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§1115 Waiver Update: California Children’s Services

Children in California Children’s Services (CCS) have designated medical conditions and are either in low-income families (less than $40,000 annual family income) or have medical bills that equal 20% or more of a family’s adjusted gross income. Currently, the CCS program is extremely fragmented. Another aspect of the §1115 Waiver is to better coordinate care for children in CCS through four different pilot programs: Existing Managed Care Plans (MCO), Enhanced Primary Care Case Management (EPCCM), Specialty Health Care Plan (SHCP), and Provider-Based Accountable Care Organization (ACO).

The pilots are aimed at improving health outcomes, improving cost-effectiveness, creating clearer accountability, improving satisfaction with care, and promoting timely access to care and family-centered care. Five counties were awarded grants to carry out the four pilots on October 12, 2011. All pilots eliminate the current Medi-Cal Managed Care Carve-out for CCS children. The contractors will manage all patient care to provide improved coordination of care, to align incentives and to optimize health outcomes.

Existing Medi-Cal Managed Care Plan: Health Plan of San Mateo

All 2,000 CCS children in San Mateo will be eligible for the MCO. They will provide holistic care including primary care, specialty care, social and psychological care, as well as whatever services are necessary to address the child and family’s well-being.

Enhanced Primary Care Case Management: Alameda County Health Care Services Agency

All 5,000 CCS children in Alameda County will be eligible for the EPCCM. The pilot will build on the County’s partnerships with local family support organizations and their current development of medical home-based care coordination, family support, and pediatric education and training. Care coordination teams will focus on coordinating services across the entire continuum of care and on creating better linkages between pre- and post-hospital discharge and transition.

Accountable Care Organization: Children’s Hospital of Orange County

The County CCS program will determine if CCS children meet the criteria to be in the demonstration project based on 10 qualifying health conditions. They estimate 5300 members will be eligible. The pilot will focus on the whole child, including a family-centered medical home and CCS-designated Specialty Care Centers. The child will be placed in a delivery system designed to meet his/her needs.

Accountable Care Organization: Rady Children’s Hospital San Diego

The County CCS program will determine if CCS children meet the criteria to be in the demonstration project based on three qualifying health conditions. They estimate 625 members will be eligible. The child will be placed in a delivery system designed to meet his/her needs.

Specialty Health Care Plan: L.A. Care Health Plan

The County CCS program will determine if CCS children meet the criteria to be in the demonstration project based on parents’ non-overlapping defined zip codes. They estimate 6000 members will be eligible. The pilot involves three hospitals that will use different networks, including Children’s Hospital LA (ACO), Millers Children Hospital (Specialty Care), and Mattel UCLA (EPCCM).

Children who are not enrolled in CCS pilots will remain at the status quo for now. Each model will be evaluated and compared based on its improvement of care coordination, quality, value, parent satisfaction, and rate of growth of expenditures.

Click here for the full CCS presentation from the November 3 Stakeholder Advisory Committee meeting.

 

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