California s New Low Income Health Programs (LIHPs)

Transcription

1 California s New Low Income Health Programs (LIHPs) Slides by: Abbi Coursolle, Western Center on Law and Poverty (WCLP) Stacey Wittorff, Legal Services of Northern California (LSNC) Presented by : Stacey Wittorff, LSNC Sacramento County LIHP Informational Meeting March 28, 2011

2 Context: Where are we now? Today, 2010: County Programs (WIC 17000) County Coverage Initiatives (Federal Matching Funds)

3 Context: Where are we going?

4 Context: Where are we going? 2014: Two New Program for Low Income Adults 1. Medi Cal Expansion (0 133%) 2. Health Insurance Exchange Subsidies (0 400%) 2014: Continuing residual obligation per WIC 17000

5 What happens in between? California s New 1115 Waiver

6 LIHPs Part of California s Purpose of the Waiver: New 1115 Waiver Slow down projected growth curve of Medi Cal to ensure sustainability. The majority of Medi Cal fee for service spending is for beneficiaries who have multiple chronic medical conditions Prepare Medi Cal program for national health reform. Provide better care coordination to assist beneficiaries in securing needed health care services. Timing of the Waiver: Medicaid Coverage Expansion / Coverage Initiative (LIHP) pieces are effective through December 31, 2013.

7 Sources of Authority

8 What about existing programs? NO change to state law obligation to provide services under this law still exists

9 Who can be eligible? Two Programs: 1. MCE (Medicaid Coverage Expansion) 0 133% FPL 2. HCCI (Health Care Coverage Initiative) % FPL

10 Who is eligible for Citizens & Qualified Immigrants Documented but Unqualified Immigrants Undocumented Immigrants Citizens & Qualified Immigrants Unqualified Immigrants Californians with income: # Californians Uninsured (2007) Medi Cal Eligible Exchange Subsidies 2014 Basic Health Plan or Exchange Subsidies Exchange Subsidies Exchange Subsidies Exchange Subsidies what? None None None None None None 2011 MCE Eligible HCCI Eligible None None None None None None < 134% FPL % FPL % FPL > 400% FPL 1,863, ,000 1,013, ,000 Source: 2007 California Health Interview Survey,

11 Who can be eligible? County may determine income limits, except that it must serve MCE population in full before expanding its program to include HCCI County may reduce income eligibility if it projects insufficient funds, but may not keep eligibility at higher income levels while cutting lower income levels, and existing recipients may not be cut off the program County may cap enrollment and institute a waitlist if it projects insufficient funds, but must cap for higher income levels before lower

12 What benefits will enrollees get? MCE Programs: HCCI Programs Medical equipment and supplies; Emergency Care Services; Acute Inpatient Hospital Services; Laboratory Services; Prior authorized Non Emergency Medical Transportation; Outpatient Hospital Services; Physical Therapy; Physician services (including specialty care); Podiatry; Prescription and limited non prescription medications; Prosthetics and orthotics; Radiology; Mental health benefits.

13 Managed Care Delivery... Network Adequacy Requirements Primary Care Services must be available within 60 minutes or 30 miles from enrollee s residence Must be available within 30 business days (until 6/12), within 20 after 6/12 Urgent primary care must be available within 48 hours of request Specialty Care Services must be available within 30 business days of request State to develop alternative standards for... Rural areas Services areas with a county with population less than 500,000 Other sparsely populated areas and circumstances where these are unreasonably restrictive

14 Managed Care Delivery... Network Adequacy Requirements Continued Office Hours must be at least equal to those offered by the plan s commercial line of business or what is provided to Medi Cal FFS recipients Services must be available 24/7 when medically necessary Enforcement State will monitor compliance Penalties will apply if counties are not meeting these requirements

15 Managed Care Delivery...

16 How much will enrollees have to pay for services? MCE Enrollees By 7/11 costsharing must be consistent with Medi Cal HCCI Enrollees Cost sharing may not exceed 5% of family income

17 What due process? DHCS to develop due process standards Appeals/DraftLIHPHearingsandAppealsProcess.pdf At a minimum, applicants & recipients are due: Notice prior to adverse actions, including content and timeframes Services maintained and reinstated Hearing rights, including... de novo hearings, neutral arbiters, review case record, present evidence, question evidence, and refute evidence (including witness cross examination); and Hearing decisions and a process for informing persons of those decisions

18 DATE March 31 April 4 April 8 LIHP Timeline ACTIVITY DHCS submits draft cost claiming protocols to CMS DHCS provides additional guidance on MOE DHCS to notify counties of application decision DHCS and LIHPs to collaborate on network adequacy By April 18 May 17 May 20 Ongoing Beginning June 1 DHCS to begin authorization process Counties to submit requests for reconsideration DHCS to submit draft HCCI allocations to CMS DHCS to provide notice of final HCCI allocations DHCS provides additional instructions/requests for info DHCS completes authorization process which includes determinations of network adequacy and readiness for the LIHPs. LIHP authorized to begin enrollment

19 Contact Stacey Wittorff, Legal Services of Northern California (916) Abbi Coursolle, Western Center on Law and Poverty (213)