Serving Persons with Disabilities in Medicaid Managed Care

HealthNet's Experience

April 17, 2002

Ana R. Clark, R.N., BSN., PHN; Public Health Program Administrator

HealthNet of California

• Network Model Managed Care Company
• Over 2.6 Million Members Statewide
• Medi-Cal (Medicaid)
• Healthy Families (SCHIP)
• Commercial
• Medicare

HealthNet's Medi-Cal Managed Care Program (D-link)

HealthNet Medi-Cal Enrollment February 2002 (D-link)

HealthNet's Definition of Children with Special Health Care Needs

18% of all children have a chronic, physical, developmental, behavioral or emotional condition that requires health care and related services.

“CSHCN are those who have, or are at increased risk for a chronic physical, developmental, or emotional conditions, and who also require health and related services of a type or amount beyond that required by children generally”
(McPherson et.al.1998)

Reaching Children and Building Successful Systems of Care for CSHCN

The following are the key aspects identified by Health Net for successfully coordinating the care of CSHCN:

• Early identification of CSHCN through Health Net’s expanded member outreach services to children and their families enrolled in the Medi-Cal Managed Care
• Assisting families by creating linkages with their primary care provider (PCP), and local community services

Reaching Children and Building Successful Systems of Care for CSHCN

• Assuring access to care for CSHCN through the use and understanding of a medical home concept
• Care coordination to promote continuity of care between PCP, sub-specialist and public sponsored programs

HealthNet Medi-Cal Contract Carve-Outs for CSHCN

Major California state sponsored programs for Children with Special Health Care Needs (CSHCN) are:

• California Children Services (CCS)
• Department of Developmental Services/Regional/Center
• Local Education Authority (LEA)
• Children’s Mental Health Services

California Children Services (CCS)

CCS is a state program developed under Title V of the Federal Social Security Act for SCHCN.

The program arranges, directs and pays for medical care, equipment and therapy services for children and young adults under 21 years of age who have serious medical conditions, as defined by the program.

Qualifications for the CCS Program

• Children under 21 years of age
• With medical CCS eligible condition
  • Present at birth
  • Resulting from accident or injury
  • Severe or disabling
• Permanent California resident
• Meets financial eligibility

Services Provided by the CCS Program

• Diagnostic Evaluations
• Treatment Services
• Medical Therapy Program
• Medical Case Management
• High Risk Infant Program
• HIV Children’s Screening Program
• Orthodontic Program

CCS Coordination of Care Agreements

Challenges:

• State vs County Program Authority
• Resource Disparity
• Case Management Definition
• System Interface
• Network

Opportunities:

• Managed Care Participation
• Common Ground
• Resource Sharing
• Medical Home Development
• CCS Eligible Tracking
• Improve Provider Availability

HealthNet CCS Eligible - February 2002 (D-link)

Building Collaborative Systems of Care for CSHCN

• School based health care collaboration program
• Refer children with ongoing health care needs to the appropriate case management program
• Assist school based health providers to develop systems and provide partnerships to enhance health care delivery, capacity and quality
• Develop wrap-around/primary care provider contracts with sponsor of school based nurse practitioner
• Contact parents of children receiving care at school to explore access to primary primary care linkages

Value of School Health Programs

• Quality
• Accessibility
• Case Management Integration
• Data Collection
• Anticipatory Guidance
• Adolescent Health
• Community/Public Health

Children's Mental Health Services Responsible Programs

• Mental Health Services for Medi-Cal Managed Care children are provided by County Managed Mental Health Care Programs
  • Medi-Cal specifically exempted from legislation requiring unlimited treatment access (AB 88)
  • Excludes certain DSM listed conditions like autism
  • Responsible for selected psychiatric pharmaceuticals
• Regional Centers have case management responsibility for children with autism and other related conditions.
• Local Education Programs provide mental health services in relationship to Individual Education Plans and in conjunction with other programs especially substance abuse.
• Medical Managed Health Care programs provide Mental Health Care for children within the scope of services provided by Primary Care and are responsible for emergency care in an acute care setting.
• Early Periodic Screening Diagnosis Treatment Supplemental Services (EPSDT) are the responsibility of:
  • Medi-Cal Managed Health Care Plans
  • Regional Center Programs
  • Managed Mental Health Care Programs

Mental Health Coordination of Care Challenges

• Identifying responsible programs
• Overcoming deliver system separations
• Defining conditions
• Developing resources
• Balancing confidentiality concerns

Department of Developmental Services

Statewide responsibility for residents with developmental disabilities

Regional Center System:
Regional Centers provide services to eligible children and adults with developmental disabilities and special needs. To qualify for services, the disability must originate before the age of eighteen years, continue or be expected to continue indefinitely, and create a substantial handicap. After initial evaluation, families are active partners with professionals in designing individualized plans for services and support. Preventive services are available to parents at high risk of having a child with developmental disability. There is no income requirement for Regional Center participation.

Regional Center Services

• Early Start Programs
• Individual Family Service Plan
• Case Management Service
• Counseling
• Respite Care
• Placement Services

Building Systems of Care for CSHCN in Managed Care

• Differentiate between childhood and adult disability
• CSHCN Dedicated Staff Outreach System
• Formal Agreements
• Resource Sharing
• Practical Operations
• Develop Policies and Integrated Quality Indicators

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