyMeet community-specific needsConsider other delivery models (e.g., delegation)

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Current Initiative: Medicaid Managed LTC

• Assume financial / administrative responsibility for community-based LTC services

• Develop global capitation rate

• Amend state’s 1115 Waiver

• Ongoing engagement with local communityElimination of adult day health care benefitFurther reductions in personal care benefit

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Current Initiative: Full Medicare / Medicaid Integration

• California recently awarded CMS Duals Pilot contract

• Legislative authority to contract with up to 4 pilot sites

• CalOptima applying to be a pilot site / contractor

States Awarded Contracts (# duals)

California (982K) Minnesota (116K) South Carolina (129K)

Colorado (69K) New York (643K) Tennessee (257K)

Connecticut (83K) North Carolina (279K) Vermont (32K)

Massachusetts (233K) Oklahoma (98K) Washington (136K)

Michigan (229K) Oregon (82K) Wisconsin (161K)

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Current Initiative: Full Medicare / Medicaid Integration

California’s timeline for duals integration pilot

Timeframe ActivityJune 1, 2011 RFI responses due

Sept 1, 2011 Submit plan for CMS approval

Oct 31, 2011 Release RFP

Dec 22, 2011 RFP responses due

March 2012 Announce pilot counties

Nov-Dec 2012 Begin operating pilots

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Considerations for Integrated System

• Impact on delivery systemMore complex, higher acuity patients (e.g., duals)More financial risk for plans and providers

• Fundamental changesRisk distributionContract arrangementsCare management

MACPAC Presentation at the Medicaid Congress

Richard Chambers

June 14, 2011

MACPAC Statutory Charge

• Legislative History– Established in February 2009 (CHIPRA)– Expanded and funded in March 2010 (ACA)

• Commission– Appointed by the Comptroller General of the United States to 3-year

terms– 17 Commissioners represent broad spectrum of interests and expertise

on Medicaid and CHIP

• Goals– Serve as a federal non-partisan and analytic resource on Medicaid and

CHIP policy for the Congress– Review federal and state Medicaid and CHIP policies and data sources

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MACPAC Duties

• Review Medicaid and CHIP policy issues:– Payment policies– Access to care issues – Eligibility – Quality of care – Interactions between Medicaid and Medicare – Data policy analysis and program accountability

• Review and comment on Secretarial reports and regulations that relate to policies under Medicaid and CHIP

• Submit annual reports to the Congress in March and June

• Collaborate and consult with states, MedPAC, and the Medicare- Medicaid Coordination Office

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Overview of MACPAC’s March 2011 Report to the Congress

• Background and overview of Medicaid and CHIP

• Foundation for MACPAC’s initial approach to addressing payment, access and data– Evolving framework to guide the Commission’s analytic approach and

research on access to care in Medicaid and CHIP– Initial approach for examining Medicaid provider fee-for-service

payment policy across states and providers– Outlines federal data sources, issues and potential areas for

improvement for policy and accountability

• Medicaid and CHIP Program Statistics (MACStats): original MACPAC data analysis of state-level and national Medicaid data on enrollment, spending, program design, budget share, etc.

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Preview of the June 2011 Report

• Current, baseline information on Medicaid managed care:– Medicaid managed care in the context of the U.S. health care

system– Populations enrolled in Medicaid managed care– Managed care models – Payment policies– Access and quality– Program accountability, integrity and data – Future issues facing Medicaid managed care

• June 2011 MACStats tables and figures will include: – Trends in Medicaid enrollment and spending– Current health characteristics, enrollment, and benefit spending

among Medicaid populations– Medicaid managed care enrollment

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June 2011 Report

Coming out June 15, 2011

www.macpac.gov

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