MEDI-CAL MANAGED CARE OVERVIEW - DHS Home
MEDI-CAL MANAGED CARE OVERVIEWJanuary 2020Sandy Damiano, PhD, Deputy DirectorSherri Chambers, PlannerDHS Primary Health
Eligibility & Enrollment Apply for Medi-Cal year round: County Department of Human Assistance (DHA) –Online, phone, mail, or in person. Covered California – Online, phone, or mail. Eligibility based on income and family size.Income and other information verified electronicallywhen possible.Once enrolled, need to renew annually.Assistance is available through certified enrollmentcounselors at community based agencies.Sacramento County Medi-Cal Managed Care2
Eligibility & Enrollment Notice of Action (NOA) – County Eligibility orCovered California sends a letter called a “Notice ofAction (NOA).”Plan Choice Information & Form – Health CareOptions (HCO) assists with plan choice. Plan mustbe selected within 30 days to avoid a “default” planassignment.ID Card and Health Plan Materials – Health Planprovides an ID card, Primary Care Medical Home, &health plan information.Sacramento County Medi-Cal Managed Care3
Medi-Cal Managed Care Health Plans Contracted by the State Department of Health CareServices (DHCS)Geographic Managed Care (GMC) Model Aetna Better Health Anthem Blue Cross Health Net Kaiser Permanente Molina HealthcareSacramento County Medi-Cal Managed Care4
Provider Networks Differ Kaiser – Closed NetworkNon-Kaiser Plans – Physician services are primarilycontracted through Independent ProviderAssociations (IPA) Hospital Contracts – Differ per Plan Pharmacy Benefits Managers – Differ per Plan Review each health plan’s network under the“Managed Care Resources” section on thewww.SacGMC.net webpage.Sacramento County Medi-Cal Managed Care5
Independent Provider Association (IPA) Definition - Network of physicians (solopractitioners and groups of physicians) who agreeto participate in an association to contract withmanaged care plans, and also vendors.Roles - Delegated network management and carecoordination.Plan Networks – Not all plans contract with thesame IPAs.Sacramento County Medi-Cal Managed Care6
IPAs with GMC Enrollment River City Medical GroupHill Physicians Medical GroupImperial Health Holdings Medical GroupNivano PhysiciansSacramento County Medi-Cal Managed Care7
Administrative Services Provider NetworkCase Management, Care CoordinationUtilization ReviewClaimsQuality Improvement SystemReportingCoordination with local Health and Mental HealthDepartmentsSacramento County Medi-Cal Managed Care8
Member Services Informing materialsMember Service LineInterpretation, accessible formatsBeneficiary protections such as grievance and fairhearingCultural & Linguistic ServicesTransportation when neededSacramento County Medi-Cal Managed Care9
Access & Availability Standards Urgent care – 48 hoursPrimary care – 10 business daysMental Health Non-Psychiatry Outpatient – 10business daysSpecialty care – 15 business daysEach Plan has: Member Service Lines 24 Hour RN Advice LinesUrgent Care CentersSacramento County Medi-Cal Managed Care10
Core Services Outpatient (Ambulatory) servicesEmergency servicesHospitalizationMaternity, Newborn CareMental Health and Substance Use Disorder servicesPrescription drugsRehabilitative, Habilitative services and devicesLaboratory servicesPreventive, Wellness & Chronic Disease Mgmt.Pediatric servicesSacramento County Medi-Cal Managed Care11
What are “Carve Outs?” “Carve outs” are services not offered within thescope of the health plan.What are they in Sacramento?- Mental Health Specialty- Drug Medi-Cal- Dental- California Children's ServicesSacramento County Medi-Cal Managed Care12
Mental Health Split BenefitServices to enrollees are provided in two systems ofcare. Health PlansCounty Mental Health Plan (MHP)Each system has an organized delivery system –member services, networks, etc.Sacramento County Medi-Cal Managed Care13
Health Plan MH BenefitsServes individuals with “low to moderate” mental healthneeds Services: Individual and Group evaluation & treatment Psychological testing – when clinically indicated Outpatient services for monitoring drug therapy Outpatient laboratory, medications, supplies andsupplements Psychiatric consultationSacramento County Medi-Cal Managed Care14
County Mental Health Plan MH BenefitsServes individuals with “serious” mental health needs Services: Mental health services – assessment, plandevelopment, therapy, rehabilitation Medication support services Day treatment intensive, day rehabilitation Crisis intervention, crisis stabilization Crisis residential Case management Psychiatric hospitalizationSacramento County Medi-Cal Managed Care15
County Mental Health Plan MH BenefitsHow is County MHP different? Separate systemServes individuals with “serious” mental healthneedsProvides mental health “specialty” servicesMHP Specialty has established points of accessAuthorization is based on medical necessity(defined target population, functional impairment)Sacramento County Medi-Cal Managed Care16
Substance Use Disorder (SUD) BenefitsThrough County Alcohol & Drug ServicesServes individuals with substance use disorders Drug Medi-Cal operates as a “carve out” frommanaged care plansServices - Outpatient Treatment, IntensiveOutpatient Treatment, Residential Treatment,Withdrawal Management, Narcotic TreatmentServices, Recovery Support Services, CaseManagement, Physician Consultation, AdditionalMedication Assisted TreatmentSacramento County Medi-Cal Managed Care17
Substance Use Disorder BenefitsException: Screening, brief intervention & referral are providedby the Plan primary care providers.Acute Medical Detoxification is covered by the Plan.Sacramento County Medi-Cal Managed Care18
Dental Managed Care Sacramento County has mandatory enrollmentPlan Selection is through Health Care OptionsDental Managed Care Plans include: Access Dental Plan Health Net Liberty DentalFor more information on dental services, visit theDHCS Dental Managed Care webpage.Sacramento County Medi-Cal Managed Care19
What is a Primary Care Medical Home? Core provider essential to patient careMay be a physician provider or a clinicPrimary and preventative health careChronic disease managementCare coordination – specialty referrals, posthospitalization follow-up, across other organizedsystems of care such as Specialty Mental Health(County MH Plan)Sacramento County Medi-Cal Managed Care20
Care CoordinationMedi-Cal Managed Care Plans ensure the provision ofcare coordination to their members. Basic Case Management – Includes coordination ofcarved-out services & referrals to other resources.Provided by the Primary Care Provider.Complex Case Management – Services for memberswith complex needs.Health Homes Program – Intensive coordination andcare management services for members withchronic conditions and high health needs.Sacramento County Medi-Cal Managed Care21
Eligibility & Enrollment Resources Covered California / www.coveredca.comPhone: 800-300-1506County DHA Eligibility / www.dha.saccounty.netApply online: www.mybenefitscalwin.orgPhone: 916-874-3100 Health Care Options (Health Plans/Dental Plans)www.healthcareoptions.dhcs.ca.govPhone: 800-430-4263 / TTY: 800-430-7077Other Languages: 800-430-4263Sacramento County Medi-Cal Managed Care22
Managed Care Resources Medi-Cal Managed Care Advisory Committee – See“Managed Care Resources” page in the link forhelpful documents www.SacGMC.netState Department of Health Care Services (DHCS) See Medi-Cal Managed Care www.dhcs.ca.govSacramento County Medi-Cal Managed Care23
Medi-Cal Managed Care Plans ensure the provision of . Health Care Options (Health Plans/Dental Plans) www.healthcareoptions.dhcs.ca.gov Phone: 800-430-4263 / TTY: 800-430-7077. Other Languages: 800-430-4263 . Sacramento County Medi -Cal Managed Care 22 Eligibility & Enrollment Resources
Medi-Cal Dental Action Reason for Action Code(s) (see enclosed for explanation) You can discuss different treatment plans with your dentist to obtain the best care allowable under the Medi-Cal Dental program. If. have a question regarding this action, please contact your dentist or Medi-Cal Dental at 1-800-322-6384 for a more detailed .
55 11-13 Crisis Referral Not Medi-Cal Eligible 55 14-16 MHS Contract Admin. Not Medi-Cal Eligible 55 17-19 Discounted MH Outreach Not Medi-Cal Eligible 55 21-23 SPMP Case Management Not Medi-Cal Eligible 55 24-26 SPMP Program Planning Not Medi-Cal Eligible 55
Directorio de Proveedores y Servicios Medi-Cal Network 661.716.7270 Toll Free: 800.918.7302 Contracted with Health Net Medi-Cal Plan Contratado con el Plan de Health Net Medi-Cal . Aceptando pacientes mayores de 5 Ned Devasia, MD (m) 661.327.3747 5801 Truxtun Ave Bakersfield, CA 93309 BC: Internal Medicine LS: Spanish. 4 Medi-Cal Jae Kim, MD .
Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) Medi-Cal Point of Service (POS) Network/Internet Agreement Note: These forms can be downloaded from the Forms page on the Medi-Cal Provider website (www.medi-cal.ca.gov). When the provider or submitter has approval for electronic submission, then a .
Transitioning pharmacy services from Medi-Cal managed care to fee-for-service will, among other things: Standardize the Medi-Cal pharmacy benefit statewide, under one delivery system. Improve access to pharmacy services with a pharmacy network that includes the vast majority of the state's pharmacies and is generally more expansive
info@medi.hu www.medi.hu medi Medical Support Sdn Bhd medi representative office Asia Unit No. B-2-19, Block B, No.2, Jalan PJU 1A/7A Oasis Ara Damansara, PJU 1A, 47301 PETALING JAYA Darul Ehsan Malaysia T: 6 03 7832 3591 F: 6 03 78323921 info@medi-asia.com www.medi-asia.com medi Middle East P. O. Box: 109307 Abu Dhabi United Arab Emirates
Medi-Cal Managed Care External Quality Review Technical Report July 1, 2019- June 30, 2020 Main Report . Managed Care Quality and Monitoring Division . Dental Managed Care Plan Performance Improvement Projects 101 . Background 101 . Requirements 101 . Objectives 102 . Methodology 102 .
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