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Waiver Implementation Picking Up Speed

There has been much progress since early November now that we have a final 1115 Waiver agreement. The state has been working with counties and CMS to ensure we are on a fast-track to implement most of the Waiver this year.

While it’s unclear whether and in what ways the eventual 2011-12 state budget may impact the Waiver, below is an update on where we stand with each of the Waiver’s 4 main sections.

Four California Children Services (CCS) Pilot Demonstration Models

The Waiver authorizes four counties to test pilot demonstration projects that integrate services under and lower costs in the CCS program. A draft Request for Proposal (RFP) was released in July 2010 and again in Jan 2011. The final RFP is set to be released March 1st. Responses from potential counties are due in May. The state will take approximately two months to evaluate them and will announce the 4 winning counties in July 2011. Operations in each of the 4 counties will begin in January 2012.

The CCS pilots will test 4 models of care coordination: (1) an Existing Medi-Cal Managed Care Plan; (2) a Specialty Health Care Plan; (3) Enhanced Primary Care Case Management; and (4) a Provider-based Accountable Care Organization.

To evaluate the models, the state is receiving help from the California Health Care Foundation, the Lucile Packard Foundation for Children’s Health, an evaluation advisory group (comprised of reps from hospitals, providers, and research individuals), and Mathematica Policy Research, an independent evaluator.

Dual-Eligibles Pilot Program / Research Project

In its original Waiver request, the state hoped for 4 county pilots to test the integration of services for those eligible for both Medicare and Medicaid (aka Dual-Eligibles or Medi-Medi’s). However, in the final waiver, this proposal was removed because CMS said such efforts were to be funded through it’s new Innovation Center established by the ACA.

CMS recently announced a grant program for 15 states to receive to $1 million each for innovation in Medi-Medi’s coordination, particularly addressing behavioral health. DHCS recently developed California’s application, requesting the full $1 million. CMS will notify recipients next month, and contracts between CMS and the awardee-states will be executed in April.

Managed Care for Medi-Cal’s Seniors & Persons with Disabilities (SPDs)

One of the biggest components of the Waiver is the move of the SPD population to Medi-Cal Managed Care. And one of the biggest concerns in this area of the Waiver is whether the managed care plans will be ready to receive this population without disruption in care and coverage. According to the state, “Good Standing Review” of plans happened in January, and all plans are in good standing with audits and medical reports. “Network Adequacy Review” is on schedule to be completed next week, and network certifications will be provided to CMS before their March 1st deadline.

After multiple and in-depth conversations between the state and participating plans, there was a decision reached on the actuarial sound rates to which both parties agreed. Final/decided rates were sent to plans Feb 2nd.

There will be considerable outreach and education regarding the SPD move to managed care. 16 community presentations will be conducted in March & April (a schedule of those meetings will be posted on the Waiver/DHCS website). There were a few 2-day SPD cultural awareness trainings in January, from which a toolkit for plans will be developed and finalized in April. On Feb 16, there will be a similar training for DHCS staff.

Low Income Health Plan (LIHP)

As of today, entities from 57 counties have submitted letters of intent to participate in the LIHP, the “coverage expansion” portion of the Waiver. The County Medical Services Program (CMSP) which represents 34 counties intends to participate, as do the 10 existing Health Care Coverage Initiative (HCCI) counties, along with 13 new counties.

Informational meetings have been held in Southern and Northern California for interested counties. There is a list of FAQs on the LIHP website.

Applications from interested entities are due on Monday, Feb 14th. Most applications that have been submitted are fairly “bare bones” but, according to the state, they do not need to be entirely complete since this is not a competitive application. The state will work with counties to shape their LIHP even after the application has been submitted.

It appears most that most counties are seeking to offer coverage up to 133% FPL (the LIHP), not all the way up to 200% FPL (the HCCI). This is likely due to projections of available county resources. Counties are also operating under the requirement to cover the lowest income populations first. [Note: if there’s unused money under the waiver, it automatically rolls over and available for other purposes, potentially coverage for the 133%-200% FPL population in a particular county. The state would need approval to redirect those funds.]

Other important dates: By March 1, draft LIHP cost protocols will be submitted to the County Workgroup that has been established. By April 4, the Maintenance of Eligibility calculation and expenditure exemptions will be released. By April 8, the state will tell counties if their apps are approved/denied [Note again: because this is a collaborative process, the state doesn’t expect any denials of applications.]

Then starts the authorization process. The state will need to prove to CMS that the plans meet network adequacy, readiness and access requirements. Applications should be approved and contracts signed in May. Counties will begin implementing their programs starting June 1, 2011.

One more thing to note in the LIHP… if a county does not send in a letter of intent by the deadline (this Monday), they can still apply again in June and anytime after. The application period stays open indefinitely (well, til Jan 1, 2104).

Stay Tuned

As you can tell, things are moving rapidly on the Waiver implementation front. For more, stay tuned to the blog and be sure to regularly check the state’s Waiver website.

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