Rate Setting 101 Flashcards
What is Medi-Cal?
Medi-Cal is California’s Medicaid health care program. (Medi-Cal and Medicaid can be used interchangeably when referring to the our California program)
What does Medi-Cal do?
As a public health insurance program, Medi-Cal provides needed health care services for low-income individuals including families with children, seniors, persons with disabilities (SPDs), pregnant women, and low income people with specific diseases such as breast cancer or HIV/AIDS.
How is Medi-Cal funded?
Medi-Cal is funded by both State and Federal taxes.
Approximately how many members/beneficiaries does Medi-Cal serve?
13,000,000 members
What did the Affordable Care Act do for health care reform?
When was it enacted?
It authorized the expansion of Medicaid to low-income individuals under age 65 who were previously ineligible.
Enacted January 1, 2014
What population does Medi-Cal serve pre- and post-ACA?
Pre-ACA, Medi-Cal primarily served children (Child), families w/ children (Adult), and seniors and persons with disabilities (SPD) based on defined eligibility criteria.
Post-ACA, a new population was created referred to as the Optional Expansion (OE) or the Adult Expansion (AE) population.
Beyond adding the OE/AE population, what else did the ACA do?
Increased prior eligibility criteria from 108% to 138% of federal poverty limit (FPL limits for SPDs differ)
What entity delegates Medi-Cal eligibility?
A) Medi-Cal Eligibility Division
B) Individual Counties
C) Health Care Options
B) Individual counties are responsible for determining Medi-Cal eligibility.
Once determined eligible, the counties assign an aid code and unique identifier referred to as a CIN.
What percentage of the Medi-Cal population receives services through the Managed Care delivery system?
What percentages receives services through Fee-For-Service (FFS)?
Approximately 80% and 20% respectively.
How does Medi-Cal Fee-For-Service (FFS) operate?
Medi-Cal beneficiaries receive care through approved FFS providers. FFS providers submit claims to DHCS using CPT codes that correspond to the services provided. DHCS pays FFS providers based on the defined FFS fee schedule and/or APR-DRG payment schedules.
In what situation do FFS providers provide services to Managed Care beneficiaries?
If a Managed Care plan does not cover a Medi-Cal-covered service such as blood factor drugs, major organ transplant (except kidneys), and Waiver Services, the beneficiary will be referred to a FFS provider.
Why are blood factor drugs not covered by Managed Care plans?
Because they are very expensive, and can be difficult to build into a capitated rate.
NOTE: When you have low utilization, but a high cost procedure or drug, it leads to volatile costs month to month. This fact makes these types of procedures or drugs a better fit for the FFS delivery system or a supplemental payment.
How does the Medi-Cal Managed Care delivery system operate?
DHCS contracts with Managed Care Plans (MCPs) to provide health care services to Medi-Cal Managed Care beneficiaries across every California county.
What are the primary Plan Model types?
- Geographically Managed Care (GMC)
- Two Plan
- County Operated Health Systems (COHS)
- Regional
How many plans may operate in a Geographically Managed Care model county?
GMC model counties have multiple managed care health plans that serve Medi-Cal beneficiaries.
