Wednesday, January 16, 2019

AMA Letter to Congress on AHCA

Earlier today, the AMA sent a letter to Congress in opposition to the American Health Care Act (H.R. 1628), which is scheduled for a vote on the House floor tomorrow.

Modifications made to the bill following consideration by the committees of jurisdiction did not address the AMA’s chief concerns, which were expressed to Congress in previous correspondence. More specifically, the bill that will be considered on the House floor will not preserve recent gains in health insurance coverage, nor will it make meaningful and affordable coverage more available to low and moderate income Americans. Changes proposed to the Medicaid program will reduce federal support and erode the health care safety net, and Medicaid enrollees will be denied access to covered services provided by certain qualified health care providers.

Prospects for a successful floor vote in the House are uncertain. If the bill does pass, the Senate intends to consider it next week and will very likely make changes due to both parliamentary issues and policy concerns.

RCMA will keep your apprised of developments.

Read AMA Letter To Congress

Becoming the Practice of the Future Today: 10 Steps to Transform Your Practice and Provide Individualized Care

By Susan Corneliuson, MHS, FACHE and Mary Witt, MSW

Reproduced with Permission
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Current business and care delivery models, even if combined with innovative or sustainable technologies, will not lead to future success. Practices must create new care delivery and business models while incorporating technological advances to effectively compete today and in the future. New payment models, disruptive technology, and care delivery vehicles (e.g., e-visits, home monitoring, retail clinics), along with changing consumer demands for immediate access and transparency, require medical practice transformation. Here are the top 10 steps you should be taking now to transform your medical practice in order to succeed now and in the future.

1. Create a profile of your current and potential patients. Who are they (e.g., age, sex, payer mix)? What is their health status? What are their priorities for their healthcare (e.g., convenience, access, relationship, continuity of care)? How do they want their care delivered? Perhaps through e-visits, urgent care, face-to-face visits, telemedicine, or e-mail? How do they want to communicate (e.g., e-mail, texting, phone, patient portal, face-to-face encounters)? Identifying who your patients are will allow you to tailor your practice to meet their needs.

2. Assess your market. What are the demographics (e.g., ages, sex, income, health status) of your service area, and how fast is it growing? What do consumers want from their physicians? What do employers want from providers? Where are payers going with their payment models? What are your competitors doing to position themselves for the future? Who else might come into your market? Market knowledge should inform your practice redesign efforts as you move to meet the needs of patients and payers.

3. Examine your practice from your patients’ perspective. Assess your practice from top to bottom as if you were a patient. Use patient shoppers and patient focus groups to understand their perspective and expectations. Scrutinize your patient satisfaction surveys for useful data on patient needs and wants. Identify the amount of value-added time (the amount of visit time spent in actual interaction about the patient’s care) versus non-value added time, and perform cycle time studies to identify reasons for long wait times. Target patient cycle time at 30 to 40 minutes for a routine visit, and value added time at 75 to 80 percent of the visit total. By examining your practice from the patient’s perspective, you will be able to identify the gaps and develop a roadmap to transform your practice.

4. Create process excellence to drive patient, provider, and staff satisfaction. Document and analyze your work flows for all key operational areas, including patient scheduling, check-in, vitaling, exam, check-out, and patient follow-up. Identify waste, duplication, and barriers in each operational function and develop revised workflows that reduce process variability. Focus on process excellence, ensuring that every step in the process is meaningful and leads to better care. This not only will improve patient satisfaction but motivates providers and staff because it eliminates unnecessary steps and increases direct patient care time.

5. Develop patient-directed, convenient access points to your practice. Based on your patient profile, develop the access points your practice requires to meet the needs of your patient population. Be able to offer same day patients appointments so they do not go elsewhere. Implement a robust patient portal with interactive email and scheduling capabilities. Offer e-visits, text messaging, expanded hours, and/or develop relationships with urgent cares. Create an environment that allows the patient to choose the method in which they will access care with convenience and ease.

6. Change your care delivery model to facilitate population health management.
With the move to fee-for-value reimbursement and the new demands of patients in this technological age, providers need to use teams more effectively to meet patient needs. Based on your patient’s needs, determine what type of team will be most successful in managing your population of patients. Consider the use of medical assistants, care managers, social workers, and health coaches to create the support network required. For example, if your practice has a high volume of chronic care patients, consider a high-touch, high-contact delivery model with the use of care managers and health coaches to continuously engage patients in their care. For panels with high commercial, healthy populations, increase the use of advanced practice clinicians, offer e-visits, and expand hours to provide easy, convenient access. Ensure that all team members are working to the top of their license and skill sets to maximize efficiency and physician support.

7. Assess your current business model based on what is necessary to succeed in a fee-for-value world.
Assess your capabilities to provide high quality, effective, affordable care not only today, but three to five years from now. Analyze your practice’s cost structure, and identify the profit formula that will allow you to compete. Based on the needs of your patients and resources required to manage your population, identify the profit margins, reimbursement, and volumes required to meet your business goals. Analyze your payer contracts and explore fee-for-value payment model options with your payers that build on your strengths as a practice. Understand the total cost of care for your patients so you can be part of the solution in bringing them the care they deserve in a cost-efficient manner. Ensure that your compensation models effectively align with practice goals and critical success factors.

8. Optimize your use of data to enhance care, ensure accountability, and achieve your goals.
Create your practice’s value proposition for the future, and use it to guide your practice metrics and dashboard reports. Apply integrated technology and automated dashboards to track and report on practice performance, including quality measures to maximize pay for performance dollars. Use the electronic medical records (“EMR”) to proactively prompt you about a patient’s care needs. Utilize real time prompts to remind physicians of needed preventive and chronic care during the patient visit so needs can be immediately addressed. Implement a patient registry to manage patients with chronic diseases and consider the integration of home monitoring and diagnostic equipment in your care model. Gather data on your use of ancillaries, and assess if you are following best practices and only performing tests and procedures when necessary.

9. Implement strategies to foster patient “stickiness” to your practice. Focus on creating patient loyalty. Use texting, email, and social media to maintain contact outside of the face-to-face visit. Provide your patients with the information they need to stay healthy on a regular basis through texting, email, and phone calls. Develop your patient portal as the “go-to” site when they have questions by making patient education materials readily available on the portal, including the provision of links to reputable internet sites. Explore the creation of a phone application that can provide patients with a ready source to answer their immediate health concerns so they don’t have to go outside the practice’s sphere of influence. For example, the application could be linked to a branded call center which could provide an immediate response to health questions and concerns.

10. Optimize the use of technology. Utilize technology purposefully to allow providers more touch time with patients and make sure your technology works for you, not against you. Assess EMR efficiency by counting the number of clicks, screens, and typing required per task; observe physician and staff as they use the EMR and record extra steps. Work with your EMR vendor to decrease extra steps and streamline the data entry process. Note variations in the use of the system and train providers and staff in the most effective and efficient processes. Implement other technology such as automated appointment reminders and easy payment tools through the use of text, email, and phone. Use your patient portal to decrease call volume by activating patient scheduling, referral management, prescription refills, lab notifications, and pre-registration and check-in features. Consider the cost benefit of each technological feature and ensure that, once the feature is enabled, it is optimized to work for the practice.

Start now: make transformation a priority to ensure you successfully achieve your practice’s value proposition. Do not wait until your payers change how they pay, retail clinics proliferate in your community, your practice is losing patients or physicians, or you are losing money. Practice transformation does not occur over night. It takes time and hard work. To succeed in the future, you need to lay the foundation now.

For information on how The Camden Group can help in your journey to transform your practice, please contact Susan Corneliuson, MHS, FACHE at or Mary Witt, MSW at They can be reached at 310-320-3990.

Don't Miss Out On Increased Medi-Cal Payments

The California Department of Health Care Services (DHCS) will soon be implementing rate increases for primary care physicians who treat Medi-Cal patients, as authorized under the Affordable Care Act. The increase also applies to services provided by physicians to Medi-Cal managed care patients. In order to see the bump in pay, providers must first attest to their eligibility. According to DHCS, less than half of eligible providers have completed the brief self-attestation process as of September 24. Have You?

For purposes of this regulation, primary care is defined as family medicine, general internal medicine, pediatric medicine or related pediatric subspecialties. Pediatric subspecialists must be recognized by the American Board of Medical Specialties, American Board of Physician Specialties or the American Osteopathic Association to receive the increased fees. If a physician is not board certified, eligibility can be determined by the physician’s billing history. Physicians will qualify if 60 percent of the codes they bill are for evaluation and management codes and vaccine administration codes covered by this rule. Physicians can self-attest to their board certification or billing history.

Although the regulations implementing the pay raise were released by the Centers for Medicare & Medicaid Services (CMS) in November 2012, DHCS is still awaiting approval of its State Plan Amendment, which details California's proposed payment methodology for both fee-for-service and managed care payments. DHCS expects to receive approval soon and plans to implement the increase in late October. Once approved, the increases will be retroactive to January 1, 2013.

The goal of the increase is to recruit more physicians to treat low-income patients who will be newly eligible for health coverage under the ACA. Under the ACA, primary care physicians will see their reimbursement rates raised to Medicare levels in 2013 and 2014. According to CMS, states must also incorporate the increased payment rates into their contracts with managed care plans so that primary care physicians contracting with Medi-Cal managed care plans see the higher rates.

Physicians are encouraged to complete the attestation form, which is available on the Medi-Cal website The attestation form must be completed online (paper copies will not be accepted).

The rate increase applies to evaluation and management codes 99201 through 99499 and vaccine administration codes 90460, 90461 and 90471 – 90474.

For more information on the increase, including which specialties qualify, see CMA’s Medi-Cal Primary Care Physician Rate Increase FAQs or contact RCMA’s Physician Advocate Mitzi Young at or (888) 236-0267.

California Health Benefits Exchange Opens

As Covered California, the state’s Health Benefit Exchange, opened today, California Medical Association (CMA) physicians remain optimistic. Throughout the health care reform debate, CMA strongly advocated for affordable access to care for California’s uninsured and for an expansion of health insurance coverage.

“CMA has long supported access to health care for all patients,” said Paul R. Phinney, M.D., CMA president. “Today marks a positive inflection point in our nation's commitment to access to health care for all Americans

Five categories of plans will be available through Covered California, consisting of four metal tiers (bronze, silver, gold and platinum) and a catastrophic plan. If offering a metal-tier health plan in Covered California, issuers also must offer the same plan at the same premium outside of the exchange marketplace.

“The opening of Covered California is an opportunity for patients who have gone without access to medical care for months, years or even decades to see a physician” added Dr. Phinney. “There is still work to do, since access to insurance does not always guarantee access to a physician. The doctors of CMA look forward to working with Covered California to ensure that all Californians have access to the care they need and deserve."

CMA, in conjunction with the CMA Foundation, the Latino Physicians of California and the American Academy of Pediatrics, California, was recently awarded a $1.5 million grant for outreach and education to physicians about Covered California. The focus of the grant is to educate physicians and their office staff about coverage eligibility and patient enrollment.

"We are on the ground, communicating with our member physicians and colleagues about Covered California," concluded Dr. Phinney. "We want to make sure physicians and their patients have the information they need to make the goals of Covered California a reality. As with any effort of this magnitude, there will be bumps along the road. We remain committed to the effort nonetheless, and will do our utmost to educate our partners and patients on the significance of this historic change in the delivery of health care."

CMA Launches Exchange Resource Center

In 2010, Congress passed historic sweeping health care legislation, the Patient Protection and Affordable Care Act (ACA), which reformed the individual and small group health insurance markets and, beginning in 2014, will provide health insurance to much of the nation's uninsured. Under the ACA, two-thirds of California's uninsured may be may be eligible to purchase coverage through the health benefit exchange. The exchange's goal is to begin open enrollment on October 1, 2013 – with coverage beginning on January 1, 2014.

To help educate physicians about the exchange and ensure that they are aware of important issues related to exchange plan contracting, the California Medical Association (CMA) has developed a resource page where physicians can find all of CMA's exchange-related news and resources.

The new exchange resource center can be found at

For more information about California's Health Exchange, contact RCMA’s physician advocate Mitzi Young at (888) 236-0267 or


Covered California Update

Covered California, the state agency implementing the Affordable Care Act (ACA), has announced participating health insurers and proposed premiums for the state's exchange.  13 commercial health plans were selected to offer products on the exchange, including California's three largest insurance providers, Kaiser Permanente, Anthem Blue Cross and Blue Shield of California. One major concern for contracting physicians is a loophole in the ACA that could see physicians left to foot the bill for services provided to patients who haven't paid their insurance premiums. The law allows for a three month "grace period" for non-payment of premiums, but only requires insurers to pay the claims through the first month of non-payment. The final version of the exchange model contract included a provision that requires 15 days advance notice to physicians when a patient has entered the second month of the grace period, but still leaves the burden of 60 days worth of unpaid claims on the physician and the patient.

For more information about Covered California, please contact your RCMA Physician Advocate Mitzi Young at or (888) 236-0267.

Legislative Alert: Urge Your Assembly Member to Support Bill to Close ACA Loophole

Please contact your legislators today and urge them to support this important bill, which would increase funding for Medi-Cal providers and incentivize large companies to provide adequate employer-sponsored coverage.
Additional information, including talking points, is available below.

Call (877) 362-8455 to be connected with your legislator

Click Here to Take Action!

 Click Here if you Made the Call!

AB 880 (Gomez) would address a loophole in the Affordable Care Act (ACA) by requiring large employers (500 or more employees) to pay a penalty for each employee enrolled in Medi-Cal. The funding generated would be used to expand access to care by increasing Medi-Cal provider rates and to pay for the nonfederal share of Medi-Cal costs.

The ACA requires individuals, employers and government to share responsibility for health coverage.  Individuals must have health coverage or pay a penalty. The government, through the “optional” Medicaid expansion and other efforts, will increase eligibility to millions of uninsured. Employers with an average of at least 50 full time employees will either provide affordable health coverage or pay a penalty for each employee who accesses subsidized coverage in the state exchange. However, nothing in the ACA or current law discourages large employers from reducing the hours or wages of their employees in order to make them Medi-Cal eligible.

Given that Medi-Cal pays some of the lowest provider rates in the country, coupled with the increased demands on the system as the state expands eligibility to 138 percent of the federal poverty level, the system simply cannot survive if large businesses begin shifting the costs of their employees' health care onto taxpayers. California already pays its Medi-Cal providers the lowest rates of all Medicaid programs in the nation. Although California has taken major steps to make health care coverage a reality for many people in our state by reducing the number of uninsured, the true test of our commitment will be improving Medi-Cal provider rates to ensure access to care.

We ask that you and your colleagues call, fax or email your legislators TODAY and urge them to protect access to care.   

Phone calls and office visits are most effective, but faxes and emails are important too. If you choose to fax or email your legislators, we strongly encourage that you personalize the letter (provided below), which will greatly increase its impact.

If you are logged into the CMA website, your legislators should automatically be displayed. If not, you can click here to locate your legislators by zip code.

You can also call CMA's legislator connect hotline at (877) 362-8455 to be easily connected to your legislator.  You will be asked to enter your zip code and select your legislator.

Give your name, specialty and let them know that you are their constituent.

Talking Points

  • The Affordable Care Act is built on a foundation of individual, employer and government responsibility. Individuals must have health insurance or pay a penalty. The federal government provides subsidies and an expansion of Medi-Cal. Employers are required to provide affordable coverage or pay a penalty to offset the cost of public subsidies for their full-time employees who go into the exchange.
  • The ACA, however, does not extend the employer responsibility penalty to employers that have workers enrolled in Medi-Cal. As a result, there have been widespread reports of employers dropping coverage for their low-wage employees as a cost-saving measure, anticipating that taxpayers through Medi-Cal will pick up the tab.
  •  Although Medi-Cal is intended to provide essential health care services to many of the poorest and most vulnerable Californians, it has unfortunately become a broken promise for access to health care.
  • Largely due to low reimbursement (ranking 50th out of 50 states), physician participation in Medi-Cal is lower than it should be as we prepare to fully implement the ACA.
  •  As a result, more than half of Medi-Cal patients report difficulty finding a provider. When they are unable to find a provider, many Medi-Cal patients seek preventive and other non-urgent care in the hospital emergency department, the most expensive kind of care.
  • The funds generated by AB 880 will be used to support the Medi-Cal program by paying the non-federal state share of the program costs for workers, increasing the reimbursement rate for providers and shoring up the safety net for all Californians who need care.

Health Reform Heats Up

More than three years have passed since the Affordable Care Act (ACA) was into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation.  For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy.

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state level. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

The Next Major Milestone
The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

California Leads the Way
Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace,, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 18 geographical rating regions.

Protecting Physician Interests
Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels. The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation.  One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs.

Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policy, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.

For more information on the implementation of health reform in California, subscribe to CMA Reform Essentials. This newsletter, available to both members and nonmembers, covers the activities of the state’s health benefit exchange board and legislation significant to California’s ongoing reform efforts. Subscribe today at

Coordinated Care Initiative Executive Summary

Passage of the Coordinated Care Initiative (CCI) in July 2012 marks an important step toward transforming California's Medi-Cal (Medicaid) care delivery system to better serve the state’s low-income seniors and persons with disabilities. Building upon many years of stakeholder discussions, the CCI begins the process of integrating delivery of medical, behavioral, and long-term care services and also provides a road map to integrate Medicare and Medi-Cal for people in both programs, called “dual eligible” beneficiaries.

Created through a public process involving stakeholders and health care consumers, the CCI was enacted through SB 1008 (Chapter 33, Statutes of 2012) and SB 1036 (Chapter 45, Statutes of 2012).

 Major Components of the Initiative

  1. Duals Demonstration: A voluntary three-year demonstration program for Medicare and Medi-Cal dual eligible beneficiaries will coordinate medical, behavioral health, long-term institutional, and home- and community-based services through a single health plan. The CCI provides state authority for the demonstration, which is pending federal approval.
  1. Managed Medi-Cal Long-Term Supports and Services (LTSS): All Medi-Cal beneficiaries, including dual eligible beneficiaries, will be required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around benefits.

 Location and Timing
The CCI will be implemented in eight counties beginning in 2013. The eight counties are Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara.

The participating health plans are part of the state’s existing network of Medi-Cal health plans and have experience providing Medicare managed care. Each underwent a rigorous selection process.

Implementation Status

The California Department of Health Care Services (DHCS) is finalizing a Memorandum of Understanding (MOU) with the Centers for Medicare & Medicaid Services (CMS). In fall 2012, the state and federal governments will conduct a comprehensive readiness review of the health plans before signing three-way contracts between the health plans, CMS, and DHCS.

Enrollment will begin no sooner than March 2013. Before any beneficiary is enrolled, the health plans must pass a readiness review process during which the state and federal governments will evaluate each health plan’s major systems to ensure they are prepared to provide required continuity of care, seamless access to medically necessary services, care coordination across LTSS, behavioral health and medical care, and beneficiary protections.

 Participating Population
The state estimates that about 560,000 (Note: this number could go down after capitation rates are released and health plans consider their participation options. ) dual eligible beneficiaries will be eligible for passive enrollment in the eight counties. An estimated one-third of those beneficiaries already are enrolled in managed care for Medi-Cal, Medicare, or both.

Dual eligible beneficiaries and Medi-Cal seniors and persons with disabilities are among California’s highest-need residents. They tend to have many chronic health conditions and need a complex range of medical and social services from many providers. This fragmentation leads to beneficiary confusion, poor care coordination, inappropriate utilization, and unnecessary costs.

Under the CCI, enrolled beneficiaries will have one point of contact for all their covered benefits. They will have one health plan membership card and access to a nurse or social worker whose job is to act as a care coordinator or navigator and help beneficiaries receive the services needed to achieve their personal heath goals and continue living in the setting of their choice. The state is developing care coordination standards that will guide how services are linked.

 Coordinated Care Initiative Goals
By consolidating the responsibility for all of these covered services into a single health plan, the CCI expects to achieve the following goals.

  1. Improve the quality of care for beneficiaries
  1. Maximize the ability of beneficiaries to remain safely in their homes and communities, with appropriate services and supports, in lieu of institutional care.
  1. Coordinate Medi-Cal and Medicare benefits across health care settings and improve continuity of care across acute care, long-term care, behavioral health, and home- and community-based services settings using a person-centered approach.
  1. Promote a system that is both sustainable and person- and family-centered and enables beneficiaries to attain or maintain personal health goals by providing timely access to appropriate, coordinated health care services and community resources, including home- and community-based services and mental health and substance use disorder services.
Financial Alignment Model

Under the CCI, the participating health plans will receive a monthly payment to provide beneficiaries access to all covered, medically necessary services. This is called “capitation.” These bundled payments create strong financial incentives for the health plans to ensure beneficiaries receive necessary preventative care and home- and community-based options to avoid unnecessary admissions to the hospital or nursing home.

 LTSS Integration
Participating health plans will be responsible for administering all Medi-Cal LTSS that historically have been excluded from managed care. LTSS includes skilled nursing facility care, along with the following home- and community-based services: In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), and other services that help beneficiaries stay in their homes and communities, as determined by the health plans.

IHSS will remain an entitlement program. IHSS consumers’ will continue being able to self-direct their care by hiring, firing, and managing their IHSS workers. County social workers will continue determining IHSS hours. The current fair hearing process for IHSS will remain in the initial years of the demonstration.

 Behavioral Health Coordination
Health plans participating in the duals demonstration will provide beneficiaries all mental health and substance use services currently covered by Medicare and Medi-Cal. County-administered specialty mental health services and Drug Medi-Cal substance use treatment services will not be included in the demonstration health plans’ capitation payments. County agencies will continue financing and administering these services, but health plans and county agencies will have written agreements outlining how they will coordinate services.

 Better Care Improves Health and Drives Lower Costs
The CCI is expected to produce greater value for the Medicare and Medi-Cal programs by improving health outcomes and containing costs, primarily through rebalancing service delivery into the home and community and away from expensive institutional settings. Better prevention will keep people healthy. Better care coordination will reduce unnecessary tests and medications. Better chronic disease management will help people avoid unnecessary hospital care.

Significant stakeholder feedback informed the beneficiary protections needed to drive success and quality in the CCI’s design and implementation. The CCI includes comprehensive protections to ensure beneficiary health and safety and high quality care delivery, which includes medical care, LTSS and behavioral health.

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