What is Managed Care? Established networks of organized systems of care – Emphasis on primary and preventive care Coordinated delivery of health services.

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Presentation transcript:

What is Managed Care? Established networks of organized systems of care – Emphasis on primary and preventive care Coordinated delivery of health services – Assures high quality and accessibility

Goals of Managed Health Care Deliver quality care in environment that manages or control costs Care delivered is medically necessary and appropriate for the member’s condition Care rendered by most appropriate provider and in least-restrictive setting

Benefits of Managed Care Medical Home – Case management – Coordination of care – Emphasis on prevention and wellness Health plans can offer more resources – Nurse advice lines – Transportation assistance – Help getting appointments with specialists – Health Education (e.g. chronic care classes) – Quality Improvement Programs – Grievance systems

Benefits of Managed Care Accountability – Healthcare Effectiveness Data and Information Set (HEDIS) – Threshold languages for health plans – Appropriate Reading level of member materials Designed to assist the member with navigation and decision making – Health Care Options (HCO) – Office of the Ombudsman

5 Medi-Cal Managed Care Models County Organized Health Systems (COHS) Geographic Managed Care (GMC) Two-Plan

6 COHS Model Locally developed & operated managed care organization (MCO) – Governing Board approved by County Board of Supervisors Capitated arrangements and full risk contracts Enrollment is mandatory No fee-for-service option in county

7 GMC Model Noncompetitive application process No local/community health plan Capitated arrangements & full risk contracts Mandatory enrollment for specific aid codes Members choose from several commercial plans No fee for service option for mandatory beneficiaries

8 Two-Plan Model Members choose between Commercial Plan or Local Initiative (LI) LI is a community developed HMO (quasi-governmental) Commercial plan is selected via competitive procurement Capitated arrangements & full risk contracts Enrollment mandatory for specific aid codes No fee-for-service option for mandatory beneficiaries

Consumer Protections Each plan has a customer service number Members can file a grievance or an appeal Medi-Cal Managed Care Office of the Ombudsman - (888) Department of Managed Health Care - (888) State Fair Hearings Medical Exemption Requests

Questions