LIHP Application Presentation 1-28-11 - California

Low Income Health Program (LIHP) Application ProcessLIHP@dhcs.ca.gov

Welcome to the Department of Health Care Services (DHCS) LIHP Application Informational Meeting

- January 2011 -

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Staff introductions and organization

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Today’s Goal Overview of process - application, authorization, and implementation. Provide tips on how to complete the LIHP application. Provide technical support to help applicants become approved.4

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The Day at a Glance Housekeeping. Agenda. Questions & Answers. Summary.

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Ground Rules One person speaks at a time. No sidebar conversations. Respect each other’s time. Turn cell phones off or set to vibrate. Ask questions.

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Authorization Chapter 723, Statutes of 2010 (Assembly Bill 342). Welfare and Institutions Code Sections 14053.7 and 15909-15915. Penal Code Section 5072. Section 1115(a) Medicaid Demonstration (Demonstration), “Bridge to Reform”.

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LIHP Purpose Provides the opportunity to begin an early implementation of key coverage expansion components of the Patient Protection and Affordable Care Act. Promotes stability in the health care delivery system. Maximizes federal funds for low income adults care. Provides for increased efficiency in state and local health care funding. Promotes quality, value, and better health outcomes in the provision of health care services.8

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LIHP Consists of Two Programs Medicaid Coverage Expansion (MCE) is not subject to a federal funding cap and provides a broader range of health care services to eligible adults who are aged 19 to 64, with family incomes at or below 133% of the FPL, and may have insurance. Health Care Coverage Initiative (HCCI) is subject to a federal funding cap and provides health care services to eligible adults who are aged 19 to 64, with family incomes above 133 through 200% of the FPL and are uninsured.Service - Accountability - Innovation 9

Voluntary ParticipationApplicants voluntarily elect to participate.

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LIHP Conditions of ParticipationIf participating, the following conditions apply: MCE must be implemented. HCCI is optional. Inpatient hospital services, limited to only those services subject to FFP pursuant to Title XIX of the Social Security Act for individuals who are determined eligible by the State, must be provided by the local LIHP.

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Additional Conditions of Participation Non-federal share of the federal reimbursement must be provided by local, non-federal funds.

No State General Fund monies will be used to fund LIHP. The non-federal share of DHCS staffi

ng/administrative costs attributable to the cost of administering the local LIHP will be reimbursed by the local LIHP. - Questions Service - Accountability - Innovation 12

LIHP Application

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General Information Section #5 - Applicant typeApplicant must be one of the government entities listed to apply. County. City and County. Health Authority. Consortium of counties serving a region consisting of more than one county (Identify each participating county member).Service - Accountability - Innovation 14

General Information Section #6 - Implementation – MCE, HCCI, or both The proposed implementation date is an estimated date to help DHCS plan the implementation for each applicant. HCCI can not be implemented if MCE is not implemented. Counties with existing HCCI enrollees have the option to not implement the MCE and/or HCCI. These counties can not continue to enroll after this decision is made. They can provide health care services to their existing enrollees and receive reimbursement. - Questions Service - Accountability - Innovation 15

Provider Network Section

#7. Open or closed delivery system Application correction/addition: – Response changed to Open or Closed instead of prior Yes or No response. – Note: An applicant’s closed network is considered a managed care delivery system for LIHP. This closed network is subject to all applicable Medicaid laws and regulations, except those expressly noted in the STCs or the expenditure authorities for the Demonstration. With an open network, the LIHP would reimburse any provider who provided services to an enrollee.

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Provider Network Section #7. Open or closed delivery system

Closed network means the specific health care providers that are authorized by LIHP to provide health care services offered to enrollees in the LIHP. CMS considers a county based delivery system with a closed network of providers to be a managed care delivery system.

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Provider Network Section #7. Open or closed delivery system

This closed network is subject to all applicable Medicaid laws and regulations, except those expressly noted in the STCs or the expenditure authorities for the Demonstration.

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Provider Network Section #7. Open or closed delivery system

Expenditure Authorities: Sect. 1903(m)(2)(A)(vi)

Enrollees right to disenroll is restricted.

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Provider Network Section #7. Open or closed delivery system

Expenditure Authorities: Sect. 1903(m)(2)(A)(xii) Enrollees have a choice of at least two primary care providers, and may request change of primary care provider at least at the times described in Federal regulations 42 CFR 438.56(c). Enrollees don’t have a choice of at least two managed care organizations. Payment for out-of-netwo

rk emergency services may differ from the requirements in statute. Refer to payment allowances set forth in STC 63fi. Approved applicants must comply with the network adequacy requirements set forth in STC 72.

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Provider Network Section #7. Open or closed delivery system

Expenditure Authorities: Sect. 1903(m)(2)(A)(xii) State is not required to develop a quality strategy. Approved applicants must comply with the standards and requirements set forth in the STCs. External quality reviews not required. Not required to comply with limitation on marketing activities.

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