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HomeMy WebLinkAboutMINUTES - 08031993 - 1.57 /. 5 7 STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY PETE WILSON, Governor DEPARTMENT OF HEALTH SERVICES - 714/744 P STREET RECEN D P.O. BOX 942732 SACRAMENTO, CA .94234-7320 (916) 654-8076 JUL 2 U ►993 JUL 1 5 1993 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Mr. Thomas Torlakson, Chairman County Board of Supervisors RECEIVE,o JUL Contra Costa County 300 East Leland Avenue, Suite 100 Pittsburg, CA 94565 Dear Mr. Torlakson: The Department of Health Services' Plan, Expanding Medi-Cal Managed Care, described the Department's intent to limit expansion of Medi-Cal managed care during the two year period before the implementation of the two-plan model described in the Plan. This limited expansion was intended to protect safety net and traditional providers from accelerated enrollment of Medi-Cal beneficiaries into managed care plans during the planning and development period of the two-plan model in each designated region. On May 14, 1993 the Department of Health Services filed emergency regulations (R-12-93) concerning prepaid health plan and primary care case management contracts in designated regions. One element of the regulations concerns the minimum beneficiary enrollment level for each plan operating under the two-plan model in each region and the maximum beneficiary enrollment level of the mainstream plan in each designated region. The regulations also establish the requirement that the Department redetermine the maximum enrollment limits every two years and describe the process for local government input on the mainstream plan maximum enrollment levels. The regulations also describe how the maximum enrollment levels will affect existing prepaid health plan and primary care case management plan contracts. The Department has calculated the proposed mainstream plan maximum enrollment levels referred to in the Department's Plan and emergency regulations. The proposed calculations are enclosed in table format (Attachment I). Also enclosed is a detailed description of assumptions and methodology used in the calculations (Attachment II). The County Boards of Supervisors in each designated region shall have 30 days from the date of this letter to submit written comments on the mainstream plan maximum enrollment levels in their counties to the Department. The Department will review and consider any written comments received from the Boards of Supervisors within the 30 day comment period for possible adjustment of the maximum enrollment levels. The maximum enrollment levels presented to you are temporary and apply only to the transition period prior to implementation of the two-plan model. The Department will evaluate the mainstream plan maximum enrollment levels in 1994 and then at two-year intervals and adjust the limits, as necessary to assure continued protection of disproportionate share hospital (DSH) funding. The methodology used to set the maximum enrollment limits is designed to assure that, even if the mainstream plan reaches the maximum enrollment limit in a county, the local initiative plan will have sufficient membership to produce DSH-qualifying days in numbers comparable to the historical DSH days experience in the county. CC : H-e�l�h Svca. ��i- Mr. Thomas Torlakson Page 2 J U L 1 5 1993 It should be noted that the mainstream enrollment levels do not constitute a guarantee of membership, only the opportunity to establish membership at that level. Regardless of the mainstream plan maximum enrollment level, enrollment in managed care. .plans will remain voluntary during the transition period before the implementation of the two-plan model in the designated regions. Those individuals receiving Supplemental Security Income (SSI) under the federal program for the Aged, Blind or Disabled, and who are now eligible to enroll in Medi-Cal managed care plans, will not be required to enroll in managed care .plans once the two-plan model is implemented in the designated regions. Enrollment in managed care plans by SSI individuals will remain voluntary. Please submit written comments to Joseph Kelly, Chief, Managed Care Expansion Branch, Department of Health Services, 714 P Street, Room 1400, Sacramento, California, 95814. If you have questions concerning the mainstream plan maximum enrollment levels, please contact Mr. Kelly at(916) 657-0977. Sincerely, Benjamin Thomas Acting Chief Medi-Cal Managed Care Division cc: Mr. Phil Batchelor Chief Administrative Officer Contra Costa County 651 Pine Street, 11th Floor Martinez, CA 94553 Mr. Mark Finucane, Director Health Services Department Contra Costa County 20 Allen Street Martinez, 94553-3191 Mr. Perfecto Villareal Social Services Director Department of Social Services Contra Costa County 40 Douglas Drive Martinez, CA 94553 • ATTACH`M 1 O C -WI -moi D D D r m Imo Z � o' n W C > D D Z m Z Z m D m —1 D NOz Nn 7Do Z n ` p Co DO Z Z D m pz -mn w (n m D D D L7 p p O n p z C1 (� C Do p O O m N D n O D � m cn D D mm.>, O -< m C: CL y � � � 0 � � N N W w N V V P �'� N Cn D D D D N O 6] CD O --� N O 00 0) co 0o W � V P m m Z Z = m 00 00 Ln W O -• N cn W CD -+ V N G7 D p p Z CD O N - W V N N - - " --' CO -4. 00 O D G) D D -� CJ CD O CD 0) -� CD O. V N W 00 O W Cn 7o p mo 0 -< D (�D Cn m r 7, v my w 0) �+� a, o ^' m -1 o w DDDDDDt� czn N CA O N N V N W cn V 0o mmDocnpu Q y O O N m m 0) 0) -� m N W O p O D O D , p m p C,) N O w 00 N O V V w CO 00 p m t = D .+ p -n �, m w D Z Dlpcpi� OcDi� DDw D Cn N N c7t Cn P N Cn O CA O W n W p X OD N O p --i 2 m D o � W Cn V m w V Ln W m V O 0 D z \ 0 C D Om 2 m z O rn rn oo m N N aD cn D D D D O ' ao �, cn v N cNn w ? c�D cD m m Z Z m V W N m V O C7 Ln 0N W G7 D D p z O N N 0D O CD Cn co co co c0 w Cn Jp p m O r N -< -i n D + w w N N N -+ Cn N CD CA Cn V Cn CO W V r _ O Cn t7 Ln W N o N N W W c0 cn N Crn O �! W cn x r n `-' C nD ro o ao r) in oo � v in v m in iD O0 D D D c' c - o Om oo m o rn w 0 V - D -� -i m21 v.00 O * 00 N � (31 -�CD O -� V CCD 00 m O C + + + + Q z c • z W a 0 W w � Cn cn - N m 0 0 CA Cn o N W V V � 00 N 00 N Cn pl O N �i W (DN W V N m N m D D y O 0) 00 N co O N V N (n W w O fJl N W N v W m W w N W 3 N Cn co N -• ou W W O W O O CD N —ic W N N Nm m O Cn 00 N W V A V C Do D rn rn cn Cn V cn w w w w 0 00 V W W wCD CD N C7 W N W w m AITAamw II MEDT-CAL MAINSTREAM PLAN MAXIMUM ENROLLMENT LIMITS - TRANSITION PERIOD CALCULATIONS - . California Department of Health Services Medi-Cal Managed Care Divison July 9, 1993 CALCULATION OF MAINSTREAM PLAN ENROLLMENT LIMITS PURPOSE The current purpose for calculating a mainstream plan maximum enrollment limit in each of the thirteen counties designated for managed care development under the Department's March 1993 managed care expansion plan is, specifically, to establish the Medi-Cal membership levels to which existing and any prospective Medi-Cal managed care contractors are allowed to grow during the two-year transition period. During the transition period, development of a local initiative and the procurement of a mainstream plan is expected to occur in each county. The mainstream plan maximum enrollment limit governing the first two- year operations period under the two-plan model described in the Department's plan will be established at a later date. MINIMUM ENROLLMENT LEVELS The calculation of the minimum enrollment levels for both the local initiative and the mainstream plan set forth in the Department's plan is unaffected by the calculation of mainstream plan maximum enrollment limit and remains at 22,500 Medi-Cal enrollees. Where the calculation of the mainstream plan maximums produced a potential membership share of less than 22,500, an adjustment raising the share to 22,500 has been made. IMPLICATIONS OF THIS MAINSTREAM PLAN ENROLLMENT LIMIT CALCULATION It must be understood that enrollment in managed care plans under current arrangements is voluntary. Similarly, beneficiary choice under the two-plan model will determine the enrollment levels of the mainstream plan and the local initiative. Thus, the mainstream plan enrollment limits do not constitute a guarantee of membership, only the opportunity to establish membership at that level. Once the mainstream maximum enrollment limits in each county are finalized, the Department will assess the current enrollment levels of existing Medi-Cal prepaid health plans (PHP) and primary care case management (PCCM) plans and determine what, if any additional enrollment growth will be allowed during the transition period. Additionally, current Medi-Cal managed care plan capacity will be assessed in relation to the mainstream plan limit in determining if health plans proposing to contract under the CAHMO agreement described in the managed care plan and pending "pipeline" PCCMs will be allowed to operate in a county. ASSUMPTIONS AND METHODOLOGICAL CONSIDERATIONS • Definitions -- DSH - Disproportionate Share Hospital. MOE- Month of Eligibility. Potential DSH Day- an acute care hospital day that would qualify as a DSH day when provided by a designated DSH facility but which may or may not have been provided by a qualifying facility. Paid DSH Day - A potential DSH day paid to State designated DSH-qualified facility. For purposes of this analysis, psych accommodation codes and Short/Doyle days are excluded because of the proposed mental health carve-out. Mandatory Aid Categories Active Medi-Cal beneficiaries required to enroll in either a local initiative or mainstream plan in one of the 13 targeted counties. These are: PA Family -- 30, 32, 33, 35, 38, 39, 40, 42, 54, 59 MN, No SOC -- 34 MI, No SOC, Children -- 03, 04, 45, 82 The February 1993 month of eligibility as of the June 1993 Medi-Cal eligibility file was used in the mainstream maximum enrollment limit calculations. • Disproportionate share hospital(DSH) days are used as the surrogate measure for safety net hospital utilization since the formula under which a hospital qualifies as a DSH facility factors in the Medi-Cal utilization and.the level of indigent care provided. • Calendar Year (CY) 1991 paid claims data were used because complete CY 1992 data has not yet been completely analyzed (pending policy decisions). • Potential and paid DSH days were determined using virtually identical criteria to that used for qualifying a hospital day for DSH purposes and the designated DSH facilities applicable to the CY 1991 paid claims data period. • Psych and Short/Doyle mental health inpatient days are excluded from the analysis in acknowledgement of the anticipated mental health "carve-out" described in the Department's managed care plan. • The point of service for hospital days, i.e., the hospital is designated as a DSH facility, is a key variable in providing DSH days "protection" for the mandatory aid categories. • In addition to actual "paid" DSH days, there is an identifiable number of hospital days in the universe that would qualify, but are not counted, as DSH days only because they were not provided by a designated DSH facility. These can be considered "unpaid" DSH days. The sum of the paid and unpaid DSH days is referred to as "total potential DSH days". TABLE 1 details potential DSH days by county with comparisons to paid DSH days. TABLE 1 DSH DAYS OVERVIEW I71 121 131 141 151 161 BENEFICIARY TOTAL PAID DSH PAID DSH DAYS- PAID DSH DAYS- POTENTIAL POTENTIAL COUNTY OF POTENTIAL DAYS-ALL NON-MANDATORY MANDATORY DSH DAYS- DSH DAYS RESIDENCE DSH DAYS• AID AID CATEGORIES MANAGED CARE NON- PROTECTED ALL AID CATEGORIES 131+121 AID CATEGORIES MANDATORY BY CATEGORIES % 141+121 AID MAINSTREAM % CATEGORIES PLAN LIMIT ALAMEDA 128,840 68,308 38,459 58 28,849 42 74,755 28,849 CNTRA CSTA 46,625 28,898 18,135 63 10,763 37 28,882 10,763 FRESNO 84,920 52,982 25,385 48 .27,597 52 40,734 27,597 KERN 52,983 33,275 16.948 51 16,327 49 29,065 16,327 L.A. 1,197,176 789,559 . 564,908 72 224,651 28 831,683 224,651 RIVERSIDE 102,967 44,694 24,478 55 20,216 45 54,455 20,216 SAN BBDO 149,187 49,394 27,632 . 56 21,762 44 70,970 21,762 SAN DIEGO 190,072 75,628 44,360 59 31,268 41 113,952 31,268 S_.F. 100,032 52,908 37,902 73 14,196 27 71,903 14,196 SAN JOAQUIN 57,627 28,397 13,355 46 15,250 54 27,556 15,250 SANTA CLARA 87,246 49,033 . 33,991 69 15,042 31 54,915 15,042 STANISLAUS 44,602 11,441 7,079 62 4,362 38 23,086 4,362 TULARE 43,715 11,828 5,708 48 6,120 52 22,886 6,120 2,285,992 1,298,345 858,340 437,403 1,444,642 437,403 • The points of service for hospital days experienced by beneficiaries in aid categories that will not be required to enroll in a. managed care plan are assumed to be unaffected by implementation of the State's expansion plan.and it is not necessary to address this population in the maximum enrollment limit calculations except to the extent that these hospital days include "potential" DSH days that have not been, but may be, captured by designated DSH facilities. TABLE 2 details the hospital days for the nonmandatory beneficiary aid categories. TABLE 2. INPATIENT DAYS NOT DIRECTLY.AFFECTED BY THE MEDI-CAL MANAGED CARE PLAN(1) [1] 121 (31 [4) (5) [61 BENEFICIARY TOTAL NON-DSH POTENTIAL POTENTIAL ACTUAL PAID AVAILABLE COUNTY OF MEDI-CAL MEDI-CAL DSH DAYS DSH DAYS AS DSH DAYS POTENTIAL RESIDENCE INPATIENT INPATIENT A%OF DSH DAYS DAYS DAYS TOTAL [31451 INPATIENT DAYS [31+[11 ALAMEDA 90,371 15,816 74,555 83 38,459 36,096 CNTRA COSTA 33,148 4,266 28,882 87 18,135 10,747 FRESNO 42,540 1,806 40,734 96 25,385 15,349 KERN 31,843 2.778 29,065 91 16,948 12,117 LOS ANGELES 906,649 74,966 831,683 92 564,908 266,775 RIVERSIDE 64,839 10,384 54,455 84 24,478 29,977 SAN BRDO 80,986 10,016 70,970 88 27,632 43,338 SAN DIEGO 151,724 37,772 113,952 75 44,360 69,592 S.F. 87,547 15,644 71,903 82 37,902 34,001 SAN JOAQUIN 29,333 1,777 27,556 94 13,355 14,201 SANTA CLARA 64,068 9,153 54,915 86 33.991 20,924 STANISLAUS 26,407 3,321 .23,086 87 7,079 16,007 TULARE 26,019 3,133 22,886 88 1 5,708 17,178 1,635,474 190,832 1,444,642 858,340 586,302 J1 I Inpatient 2ays for the aged,bhnd,_zfl-sabled and o er nonmandatory aid catepones. SOURCE:CALENDAR YEAR 1991 PAID CLAIMS DATA • The points of service distribution for hospital days experienced by beneficiaries required to enroll in a managed care plan are potentially directly affected by the distribution of beneficiaries between the local initiative and mainstream plans. Protection of DSH hospital days is necessary for this population, as assured in the Department's managed care expansion plan. TABLE 3 details the hospital days that must be considered. TABLE 3. INPATIENT DAYS POTENTIALLY AFFECTED BY THE MEDI-CAL MANAGED CARE PLAN(1) [1] (21 131 (4) (5) (61 BENEFICIARY TOTAL NON-DSH POTENTIAL POTENTIAL DSH ACTUAL PAID AVAILABLE COUNTY OF MEDI-CAL MEDI-CAL DSH DAYS DAYS AS A% DSH DAYS POTENTIAL RESIDENCE INPATIENT INPATIENT OF TOTAL DSH DAYS DAYS DAYS INPATIENT (31-151 DAYS 131+(11 ALAMEDA 61,154 6,869 54,285 89 --29,849 24,436 CONTRA COSTA 19,729 1,986 17,743 90 10,763 6,980 FRESNO 46,230 2,044 44,186 96 27,597 44,185 KERN 27,377 1 3,459 23,918 87 16,327 7,591 LOS ANGELES 384,837 18,894 365,943 95 224,651 141,292 RIVERSIDE 57,202 8,690 48,512 85 20,216 28,296 SAN BRDO 90,523 12,306 78,217 86 21,762 56,455 SAN DIEGO 90,554 14,434 76,120 84 31,268 44,852 SAN FRANCISCO 32,442 4,313 28,129 87 14,196 13,933 SAN JOAQUIN 32,446 2,375 30,071 93 15,250 14,821 SANTA CLARA 34,007 1,676 32,331 95 15,042 17,289 STANISLAUS 25,313 3,797 21,516 85 4,362 17,154 TULARE 23,374 2,545 20,829 89 6,120 14,709 925,188 83,838 1 841,800 91 437,403 404;397 it I inpatient days Tor Uie man atory aia categories. SOURCE:CALENDAR YEAR 1991 PAID CLAIMS DATA • It is assumed that all beneficiaries in aid codes required to enroll in a managed care plan have an equal likelihood of producing DSH days, i.e., the DSH day utilization rate will be the same across the mandatory aid categories. Thus, if measures such as hospital utilization rates per 1000 enrollees had been in this methodology, the outcome would be the same. This presumption has been discussed with and is acceptable to the Department's actuary. • The analysis assumes the same distribution of DSH days as that experienced in a county in a prior year. This will result in acceptable DSH days protection. • Acceptable DSH days protection is realized by placing under the control of the local initiative "potential DSH days" equivalent to the actual number of "paid" DSH days. It then becomes the responsibility of the local initiative to convert the available "unpaid"to "paid" DSH days through the design and operation of their hospital referral and inpatient utilization control procedures that will favor DSH facilities in caring for the inpatient hospital care needs of a local initiative's beneficiary population. The method selected for establishing the mainstream plan limit provides a reasonable probability that beneficiaries will have a continuing choice among two plans.The method also provides that the mainstream plan enrollment level in any county will never reduce the potential DSH days available to the local initiative below the number of paid days provided in the county in the period prior to the onset of the two-plan model in a county. TABLE 4. details this analysis. TABLE 4. MAINSTREAM PLAN MAXIMUM ENROLLMENT LIMIT CALCULATIONS [71 121 [3]. 141 151 161 [71 181' BENEFICIARY POTENTIAL PAID DSH PAID DSH TOTAL LOCAL MAINSTREAM COUNTY OF DSH DAYS- DAYS- DAYS MANDATORY INITIATIVE % PLAN % RESIDENCE MANDATORY MANDATORY ASA%OF MANAGED ALLOCATION MAXIMUM MANAGED MANAGED POTENTIAL CARE AID [31441 CARE AID CARE AID DSH DAYS CATEGORIES CATEGORIES CATEGORIES TDSH T R• ALAMEDA 54,285 29,849 55.0 129,305 74,118 55 58,127 45 CNTRA CSTA 17,743 10,763 60.7 59,273 35,979 61 23,294 39 FRESNO 44,186 27,597 62.5 149,618 93,511 62 56,107 38 KERN 23,918 16,327 68.3 84,868 57,965 68 26,903 32 L.A. 365,943 224,651 61.5 1,150,629 707,637 61 442,992 . 39 RIVERSIDE 48.512 20,216 41.7 133,119 55,511 42 77,608 58 SAN BRDO 78,217 21,762 27.8 225,755 62,760 28 162,995 72 SAN DIEGO 76,120 31,268 41.1 232,139 95,409 41 136,730 59 S.F. 28,129 14,196 50.5 57,150 28,861 51 28,289 49 SAN JOAO. 30,071 15,250 50.7 85,826 43,514 51 1 42,312 49 STA.CLARA 32,331 15,042 46.5 114,434 53,212 47 61,222 1 53 STANISLAUS 21,516 4,362 20.3 61,082 12,400' 38,582 63 22,500•• 37 TULARE 20,829 6,120 29.4 68,542 20,151 46,052 67 22,500•• 33 841,800 437,403 52.0 2,551,740 1,338,028_• 1,201,273 1,350,477-- Actual ,350,477•- ctua ••Adjusted up to 22,500 minimum. SOURCES:Calendar Year 1991 Paid Claims Data 2/93 MOE using 6/93 Medi-Cal Eligibility File. • This analysis does not account for factors that could lead to more paid DSH days than those projected due to the local initiative membership and beneficiary population remaining in fee-for- service under the managed care expansion plan. Examples are: • The use of DSH hospitals by members of the mainstream plan -- which could occur if the mainstream plan chooses or is required by the State to contract with DSH facilities and through emergency, burn center or other tertiary care admissions that are typically handled by DSH facilities. • The assertion by local initiative developers that they will serve a sicker population. If true, more inpatient hospital days will be under the control of the local initiative than assumed under this analysis. • The possible expansion of the definition of a hospital day qualifying for DSH consideration.