Low Income Health Program (LIHP) Application Process LIHP@dhcs

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

2. Welcome to the Department of Health Care Services (DHCS) LIHP Application Informational Meeting - January 2011 - Service - Accountability - Innovation

3. Staff introductions and organization Service - Accountability - Innovation

4. 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. Service - Accountability - Innovation

5. The Day at a Glance • Housekeeping. • Agenda. • Questions & Answers. • Summary. Service - Accountability - Innovation

6. 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. Service - Accountability - Innovation

7. 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”. Service - Accountability - Innovation

8. 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. Service - Accountability - Innovation

9. 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

10. Voluntary Participation Applicants voluntarily elect to participate. Service - Accountability - Innovation

11. LIHP Conditions of Participation If 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. Service - Accountability - Innovation

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

13. LIHP Application Service - Accountability - Innovation

14. General Information Section#5 - Applicant type Applicant 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

15. 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

16. 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. Service - Accountability - Innovation

17. 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. Service - Accountability - Innovation

18. 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. Service - Accountability - Innovation

19. Provider Network Section#7. Open or closed delivery system Expenditure Authorities: Sect. 1903(m)(2)(A)(vi) • Enrollees right to disenroll is restricted. Service - Accountability - Innovation

20. 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-network 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. Service - Accountability - Innovation

21. 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. Service - Accountability - Innovation

22. Provider Network Section Question #8 Delivery System • Managed Care Organizations (MCOs) • Health-Insuring Organization (HIOs) • Prepaid Inpatient Health Plans (PIHPs) • Prepaid Ambulatory Health Plans (PAHPs) • Primary Care Case Management Systems (PCCMs) Service - Accountability - Innovation

23. Provider Network Section Question #9 Mental Health Delivery System Option to carve out the mental health delivery system. Service - Accountability - Innovation

24. Provider Network Section Question #9 Mental Health Delivery System • MCE: minimum evidence-based mental health benefits. • HCCI: mental health benefits are additional services. Service - Accountability - Innovation

25. Eligibility and Enrollment Section • What is the only eligibility criteria that can be limited? Service - Accountability - Innovation

26. Eligibility and Enrollment Section • What is the only eligibility criteria that can be limited? Answer: Income range Service - Accountability - Innovation

27. Eligibility and Enrollment Section Question #10 Upper Income Limit Allowable income range: • MCE- family income at or below 133% FPL. • HCCI- family income above 133% through 200% FPL. Service - Accountability - Innovation

28. Eligibility and Enrollment SectionQuestion #10 Upper Income Limit • The purpose of the upper income limit is to ensure eligible adults can continue to be enrolled without exceeding the available amount of local funds and minimize the need for an enrollment cap, especially for the MCE program. Service - Accountability - Innovation

29. Eligibility and Enrollment SectionQuestion #10 Upper Income Limit • The applicant should set an upper income limit if they determine they are unable to enroll all eligible MCE applicants within the allowable income range for the MCE program. Service - Accountability - Innovation

30. Eligibility and Enrollment SectionQuestion #10 Upper Income Limit • The applicant should set an upper income limit if they determine they are unable to enroll all eligible HCCI applicants within the allowable income range for the HCCI program. Service - Accountability - Innovation

31. Eligibility and Enrollment SectionQuestion #10 Upper Income Limit • Applicants may set an upper income limit within the allowable income range. • If applicant is implementing MCE and HCCI, the MCE income range can not be set below 133% of the FPL. • If applicant is implementing only the MCE, the MCE income range can be set below 133% of the FPL. Service - Accountability - Innovation

32. Eligibility and Enrollment SectionQuestion #10 Upper Income Limit How does a reduced upper income limit affect existing enrollees? • There is no affect. • At redetermination, the existing enrollee is exempt from the reduced upper income limit. • The existing enrollee is redetermined using the income level in effect at the time of their initial eligibility determination. Service - Accountability - Innovation

33. Eligibility and Enrollment SectionQuestion #11 Enrollment Estimates • These estimates are non-binding and may be changed during the authorization/contract process. • If applicant has existing HCCI enrollees, complete the existing and new enrollment estimates. • If applicant doesn’t have existing HCCI enrollees, complete only new enrollment estimates. Service - Accountability - Innovation

34. Eligibility and Enrollment SectionQuestion #11 Enrollment Estimates MCE Population • Existing MCE enrollees: Enrollees who have family incomes at or below 133 percent of the FPL, and who were enrolled in the “Medi-Cal Hospital/Uninsured Care Demonstration” on November 1, 2010. • New MCE enrollees: Enrollees who have family incomes at or below 133 percent of the FPL and meet the income standards as established for each MCE, are not eligible for Medicaid or CHIP, and who were enrolled after November 1, 2010. Service - Accountability - Innovation

35. Eligibility and Enrollment SectionQuestion #11 Enrollment Estimates HCCI Population • Existing HCCI enrollees: Enrollees who have family incomes above 133 through 200 percent of the FPL, and who were enrolled in the “Medi-Cal Hospital/Uninsured Care Demonstration” on November 1, 2010. • New HCCI enrollees: Enrollees who have family incomes above 133 through 200 percent of the FPL and meet the income standards as established for each HCCI, are not eligible for Medicaid or CHIP, do not have third party coverage, and who were enrolled after November 1, 2010. Service - Accountability - Innovation

36. Eligibility and Enrollment SectionQuestion #12 Enrollment Cap What would trigger an enrollment cap? Service - Accountability - Innovation

37. Eligibility and Enrollment SectionQuestion #12 Enrollment Cap What would trigger an enrollment cap? Answer: Need to maintain level of services for enrollees exceeds initial projections and local available funding Service - Accountability - Innovation

38. Eligibility and Enrollment SectionQuestion #13 Retroactive Eligibility Enrollment Date • Enrollment date is the first day of the month in which the application is dated and is no earlier than November 1, 2010. • Enrollment date does not include the addition of retroactive eligibility. Service - Accountability - Innovation

39. Eligibility and Enrollment SectionQuestion #13 Retroactive Eligibility • Option to allow retroactive eligibility for enrollees. • Up to 3 months retroactive eligibility allowed. • Can not extend earlier than November 1, 2010. - Questions - Service - Accountability - Innovation

40. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms Claiming for existing HCCI enrollees • FFP can be claimed for services provided to enrollees from November 1, 2010 until implementation of their program according to the claiming protocol in the STCs for the prior Demonstration. • After the MCE program is implemented, these expenditures for existing enrollees with family incomes at or below 133% FPL, can be claimed as MCE expenditures outside the SNCP limit. Service - Accountability - Innovation

41. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms Two reimbursement mechanisms • Cost based payments. • Actuarially sound per capita rate. Service - Accountability - Innovation

42. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms Cost based payments • Non-federal share is CPEs from governmental entities. Service - Accountability - Innovation

43. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms CPEs • CPEs must be certified in accordance with federal guidance to claim the federal funds. • Only expenditures that have actually been made may be certified. • CPEs may not be made on the basis of invoices or billings that have not been paid. Service - Accountability - Innovation

44. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms Actuarially Sound per capita rate • Non-federal share may be IGTs or CPEs from governmental entities. • CPEs are restricted to CPEs incurred in payment of rates to a third party contractor. Service - Accountability - Innovation

45. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms Intergovernmental transfers (IGTs) • On a quarterly basis the applicant transfers to DHCS the amount necessary to meet the non-federal share of estimated reimbursement for the next quarter. Service - Accountability - Innovation

46. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms • LIHP is a reimbursement program. • DHCS claims the FFP for reimbursement of the LIHP provision of health care services. • DHCS reimburses the applicant an amount equal to the FFP received from CMS at the applicable FMAP. Service - Accountability - Innovation

47. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms Federal Medical Assistance Percentage (FMAP) Amounts • 61.59% 10/1/08-12/31/10 • 58.77% 1/1/11-3/31/11 • 56.88% 4/1/11-6/30/11 • 50% 7/1/11 forward Service - Accountability - Innovation

48. Expenditure and Reimbursement MechanismsQuestion #14 Reimbursement Mechanisms • Reimbursement mechanism can be changed per program year. Service - Accountability - Innovation

49. Expenditure and Reimbursement MechanismsQuestion #15 Total funds expenditures (TFEs) • TFEs are the total allowable costs incurred by the applicant for providing LIHP services to enrollees. • Must be from an appropriate source of local funds and must not include other federal funds or impermissible provider taxes or donations. Service - Accountability - Innovation

50. Expenditure and Reimbursement MechanismsQuestion #15 Total funds expenditures (TFEs) • Funding, such as a grant, that is currently received from a particular source that is targeted for a specified purpose or program other than health care, can not be used as the non-federal share of funds. • The federal reimbursement for LIHP expenditures is considered revenue and not a federal grant. Service - Accountability - Innovation