The 131st Annual Meeting (November 15-19, 2003) of APHA

Abstract #66256

Rogelio Lopez, Public Health Programs Administration, Health Net of California, 11971 Foundation Place, D-1, Rancho Cordova, CA 95670, 916-935-1437, effie.ruggles@healthnet.com

During the 1990s, California moved approximately two million Medicaid (Medi-Cal) beneficiaries from the traditional fee-for-service system into managed care organizations (MCOs). The delivery system for these beneficiaries include requirements and arrangements associated with waivers, exclusions, and "carve-outs". The "carve-outs" in the California Medi-Cal managed care model are linked to specific conditions, treatments and populations. Health Net, a health plan under contract to the California Department of Health Services, developed procedures and agreements for "carve-outs" in various counties, the largest being Los Angeles.

In this environment, Health Net administers health care using the indispensable components of the "carve-out" interface; functional agreements, internal policies and procedures, problem resolution processes, and information exchange. The organizational experiment associated with achieving collaboration across dual, or even in some cases, multiple systems of care has challenged MCOs and public entities with; administrative expenditures, program resources, and confidentiality matters.

This session will offer background, lessons learned and insights associated with various "carve-out" arrangements in the redefined health delivery system. The observations will illustrate the continued importance of mutual agreements, interagency communication, and problem resolution to provide basic coordination of care.

Learning Objectives:

At the conclusion of the session, participants will:
• articulate the function of “carve-out” arrangements in California’s Medicaid managed care program,
• recognize why "carve-out" services serve a specific role in California's Medicaid managed care program, and
• understand the enduring challenges associated with coordination of care and "carve-out" services.

Keywords: Carve Outs, Coordination

Presenting author's disclosure statement:
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.