Health Plan Pilots (voluntary, fully integrated service delivery models)

Goal: Develop voluntary, fully integrated service delivery models to test the efficacy and effectiveness of capitation across health and social services to improve outcomes for persons with chronic conditions.

PILOT 1, HEALTHY SAN DIEGO PLUS (HSD+) – A voluntary, fully integrated service delivery model, with a capitated payment from Medi-Cal, and from Medicare for the “dually eligible.” HSD+ plans to build on the “medical home” approach provided by HSD, the Medi-Cal managed care program in San Diego, extended to include the broader array of services that become possible when Medi-Cal and Medicare are integrated. Characteristics of the HSD+ initial phase of implementation (July 2006) include voluntary enrollment of those 65 years and older who have Medi-Cal or Medi-Cal and Medicare coverage into one of the contracted, integrated provider networks. It is anticipated that up to 10,000 aged and disabled persons will choose to enroll in HSD+ in the first three years. The Board will be asked to approve initial implementation before July 2006.

Next Steps: (1) Secure funding to complete the final stages of planning for Healthy San Diego Plus (HSD+), as outlined in the Administrative Action Plan Final Draft. Pre-implementation activities over the next two years will focus on (a) assuring HSD+ feasibility; (b) expanding HSD infrastructure and governance for new populations and services; (c) working with the State to gain waivers/variances needed; and (d) fleshing out the detail that will provide for the minimum qualifications required in a process similar to HSD’s Request for Statement of Qualifications. Several small planning and development grants from the State Office of Long Term Care have supported this fully integrated strategy since 1999. The State is now considering funding for counties to complete the final stages of planning. LTCIP will pursue this funding when it becomes available.

Click here for the AAP Final Draft (June 10, 2004)

PILOT 2, PRIVATE SECTOR PILOT - In a parallel but independent effort, the State Department of Health Services may also award a Medi-Cal contract for a pilot demonstration to a private contracting entity, Evercare, an affiliate of United Health Group. The pilot will not mirror Healthy San Diego Plus, but will provide the ability to evaluate the impact of an integrated pilot locally. Evercare is in a position to contract with the State due to a Medicare demonstration that has been awarded to the organization in San Diego by the Center for Medicare and Medicaid. If implemented, the pilot would not seek local resources, but would pool Medicare and Medi-Cal capitated rates for those who volunteer to enroll in the private pilot.