While Medi-Cal is typically thought of as providing health care coverage to low-income mothers and children, nearly 44 percent of the program's expenditures go toward services for non-elderly beneficiaries with disabilities. In July 2002, roughly 13 percent of the Medi-Cal population (767,314 people) were non-elderly people who qualified for the program due to a disability. An indeterminate number of additional people with disabilities qualify for Medi-Cal due to a factor other than their disability, such as being part of a low-income family.
Adults with Disabilities in Medi-Cal: The Beneficiary Perspective
Center for Disability Issues and the Health Professions
Medi-Cal provides health care coverage to nearly three quarters of a million Californians with disabilities. Care is delivered to this population through one of two primary delivery systems: traditional fee-for-service and managed care. To date, there has been a lack of information about how well the program is doing at delivering health care services to people with disabilities through either delivery system. In light of recent proposals to expand Medi-Cal managed care for people with disabilities, the Center for Disability Issues and the Health Professions was commissioned to conduct a series of focus groups to solicit direct input from people with disabilities and their families who will be most affected by any major policy changes in the Medi-Cal program.
Based on input from the study focus groups, there appear to be significant problems in both the Medi-Cal fee-for-service and managed care delivery systems in providing services to beneficiaries with disabilities. Focus group participants in both systems displayed an almost universal lack of understanding, and sometimes-outright confusion, about Medi-Cal benefits, services, and grievance procedures. Across the board, participants reported difficulty finding physicians and adequately accessing services, programs, and facilities. Nearly all participants reported difficulty in locating a primary care physician, but it appears to be slightly easier for those in managed care plans to find a primary care physician. All focus group participants, regardless of service model, expressed difficulty with locating specialists. Some of the barriers identified through this study may be unique to the Medi-Cal program, while others are likely to be indicative of problems that all people with disabilities experience, regardless of the type of health insurance they have.
Adults with Disabilities in Medi-Cal Managed Care: Lessons from Other States
Nicki Highsmith and Stephen Somers, Center for Health Care Strategies
Across the country, states are exploring how to provide more cost-effective managed care for people with disabilities. Those who have embraced Medicaid managed care for this population believe it can deliver better access and quality at a more predictable cost. To help policymakers determine whether such an approach might be appropriate for California, we commissioned the Center for Health Care Strategies to determine how well managed care for people with chronic illnesses and disabilities has functioned in four other states: Massachusetts, New Jersey, Oregon, and Pennsylvania.
The perspectives from the interviews in this study provide valuable insights for consideration in six priority areas of managed care for people with disabilities. These include model design; beneficiary enrollment and consumer engagement; financing, rate setting, and cost containment; network adequacy; care coordination and carve-outs; and quality monitoring and improvement. The firm consensus among states and health plans is that some form of managed care is the best path to take in meeting the needs of this population. Consumers, while less sure, also agreed that managed care offers the potential for better access and increased quality.
Adults with Disabilities in Medi-Cal Managed Care: Conference Summary
Health Systems Research, Inc.
In January 2002, the California Legislative Analyst's Office proposed that the state consider expanding Medi-Cal managed care for beneficiaries with disabilities as part of the solution to cover the state's $20 billion budget deficit at that time. Although the California Legislature did not adopt this change, the proposal raised questions about the state of the current Medi-Cal delivery system for people with disabilities and the implications of moving more of this population into managed care.
On February 27, 2003, The California Health Care Foundation sponsored a conference to provide a forum in which policymakers, program administrators, representatives from health plans and provider organizations, consumer advocates, and researchers could discuss the implications of expanding Medi-Cal managed care for people with disabilities. To this end, findings from a number of recent studies commissioned were released and discussed at the meeting.
This report summarizes the presentations and discussions that took place at the meeting. It is organized around the following four areas:
- The current policy context with respect to Medi-Cal managed care for people with disabilities;
- The opportunities and challenges associated with a transition to mandatory managed care for Medi-Cal beneficiaries with disabilities, as perceived by consumers, providers, and health plans;
- An examination of the lessons learned from other states that have enrolled working-aged Medicaid recipients with disabilities in managed care; and
- The outstanding issues and information needs identified by participants.
The Olmstead Decision and Long-Term Care in California
Eliot Z. Fishman, Bruce C. Vladeck, Ann-Gel S. Palermo, and Margaret H. Davis
Along with all other states, California is required to comply with the U.S. Supreme Court's 1999 landmark Olmstead decision, which concluded that confining persons with disabilities in institutions without adequate medical reasons is a form of discrimination that violates the Americans with Disabilities Act. In Olmstead, the Supreme Court held that states cannot make institutionalization a condition for publicly funded health coverage unless it is clinically mandated. Instead, states must direct their health programs for persons with disabilities towards providing community-based care.
This report finds that although California's long-term care system has distinct strong points, glaring problems will hinder the state's ability to comply with Olmstead unless resolved. These include the paucity of alternatives to nursing homes for people who need more than part-time unskilled personal assistance.
California's long-term care programs and services for the frail elderly, physically disabled, people with mental illness, and people with developmental disabilities are examined, and comparisons are made with three states (Colorado, Washington, and Wisconsin) that have successfully reduced institutionalization, shifting resources into home and community-based services while holding down growth in overall costs. The report makes several specific recommendations for solving lingering problems and spurring the state's fulfillment of the Olmstead mandate.
Adults with Disabilities in Medi-Cal Managed Care: Health Plan Practices and Perspectives
Jackie Rudich Nolen
In a February 2002 analysis of the California state budget, the California Legislative Analyst's Office proposed that the state consider expanding Medi-Cal managed care for people with disabilities as part of the solution to closing the state budget gap. Public dialogue throughout the 2002 budget discussions regarding the proposal to expand managed care for people with disabilities did not result in any clear policy direction. However, with a projected budget gap of more than $26 billion for the 2003-04 fiscal year, this issue may well be revisited by California policymakers during the upcoming legislative session.
This research to provide policymakers and other stakeholders with insights and information relevant to the expansion of managed care to non-elderly Medi-Cal beneficiaries with disabilities. This report describes the findings from a survey of health plans that currently provide care to members with disabilities in Medi-Cal managed care; identifies barriers and challenges that health plans have faced in enrolling and serving Medi-Cal beneficiaries with disabilities in managed care; and highlights promising health plan practices and innovations learned from the interviews.
The California Working Disabled Program: Lessons Learned, Looking Ahead
Joanne Jee and Joel Menges of The Lewin Group
The California Working Disabled Medi-Cal Buy-In Program (CWD) was implemented in April 2000 to enable disabled individuals to participate in the workforce without the threat of losing their Medi-Cal coverage. Although a relatively new program, policymakers and advocates have already begun considering programmatic and policy changes that would build on the existing program, expand eligibility, and broaden access to certain services. This study was initiated to better understand the factors affecting enrollment in CWD and to estimate the enrollment and cost impacts of select programmatic changes.
The California Working Disabled program currently covers individuals with net countable family incomes up to 250 percent of the federal poverty level (FPL) and assets up to $2,000 for an individual ($3,000 for a couple). Net countable income is derived by exempting all disability-related income and disregarding the first $65 of earned income, impairment-related work expenses, and approximately half of the disabled person's earned income. Thus, some working disabled people can have overall income well above 500 percent of FPL and still be eligible for the program. Relative to income eligibility requirements for other Medi-Cal aid categories, the income threshold for CWD is quite high; the CWD assets threshold is the same as that used in many other aid categories.
Enrollment in CWD totaled 652 as of June 2002, far below original enrollment estimates and the number of individuals estimated to be eligible. Prior to implementation, the California Department of Health Services (DHS) estimated that 7,000 to 14,000 individuals would enroll by the end of the second year of the program. Thus, enrollment in the CWD Program has reached only about ten percent of its estimated level. The modest enrollment experience to date made it important to assess the program in order to identify whether program design changes are needed to allow larger numbers of disabled individuals in California to work while maintaining health care coverage through Medi-Cal.
The goal of this study was to gain a better understanding of the factors affecting enrollment in CWD and to estimate the enrollment and cost impacts of select programmatic changes. To further study these issues, two sets of analyses were conducted. The first was a qualitative review of stakeholders' experience with the program. The experiences of CWD enrollees, those eligible but not enrolled, and county eligibility workers were gathered to lend insight into the factors contributing to the program's current enrollment trend as well as to solicit suggestions for program improvement. This qualitative research included an enrollee survey, and in some cases follow-up interviews; a teleconference with a group eligible but not enrolled (nonenrollees); and telephone interviews with county eligibility workers. The second was a set of quantitative analyses of Census Bureau and DHS data to model program eligibility alternatives that might allow more disabled workers in California to access Medi-Cal coverage. The enrollment and cost implications of these alternatives were also explored.
Understanding Medi-Cal: Long-Term Care (Revised Edition)
Lucy Streett, M.P.H.
The long-term care system in California, including the programs and services funded by Medi-Cal, is complex and fragmented. The system serves a diverse group of individuals with different needs, from the frail elderly to chronically ill children.
Medi-Cal pays for 64 percent of all nursing home days in the state and accounts for 45 percent of total nursing home expenditures. In 1998, it paid for 42 percent ($5 billion) of all public long-term care expenditures. It covers a wide array of short- and long-term care services through more than 20 different programs.
But Medi-Cal encompasses much more than just nursing home care: It covers a range of services provided to the elderly and people with disabilities who need care due to chronic conditions. These services include medical care, therapy, rehabilitation, case management, protective supervision, and assistance in daily activities (bathing and eating).
This guide serves as a primer to understanding the Medi-Cal long-term care system. The booklet is published in an easy-to-understand format that combines data and descriptions to give readers a snapshot of a complicated network of services. It covers:
- Defining Medi-Cal and long-term care;
- Eligibility and enrollment;
- Funding and administration;
- Covered services; and
- Policy issues.
Readers will also find that the issues facing Medi-Cal long-term care are issues that face the health system in California as a whole. These include the swelling of the Medicare population as the baby boomers age, lack of workforce to meet demands, lack of integrated and coordinated services, quality of care, and funding for services.
The Impact of California's Fiscal Crisis on Medi-Cal Health Plans
Mercer Government Human Services Consulting
How long will health plans participating in Medi-Cal managed care be able to remain fiscally viable following recently enacted Medi-Cal rate cuts? This report assesses the current financial condition of Medi-Cal health plans and projects the financial viability of these health plans for the next four years.
Understanding the current financial position and future viability of the health plans participating in Medi-Cal is crucial, because more than half of Medi-Cal's membership is enrolled with, and receiving health care services through, 22 contracted health plans.
Produced by Mercer Government Human Services Consulting, The Impact of California's Fiscal Crisis on Medi-Cal Health Plans found that overall, the financial performance of the 22 health plans participating in Medi-Cal improved between 1998 and 2002. They remained profitable as a group, which allowed them to build equity, and most health plans also appear to be financially sound on an individual basis. As good as this sounds, unfortunately, not all plans appear to be financially strong. Moreover, the picture could change dramatically if Medi-Cal capitation rates do not keep pace with medical expense trends, even for plans in good financial health.
Adults with Disabilities in Medi-Cal: Utilization and Expenditure Trends, 1995-2001
Todd Gilmer, University of California San Diego
The Medi-Cal program provides health care services to almost one million Californians with disabilities. These beneficiaries account for about 17 percent of Medi-Cal enrollment and nearly 44 percent of the program's expenditures.
This report provides a detailed picture of Medi-Cal beneficiaries with disabilities between 1995 and 2001. It compares their demographics, disease conditions, service use, and expenditures with two other major group of Medi-Cal beneficiaries: (1) beneficiaries who are eligible for Medi-Cal coverage due to a link with the Temporary Assistance for Needy Families (TANF) program (called CalWORKs in California); and (2) the aged (beneficiaries aged 65 and older).
Medicaid's Role for People with Disabilities
This primer is on Medicaid's role as the major provider of health coverage for non-elderly persons with disabilities and on the policy challenges that lie ahead. It also provides short profiles of people with disabilities from across the country.
The Role of Health Coverage for People with Disabilities
People with disabilities are at risk in the health-care system because of their wide-ranging health-care needs, their relatively heavy use of prescription drugs, health-care and support services, and typically low incomes. A new survey of people with permanent mental and/or physical disabilities explores their health-care experiences and challenges in accessing and paying for care.
Implications of the New Medicare Prescription Drug Benefit for State Medicaid Budgets
Publication Number: 4162
Publish Date: 2003-12-15
For a number of years, Governors and other state policymakers have maintained that Medicare - rather than state Medicaid programs - should play the key role in providing prescription drug coverage to Medicare beneficiaries, including those who also qualify for Medicaid because they are impoverished and/or have extensive health care needs (i.e, the "dual eligibles"). Although the new Medicare prescription drug benefit law shifts drug coverage for dual eligibles from Medicaid to Medicare, it does not provide all of the fiscal relief that states had expected would accompany this shift, nor does it guarantee equivalent coverage to dual eligibles.
This issue brief describes the key provisions of the new law with implications for state Medicaid budgets and dual eligibles, reviews the estimates available at this time on the effect of these provisions on state Medicaid expenditures; and discusses why the fiscal impact of the new law can be expected to vary widely across states.
The California Center for Long Term Care Integration, Final Report
September 2001-June 2003
Submitted to the California HealthCare Foundation
CHCF Grant #01-1364
Improving County Long Term Care Systems to Build Toward Integration
California Olmstead Plan
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
May 2003