1 million Ga. Medicaid & PeachCare patients to move to HMOs (CMOs); 100,000 elderly & disabled to enter disease management

Who Goes Into CMOs Low-Income Medicaid families Right from the Start children Right from the Start pregnant women Refugees PeachCare children

How It’s Different Today: Georgia Better Health Care Primary Care Case Management Member chooses PCP from list of enrolled doctors Doctor gets $2.00/mo management fee + fees for services – not “at risk” PCP doctor approves specialty care, etc. Under CMO: “Georgia Cares” Member chooses from at least 2 CMOs per region CMO gets monthly fee for each enrollee Company provides virtually all services – “at risk” Member chooses a PCP from those signed up with CMO

CMO Services Physician visits, laboratory and diagnostic testing, and inpatient and outpatient hospitalization Mental health and substance abuse treatment Pregnancy-related services Prescription drugs Dental and vision care services (to eligible populations) Screening and preventive services (to eligible populations) Durable Medical Equipment

Services Not Under CMO ICFMR- Intermediate Care Facility/Mentally Retarded HCBS- Home and Community-based Services under a 1915 (c) waiver Other long-term services Non-emergency transportation -- still under brokers

Accessibility CMOs must : Have sufficient numbers of providers of primary and specialty care Include safety-net providers, and rural and critical access hospitals (2 years) Have a culturally appropriate provider mix Provide oral interpretation services – all languages & written notices in “prevalent languages Comply with ADA, Title VI, etc.

Geographic Access Provider TypeUrbanRural PCPs2 within 8 miles2 within 15 miles Specialists1 within 30 minutes/miles1 within 45 minutes/miles Dental Providers1 within 30 minutes/miles1 within 45 minutes/miles Hospitals1 within 30 minutes/miles1 within 45 minutes/miles Mental Health Providers1 within 30 minutes/miles1 within 45 minutes/miles Pharmacies1 open 24/71 open 24/7 within 15 minutes/mileswithin 30 minutes/miles

Visit Access PCP (routine visits)21 calendar days PCP (adult sick visit)72 hours PCP (pediatric sick visit)24 hours Specialist30 calendar days Dental provider30 calendar days Non-emergency hospital stay30 calendar days Mental health provider14 calendar days Urgent care provider24 hours Emergency provider24/7 no prior authorization Initial visit pregnancy14 calendar days from plan entry Health Check90 days from plan entry

CMO Regions & “go live” dates 1/06 12/06 7/06

Enrollment Independent broker Outreach & enrollment for January 2006 beginning Member can change within 1 st 90 days of effective date Then, 1 year enrollment unless lose Medicaid or PeachCare

Why CMOs? DCH says: Improved health status of members Contractual accountability for access and quality Lower costs through effective utilization management Budget predictability & administrative simplicity

Population-based Strategy The DCH strategy for the implementation of CMOs will be unique to the needs of our population. Required enrollment for statewide CMOs will be for: Low-income Medicaid adults and children PeachCare for Kids Right from the Start Medicaid Refugees DCH Fact: DCH is putting the lowest-cost members in CMOs.

In FY2005, Medicaid will require 43% of all new state revenue By FY2008, Medicaid will require over 50% of all new state revenue. By FY2011, Medicaid will require 60% of all new state revenue. FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 New Revenue (Discretionar y) 60%56%55%52%47%46%40% New Revenue (Medicaid) 43%44%45%48%53%54%60% Medicaid Growth is Unsustainable! FACT: Cost increase per enrollee in 2003 was in single digits for all member categories. Compare to employer- based premium increase of 13.9%. FACT: Medicaid enrollment is up despite improving economy because employers are dropping coverage. DCH

National Medicaid Managed Care Programs NOTE: 34 other states have moved to using managed care principles to deliver Medicaid benefits to the TANF population FACT: Georgia already spends less per enrollee than all but 6 other states. DCH

Questions CMOs’ business plan? Adequate service to all patients? Amount of administrative overhead? Adequate lead time? Enough providers? Protection of patients’ rights ? Savings? From where? CMO qualifications/relevant experience?

What About Elderly & Disabled? Disease management through contracted systems 100,000 members in one or two regions enrolled August 2005 Direct voluntary enrollment Focus on asthma, diabetes, coronary artery disease, chronic obstructive pulmonary disease, hemophilia, schizophrenia

How It’s Different Today: Georgia Better Health Care Primary Care Case Management Member chooses PCP from list of enrolled doctors Doctor gets $2.00/mo management fee + fees for services – not “at risk” PCP doctor approves specialty care, etc. Under Disease Management: Disease Management Organization (DMO) works with patient and providers to develop care management plan DMO provides certain services to patient and providers to help carry out plan DMO is “at risk” for performance and savings

Disease Management Regions Dise ase me

Disease Management Services Assessment Risk factor improvement Medication monitoring Preventive care & wellness promotion Evaluation of home environment for disease triggers Action plans based on clinical guidelines Prevention of acute episodes Member self-management Feedback to providers Member and provider adherence to guidelines Referrals to community services to address socioeconomic issues Communication to treating physician on hospital & ER visits Nurse call Education of family & caregivers

Expected Results Improve health status at least 10% Decrease hospital admissions 10% Decrease inpatient days 10% Decrease ER visits 10% Increase knowledge of providers and members 10% Save 4% net annually?

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