1115 WAIVER CALIFORNIA’S BRIDGE TO REFORM

1. 1115 WAIVERCALIFORNIA’S BRIDGE TO REFORM Los Angeles County Implementation May 2011

2. Key Waiver Facts ▪ Expands Medicaid Coverage through December 31, __2013 ▪ Establishes Delivery System Reform Incentive Pool ▪ Implements Managed Care for Seniors and Persons with Disabilities (ongoing) • Continues Safety Net Care Pool funding ▪ New Waiver funding will partially address the __Department's budget gap

3. Medicaid Coverage Expansion (MCE) • Builds on current Coverage Initiative (HWLA) • Funded by 50% County and 50% Federal funds • Adults ages 19-64 years with incomes of 133% or less of the Federal Poverty Level, citizen/legal permanent residents 5+ years • New program start date: July 1, 2011

4. MCE (HWLA) Enrollment • Approximately 60,000 current HWLA members will be “grandfathered in” to the new program • Initial focus on enrolling existing DHS/PPP patients (150,000 potentially eligible) • DHS/PPP patients on General Relief (50,000+) • Patients using both DHS and DMH services (8,000) • Next enrollment wave to target homeless, General Relief, and DMH high utilizers not currently using DHS/PPP • Ultimate goal to enroll all eligible LA County residents

5. MCE Network Adequacy:Out-of-Network Emergency Services ▪ Coverage for out-of-network ED and post-stabilization care ▪ Coverage only for "true" emergencies ▪ Private EDs will receive payment for previously uncompensated care to the MCE population ▪ Patients cannot be billed for emergency services

6. MCE Network Adequacy:Geographic Access Standards • Non-DHS hospitals (or transportation) will be required in three areas: • Antelope Valley • West LA • San Gabriel Valley • Public Private Partner (PPP) community clinics will help ensure primary care coverage

7. MCE Network Adequacy:Timely Access Standards • Primary care appointments within 30 business days initially, reducing to 20 days from 7/1/12 to 12/31/13 • Urgent care appointments within 48 hours • Specialty care appointments within 30 business days • After-hours consultation available 24/7

8. MCE Network Adequacy:Timely Access Standards (cont.) • Primary care access • Empanel patients with primary care teams (6 pilots started late February) • New county personnel item: Certified Medical Assistant -- will allow other staff to work at “top of license” • Conduct staff trainings on medical home model and registry use • Implement Disease Management Registry in primary care medical homes

9. MCE Network Adequacy:Timely Access Standards (cont.) • Specialty care decompression • Identify patients no longer requiring specialty care, and hand off to medical home provider • Develop standardized referral guidelines • Move to centralized referral process for more timely processing • Expand alternatives to face-to-face visits (e.g., telemedicine, telephone/email consults, etc.) • Work with affiliated medical schools to ensure DHS specialty care priorities are met

10. MCE Behavioral Health Integration: • Co-locate mental health services with primary care in DHS facilities • 3 sites already implemented; 3 more scheduled • Implement depression screening and treatment by primary care providers in DHS facilities • Additional integrated services under development

11. MCE Due Process Requirements: • Applicants can appeal eligibility denials • Members can file grievances regarding access to care, etc. • Members have right to appeal grievance findings and right to hearing

12. Safety Net Care Pool ▶ New Waiver continues SNCP funding for public hospitals‘ uncompensated care ▶ South Los Angeles Preservation fund will be covered through the CI (Medicaid expansion) and the SNCP ▶ State will also claim from the SNCP for State general fund relief ▶ If certain State and County commitments are not accomplished, the SNCP will be reduced

13. SNCP Delivery System Reform Incentive Pool (DSRIP) ▪ Approximately $200M to LAC DHS in first year, approx. $230M in years 3 to 5 of Waiver; plan approved by CMS ▪ Receipt of funds conditional on achievement of milestones and Waiver goals: - Improving patient care experience - Improving population health - Reducing per capita health care costs ▪ Four general project areas eligible for funding: - Infrastructure Development - Innovation and Redesign - Population-Focused Improvement - Urgent Improvement in Care

14. DSRIP: LAC DHS Proposal • Infrastructure Development • Expand Disease Management Registry utilization • Expand access and utilization of nurse advice line • Enhance coding and documentation • Enhance performance improvement and reporting capacity • Innovation and Redesign • Expand medical homes • Expand chronic care management models • Integrate physical and behavioral health care

15. DSRIP: LAC DHS Proposal (cont.) • Population-Focused Improvement (measurement) • Patient and caregiver experience • Care coordination • Patient Safety • Preventive Health • At-risk populations • Urgent Improvement in Care (inpatient) • Improve outcomes for patients with sepsis • Prevent central line bloodstream infections • Reduce surgical site infections • Prevent and treat venous thromboembolism (VTE)

16. Managed Care for Seniors and Persons with Disabilities (SPDs) ▪ One year phase-in of SPDs to Medi-Cal managed care based on month of birth starting June 2011 ▪ Default assignments will be based on previous providers and utilization history; may also consider plan quality and whether safety net providers are included in plan network ▪ Knox-Keene requirements, including adequate network and timely access, must be met ▪ County will be assigned lives through LA Care and will work to assure adequate numbers are assigned to DHS

17. Next Steps - Waiver Implementation ▪ Proceed with implementation of ambulatory care restructuring and MCE requirements ▪ Assess need for other internal restructuring and process changes to ensure achievement of milestones ▪ Develop retention strategy for SPDs and new Medicaid enrollees ▪ Restructure relationships with PPPs to meet Waiver requirements and system goals ▪ Continue working with DMH and DPH to integrate _behavioral health services