California has moved approximately 2 million Medi-Cal beneficiaries from the traditional FFS system into managed care plans. This system of care includes service arrangements stemming from requirements associated with waivers, exclusions, and carve outs. The health care delivery model includes specific condition; specific treatment and population carve outs. Health Net, an IPA model HMO, under contract to the California Department of Health Service's Medi-Cal Managed Care (MMC) Division, has carve out arrangements in eight counties--the largest being LA.
Health Net's PH Coordination Department is at the forefront in negotiating agreements, developing policies and procedures, and conducting problem resolution associated with "carve out" systems of care. The challenges associated with information sharing across dual/multiple systems of care continue to impact administrative costs, confidentiality issues, and coordination of care. Beneficiaries disenrolling from the MMC system face the continuing challenge of losing the medical home that coordinates care.
Years of interaction among private and public sectors with carve out services confirms that LHD's and MCO's have redefined the California public health-linked health care delivery system. This session will offer insights from the experiences associated with "building a system" and the use of a communication and collaboration framework promoting coordination of care. The session will also provide insight into how a comunication framework is needed to address problems related to access and coordination of care for children moving between both Medicaid and SCHIP. The session illustrates attempts to chart new paths as well as promote a new coordination of care model in a rapidly changing health care environment.
Learning Objectives: At the conclusion of the session, participants will: 1) understand the enduring challenges associated with the public/private coordination of care arrangements with "carve out" services in Medi-Cal Managed Care Programs; 2) articulate how a managed care organization interfaces with "carve out" systems of care in the Medi-Cal Managed Care program; and 3) recognize the formidable tasks to operationalize public-private coordination of care policy and procedures.
Keywords: Medicaid Managed Care, Carve Outs
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.