Managed Care Components of the MediCal 2020-25 Proposed Waiver
The state of California is proposing to expand and improve its managed care programs. Currently California has three different types of managed care: single choice County Organized Health Systems, dual choice between a county public plan and a commercial private plan, and multiple choice among multiple private commercial plans. They have different rates, different covered services and different eligibility groups mandatorily enrolled into managed care. There are wide differences in quality and performance among the plans, with Kaiser and several of the public plans being top performers.
Under the waiver, all MediCal enrollees must enroll in managed care with exemptions only for those with limited benefits (e.g. emergency and perinatal care only coverage for some undocumented) or time restricted coverage (medically needy share of cost or spend down categories). Those with Medi-Medi coverage (dual eligibles) will have bifurcated coverage choices (fee for service Medicare and managed care MediCal) or consolidated coverage choices (managed care for both their Medicare and MediCal benefits).
Under the waiver, all plans must offer the same covered benefit packages. Very little is exempt; however pharmacy benefits are a statewide, fee for service benefit, with prices negotiated and utilization managed by the state. Over time, all long-term care benefits for seniors and the disabled will be included.
All plans must become NCQA (National Committee on Quality Assurance) accredited, so must their delegated subcontractors. This assurance of plan quality must be secured by 2025; it is long overdue.
Annual open enrollment will give beneficiaries a choice of plans when they enroll and thereafter only once a year unless the beneficiary can show a real need to change plans mid-year. This will allow better, more consistent and sustained management of patient’s medical conditions.
Regional rate setting will replace county specific rates. Thus for example, all Bay Area plans might have the same rates, rather than differences between Alameda, San Francisco, Santa Clara and San Mateo. Likewise all Central Valley plans might be paid the same rates, rather than the reimbursement differences between Kern, Tulare, Kings and Fresno plans. It will be interesting to see how this is handled for Orange and San Diego health plans or the Ventura and Santa Barbara plans.
Prepared by: Lucien Wulsin
Dated: 1/24/20