Cal MediConnect

Cal MediConnect
Medicare
Medi-Cal
+
Cal MediConnect Health Plans
What we are doing to take care of all of your
health care needs.
Cal MediConnect
Health Plan Representatives
• Michael Montoya
General Manager, CareMore
• Eileen Kunz
Director of Policy & Regulatory Affairs
• Matthew Woodruff
Chief Operating Officer
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Cal MediConnect
Agenda
•
Santa Clara County Demographics
•
Health Plan Preparations
•
Accessible Care
•
Consumer Protections
•
When You Enroll
•
Health Risk Assessment
•
Care Coordination
•
Participating Health Plans
•
Questions
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Cal MediConnect
Dual Eligible Demographics in Santa Clara County
Approximately 35,255
residents of
Santa Clara County
are eligible for both
Medi-Cal and
Medicare
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Cal MediConnect
Dual Eligible Demographics in Santa Clara County
Ethnicity
Asian
Caucasian
Latino
African American
Santa Clara
51%
21%
14%
2%
Primary Language Spoken
Santa Clara
English
39%
Vietnamese - tiếng Việt
23%
Spanish - Español
9%
Mandarin - 普通话
8%
Tagalog
4%
Cantonese - 广东话
4%
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Cal MediConnect
Dual Eligible Demographics in Santa Clara County
Examples of Chronic Conditions
Diabetes
Osteoporosis
Ischemic Heart Disease
Cataracts
Arthritis
Depression
Receiving County Behavioral Health Services
Congestive Heart Failure
Alzheimers Related Condition
Alzheimers
39%
21%
19%
19%
18%
12%
11%
10%
10%
4%
Sources:
1. Duals 2013-17 Member Projections v. 22
2. Profiles of Medi-Cal's FFS CCI Population - LA & Santa Clara County Data
3. Dual Eligible Fast Facts, Calduals.org
4. Dual Eligibles and Demand for Behavioral Health Services - Behavioral Health Public Meeting; December 2, 2011
5. Analysis of Short-Doyle (SDMC) Approved Claims, 2009-2010
6. CCI Population in Eight Counties, Chart Book Figure 11 - CalDuals.org
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Cal MediConnect
Health Plan Preparation – Readiness Reviews
• Two readiness review audits conducted by CMS
(Federal) and DHCS (State)
• Areas reviewed included:
• Continuity of Care workflows
• Contracts with providers
• Claims and payment
processes and systems
• Appeals and grievances processes
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Cal MediConnect
Health Plan Preparation – Ongoing
• Stakeholder input – consumers,
providers, community based organizations
• Model of Care
• Continuity of Care
• Enrollee and provider communications
• Provider networks and provider training
• Behavioral health coordination
• Santa Clara County Mental Health
• County sub-contractors
• Long Term Services & Supports coordination (IHSS, CBAS,
MSSP, ILC)
• Health Plan staffing and training
• Consumer rights and protections
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Cal MediConnect
Accessible Care - Communication, Cultural, Physical
Staff Training – Health Plan and Providers
 Model of Care
 Cultural Competency
 Disease Prevention and Health Promotion Programs and
Services
 Health education services in languages other than English
 Community resources that meet the needs of a diverse
population
 Cultural & Language Services – interpreter services CA Relay
 Disability Access & Sensitivity (ADA training)
 Health literacy
 Provider-specific trainings
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Cal MediConnect
Accessible Care - Communication, Cultural, Physical
Communication & Cultural Accessibility
 Bilingual staff
 Qualified interpreters
 Relay Service
 Assistive Listening Device
 Availability of translated materials or
alternate formats (Braille, audio, large font, etc.)
 Availability of low literacy materials
 Visual Language Translator
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Cal MediConnect
Accessible Care - Communication, Cultural, Physical
Physical Accessibility
 Access to exam rooms, lab areas or restrooms
 Height adjustable
exam table or Hoyer lifts
 Wheelchair weight scale
 Accessible mammography
equipment
 Accessible podiatry chairs
 Bilingual signage
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Cal MediConnect
Consumer Protections
Rights and Protections
 Notifications and participant communications
 Enrollment assistance and options counseling
 Ombudsman – through State of California
 Person-centered, appropriate care
 Self-direction of services
 Continuity of care
 Member participation on Advisory Boards
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Cal MediConnect
Consumer Protections – Continuity of Care
What if my doctors
are not in the health
plan’s network?
What if I have a
surgery or procedure
already scheduled?
 Continuity of Care allows you to continue to see your
Medi-Cal providers for up to 12 months and your Medicare
doctors for up to 6 months.
 You may also switch your health plan if the other plan
has your doctors in their network.
 Health plans are required to provide, maintain, and
coordinate covered services you are already receiving.
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Cal MediConnect
Consumer Protections – Consumer Advisory Committee
Purpose:
For Cal MediConnect members to provide input to the health
plans on policies impacting care of the consumers.
Membership:
Members of this committee reflect the diversity of the
population, including but not limited to:
 People with disabilities
 People of different cultural backgrounds
 People who receive In-Home Supportive Services
Talk to us if you are interested in joining
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Cal MediConnect
Consumer Protections – Stakeholder Advisory Committee
Purpose:
To provide input to the health plans on program development
and implementation.
Membership:
Health plan leadership, consumers and representatives of
other groups that serve Cal MediConnect members, including
representatives of:






Community Based Organizations
Providers
Long Term Services and Supports
Long Term Care
Behavioral Health
Appointed member from the Cal MediConnect Consumer
Advisory Committee
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Cal MediConnect
What happens when I enroll?
• You receive a packet in the mail
from your health plan, including:
• Welcome letter
• Cal MediConnect Member ID card
• Plan-specific information (e.g. Evidence of
Coverage/Member Handbook and Formulary)
• Your health plan contacts you within 45 days of
enrollment to complete a Health Risk Assessment
(HRA).
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Cal MediConnect
What is a Health Risk Assessment?
• A Health Risk Assessment collects
information that:
• Identifies your health needs
• Provides individualized feedback to you and your
doctor
• Provides information needed to create your
individual care plan
• Each health plan is committed to working with each
member to evaluate your health needs.
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Cal MediConnect
Who completes the HRA and What
Information is Collected?
• A Registered Nurse, Nurse Practitioner,
Physician’s Assistant, or Care Coordinator
works with each member to complete the HRA.
• Information collected may include:
• Demographic characteristics – age, gender
• A review of your health history and medications
• Personal data – weight, height, blood pressure, cholesterol
• Lifestyle – exercise, smoking, alcohol intake, diet
• Information about social services you are receiving (e.g.
IHSS, CBAS, MSSP)
• Additional information about your unique health care needs
and goals
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Cal MediConnect
Why is the Health Risk Assessment
Important?
The HRA is a starting point in:
• Developing a personalized care plan
specific to your health care needs
• Coordinating your health care with other services
you may be receiving, such as In-Home Supportive
Services or CBAS
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Cal MediConnect
Care Coordination
What are the goals of Care
Coordination?
 To integrate health care and social services
 To promote member-directed care
 To work collaboratively with you and all others
involved in your care
Who helps coordinate your care?
 You
 Your Case Manager
 Your Interdisciplinary Care Team (ICT)
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Cal MediConnect
Care Coordination and
Interdisciplinary Care Team
Who selects your Interdisciplinary
Care Team (ICT)?
 You do, working together with your Primary Care
Provider and your Case Manager
Who can you choose to be part of your ICT?
 Family members or caregivers
 Your Primary Care Provider
 Specialists, Pharmacists, Therapists
 Long Term Services & Supports providers
 Your Case Manager
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Cal MediConnect
Care Coordination and
Interdisciplinary Care Team
What does an Interdisciplinary
Care Team do?
 Collaboratively develops your personal care plan and
goals to meet your health care and social services needs
 Ensures timely and appropriate delivery of services
 Ensures communication between all care team
members
How often and where do I meet with my ICT?
 At least annually or more frequently based on needs
 By telephone, web conference, at your home, at a
provider’s office, or wherever you choose
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Cal MediConnect
Participating Health Plans
You have a choice:
• Required benefits and protections are the same across
all plans.
• Differences between plans are in the way care is
delivered and coordinated by plans, plan providers and
provider networks.
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Who We Are
Anthem Blue Cross offers a variety of
health care plans to meet the needs of
individuals and families in California.
Anthem Blue Cross Cal MediConnect
members in Santa Clara county will
have access to CareMore’s network of
providers. This includes access to their
neighborhood CareMore Care
Centers.
That means Anthem Blue Cross
members will experience personalized,
fully coordinated care to help them feel
their best.
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CareMore – Who We Are
• CareMore started over 15 years ago caring for
patients as a Medical Group in California.
• We were founded by a team of physicians and
continue to be guided by the ideas and direction of
physicians.
• The name “CareMore” embodied the philosophy that
inspired a proactive model of care with a caring touch
and a focus on wellness.
This document is the PROPRIETARY and CONFIDENTIAL information of ANTHEM HEALTH PLAN. It may not be used,
disclosed or reproduced, in whole or in part, without the express written permission of ANTHEM HEALTH PLAN.
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CareMore Care Centers
This document is the PROPRIETARY and CONFIDENTIAL information of ANTHEM HEALTH PLAN. It may not be used,
disclosed or reproduced, in whole or in part, without the express written permission of ANTHEM HEALTH PLAN.
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CareMore Care Center Local Staff
Friendly and dedicated staff, include:
 Nurse Practitioners
 Physicians
 Medical Assistants
 Case Management Teams
 Podiatrists
 Nutritionists
 Care Center based Specialists
This document is the PROPRIETARY and CONFIDENTIAL information of ANTHEM HEALTH PLAN. It may not be used,
disclosed or reproduced, in whole or in part, without the express written permission of ANTHEM HEALTH PLAN.
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Services offered at the Care Center
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Anti-Coagulation Clinic
Fall Prevention
Wound Care
Dietary Counseling
Behavioral Health
Smoking Cessation
Pre-Op and Post-Op Clinic
Routine Foot Care
Exercise and Strength Training
Healthy Start
Disease Management Programs:
• Congestive Heart Failure
• High Blood Pressure
• Diabetic Management
• COPD
• Chronic Kidney Disease
This document is the PROPRIETARY and CONFIDENTIAL information of ANTHEM HEALTH PLAN. It may not be used,
disclosed or reproduced, in whole or in part, without the express written permission of ANTHEM HEALTH PLAN.
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Healthy Start Program
 Head-to-toe medical assessment
 Review their medications
 On-site, same day lab results
 Personalized Care Plan
 Coordination of Care and Services
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CareMore Care Centers, Santa Clara County
CareMore Care Center - East
255 N. White Road, #200
San Jose, CA 95127
CareMore Care Center – West
4855 Atherton Avenue, #101
San Jose, CA 95130
CareMore Care Center – South
7888 Wren Avenue, Bldg. C, #131
Gilroy, CA 95020
This document is the PROPRIETARY and CONFIDENTIAL information of ANTHEM HEALTH PLAN. It may not be used,
disclosed or reproduced, in whole or in part, without the express written permission of ANTHEM HEALTH PLAN.
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Our Goals to Serve You
•
To get all of your health care services needs met through a
single health plan.
•
To keep you out of the hospital and independent for as long as
possible.
•
To improve care coordination for our dual eligible Cal
MediConnect members.
•
To link all of your Long Term Care Services and Supports
(LTSS) providers with your medical and behavioral health
providers for optimal care.
•
To ensure you get appropriate care at the appropriate time by
our network of providers.
This document is the PROPRIETARY and CONFIDENTIAL information of ANTHEM HEALTH PLAN. It may not be used,
disclosed or reproduced, in whole or in part, without the express written permission of ANTHEM HEALTH PLAN.
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Who is Santa Clara Family Health Plan?
• Your local not-for-profit health plan
• Serving residents of Santa Clara County
for over 16 years
• More than 154,000 members currently
enrolled in Medi-Cal
• Governing Board
– Appointed by SCC Board
of Supervisors
– Includes community
representatives, providers,
members, local elected
representatives
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Benefits with Cal MediConnect
• Medicare
• Medi-Cal
• Long Term Services & Supports
–
–
–
–
Multipurpose Senior Services Program (MSSP)
Community Based Adult Services (CBAS)
In-Home Supportive Services (IHSS)
Skilled Nursing Facilities (SNF)
• Additional/Optional Benefits
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SCFHP Provider Network
• Extensive Provider Network
– 574 Primary Care Providers
– 922 Specialists
– All hospitals except Regional (not a Medi-Cal provider)
• Provider Groups
– Santa Clara County Health & Hospital System (168 PCPs,
503 Specialists)
– Physicians Medical Group (105 PCPs, 81 Specialists)
– Premier Care (31 PCPs, 4 Specialists)
– Palo Alto Medical Foundation (270 PCPs, 334 Specialists)
• Sourcewise and Silicon Valley Independent
Living Center
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Organizational Structure & Staffing
• Staffing plans reviewed and approved by CMS and
DHCS
• Medical Staffing – currently coordinate medical
benefits for 8k dual eligible members
• New Staffing Models
– Long Term Services & Supports
– Intensive case management
for the homeless
– Social Workers
– Care Coordinators to enhance
and combine medical and
social services
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Orientations & Trainings
• Members & Caregivers
– Orientation sessions
– Care Plan meetings
• Providers
– What we do now
– What we will continue to do
– What we will incorporate for
Cal MediConnect
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Santa Clara Family Health Plan
Your Local Health Plan for
Medi-Cal
Healthy Kids
Cal MediConnect
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On Lok Lifeways and Cal MediConnect
www.onlok.org or 1-888-886-6565
On Lok’s History of Serving Dual Eligibles
• Created over 40 years ago to enable low-income seniors stay
in their own homes and communities
• One of the first adult day health care programs in the country
• National prototype for the Program of All-inclusive Care for the
Elderly (PACE) model of care
• PACE is established in federal law as permanent part of the
Medicare program and in state law as Medi-Cal benefit
• On Lok Lifeways, our PACE program, currently serves over
1,270 seniors in three San Francisco Bay Area Counties
• Program has enabled thousands of seniors to remain living in
their homes and communities
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Who Does PACE Serve?
• Eligibility criteria for joining On Lok Lifeways:
• 55 years of age or older
• Live in Santa Clara County (not including
Gilroy, Morgan Hill or San Martin)
• Certified by California Department of Health Care Services to meet
nursing home level of care
• Able to live safely in the community at the point of enrollment
• Enrollment requires in-person comprehensive assessment by
PACE intake team
• Typical participant has multiple medical conditions and needs
assistance in activities of daily living (bathing, walking, etc.)
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On Lok Lifeways PACE
Comprehensive and Coordinated
• Complete coverage
• Excellent care coordination
• Individualized care
• Focus on prevention,
health & wellness
• Expertise in geriatric care
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How does PACE work?
Interdisciplinary teams assess need, deliver and manage
care across settings.
Physician
Social Worker
Program
Manager
Nurse
Activities
Coordinator
Dietician
Home Care
Coordinator
Personal Care
Aide
Rehabilitation
Therapists
Transportation
Coordinator
PACE Centers:
The Hub of Activity and Care
Each PACE Center houses:
• Primary care and urgent care
• Interdisciplinary team
• Medical rooms for on-site
specialty services
• Rehabilitation facilities and staff
• Recreational activities
• Adult day center
• Shower and personal care
facilities
• Transportation vans and services
for member seniors
• Nutritional services and meals
• Lab/diagnostic services
Access to services all in one place
Operational Days and Hours
• Monday – Friday, 8:00am – 4:30pm
Transportation
• Van transportation to/from Centers and
medical appointments
Meals
• Dietitian-managed lunch, take-home dinner,
snacks
Prescription Medications
• Administered at centers and available for
home delivery
On-site specialists
• Dental, Podiatry, Audiology, Optometry,
Speech Therapy
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On Lok Lifeways PACE Center
San Jose PACE Center
299 Stockton Avenue, San Jose
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Opening in Early 2014
On Lok ADHC Center
130 N. Jackson Avenue, San Jose
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Santa Clara County Service Area
(not including Gilroy, Morgan Hill or San Martin)
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How does PACE fit into Cal MediConnect?
• PACE is a proven model of comprehensive integrated care
designed for a segment of the population
• On Lok Lifeways is a choice in Santa Clara County now
and in Cal MediConnect implementation
• PACE will be an option on state enrollment materials and notices
• An assessment by a nurse will be needed prior to enrollment
• Individuals cannot be passively enrolled into PACE
• Individuals already served in PACE are exempt from the
passive enrollment process
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Questions?
Talk to our Outreach Specialists
Visit On Lok website at www.onlok.org
Contact us at 1-888-886-6565
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Cal MediConnect
Medicare
Medi-Cal
+
Questions?