The Basics Flashcards
When do regional rates implement?
Phase I
Phase II
(No sooner than)
Phase I January 1, 2021 (1/1/2021)
Phase II January 1, 2023 (1/1/2023)
What is the purpose of implementing regional rates?
The purpose is to consolidate existing rating regional.
What are the stipulations for consolidating rates?
Benefits must be consistent and cost profiles must be similar between consolidated plans. Similar cost profiles (high cost with high cost, etc.).
How is risk adjustment addressed?
Risk adjustment will still occur, but the cost/1000 members will be across all counties in the region.
Will CCI counties be consolidated into regional rates?
No. Although there are consistent benefits, CCI rates will continue to be separate until CCI ends 1/1/2023.
If two separate plans work in the same county, can they be consolidated?
Yes, assuming benefits and cost profiles are consistent.
What are the consolidated regions?
1) Partnership will be consolidated into 1 region made up of 14 counties.
2)
How will plan reporting occur for rate development?
Plans will report at the county level until full regional rates are phased in. Rates will continue to be provided individually by the county until we begin developing CY 2026 rates when plans are reporting CY 2023 RDT data.
When is the CCI program ending?
January 1, 2023 (1/1/2023)
When will a maternity rate be implemented in COHS counties?
January 1, 2021 (1/1/2021)
Describe LTC benefit prior to managed care carve-in.
a) COHS Counties
b) CCI Counties
c) Non-COHS/CCI Counties
LTC is covered in COHS and CCI counties. Duals and non-Duals in these counties are mandatorily enrolled in managed care.
In non-COHS and non-CCI counties, beneficiaries may receive up to 60 days of LTC services in managed care before being admitted to a LTC facility and being disenrolled to FFS. (The costs of the 60 days is spread across all categories of aid. This is captured under the LTC category of service on the CRCS sheets).
When will LTC beneficiaries be enrolled in non-COHS/CCI managed care plans?
Mandatory Enrollment:
January 1, 2021 (Non-Duals)
January 1, 2023 (Duals)
Note: Duals will be eligible and may voluntarily enroll as of January 1, 2021.
Is the LTC COA primarily made up of Dual or non-Dual beneficiaries?
Which transition will have a larger impact on rate setting?
Duals.
The LTC transition for non-Duals (1/1/2021) is not anticipated to make as substantial an impact as the Duals transition.
What is CRDD’s definition for
Dual and non-Dual beneficiaries as it pertains to MHCFA?
(TBD)
Describe enrollment status of the SPD COA prior to full managed care carve-in.
a) COHS Counties
b) CCI Counties
c) Non-COHS/CCI Counties
Both SPD Duals and non-Duals are mandatorily enrolled in managed care plans in COHS and CCI counties.
Non-Duals are mandatorily enrolled in managed care plans in non-COHS and non-CCI counties,
Pre-full managed care carve-in, SPD Duals in non-COHS and non-CCI counties are eligible for voluntary enrollment in managed care plans.
When will SPD Dual beneficiaries be mandatorily enrolled in non-COHS/CCI managed care plans?
January 1, 2023 ( 1/1/23)
Describe the MOT benefit prior to managed care carve-in.
a) COHS Counties
b) CCI Counties
c) Non-COHS/CCI Counties
In COHS counties, MOT is covered for both non-Dual and Dual beneficiaries.
In CCI counties, only kidney transplants are covered for non-Dual and Dual beneficiaries.
In non-COHS/CCI counties, only kidney transplants are covered for non-Dual and Dual beneficiaries.
When will MOT be covered in all counties?
MOT is covered in COHS counties.
In CCI counties, MOT will be covered for both non-Dual and Dual beneficiaries as of January 1, 2021 (1/1/21).
In non-COHS/CCI counties, MOT will be covered for non-Dual beneficiaries as of January 1, 2021 (1/1/21).
Dual beneficiaries may voluntarily enroll in a managed care plan as of 1/1/21. If member voluntarily enrolls, MOT will be covered.
Dual beneficiaries that do not voluntarily enroll, will be mandatorily enrolled as of January 1, 2023 (1/1/23).
What is the MOT process pre-MOT transition to managed care?
When a beneficiary needs an MOT, they are temporarily disenrolled and all costs are covered by FFS. The disenrollment is completed through the Medical Exemption Request (MER) process. After approximately 12 months post-MOT, the beneficiary will be re-enrolled into a managed care plan.
What will happen once MOT is transitioned to managed care?
Beneficiaries enrolled in managed care plans, needing a MOT, will no longer be disenrolled to FFS.
Members that were disenrolled to receive a MOT will complete the 12 months in FFS before re-enrolling into a managed care plan.
When will MSSP be removed from MLTSS and CMC?
January 1, 2021 (1/1/21)
When will Pharmacy be removed from MLTSS and CMC?
Pharmacy will be removed from all of managed care, except CMC, as of January 1, 2021 (1/1/21).
What did the 2019 Medicaid Fiscal Accountability Regulation (MFAR) propose?
Any risk sharing arrangement must be in the contract prior to the start of the rating period.
What is the enhanced care management (ECM) program?
The goal of the ECM benefit is to provide a whole-person approach to care that addresses the clinical and non-clinical needs of high-need Medi-Cal beneficiaries. The proposed ECM benefit would replace the current Health Homes Program (HHP) and Whole Person Care (WPC) care management pilots. Ultimately, the program should result in decreased inpatient, ER, and LTC stays.
When is the HHP expected to end?
January 1, 2021 (1/1/21)
Will ECM completely replace the HHP, WPC, or Targeted Case Management (TCM)?
No, only a portion of each program will transition to ECM. Remaining services may transition to ILOS or go away all together.
What are In Lieu of Services (ILOS)?
ILOS are flexible wrap-around services that the MCP would integrate into its population health strategy. These services are provided as a substitute, or to avoid, other Medi-Cal covered services such as ER utilization, a hospital or skilled nursing facility admission, or a discharge delay. ILOS would be integrated with Case or Care Management for members at medium-to-high levels of risk and may fill gaps in State Plan benefits to address medical or social determinants of health needs.
Examples of ILOS include:
1) housing transition and sustaining services;
2) recuperative care;
3) short-term non-medical respite;
4) home and community-based wrap around services for beneficiaries to transition or reside safely in their home or community;
5) sobering centers.
Will MCPs be required to provide each of the ILOS?
No, the use of ILOS is voluntary.
When will ILOS implement?
January 1, 2021 (1/1/21)
Why are these services (ILOS) not afforded as benefits presently?
Some plans do exercise their right to use ILOS; however, it remains optional. Additionally, historically, dollars spent on ILOS have not been factored into rate development. This will change moving forward, and with enough cost data, some of these services may become new benefits.
