Services for Children with Special Needs March 23, 2011 1 Agenda - PDF document

3/21/2011 Services for Children with Special Needs March 23, 2011 1 Agenda • About the ADRC • Services for Children with Special Needs Services for Children with Special Needs  Background – Gertrude Carter, M.D.  CalOptima – Peter Scheid, M.D.  California Children’s Services – Hoda Kaddis, M.D., F.A.A.P.  Regional Center of Orange County – Peter Himber, M.D.  OC HCA Behavioral Health Services/Children & Youth Services – Marcy Garfias, L.C.S.W.  Transitions – Linda O’Neal, M.A. , • Case Study and Q&A 2 1

3/21/2011 Supported by the California Health and Human Services Agency and U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services under Grant CFDA 93.779 3 4 2

3/21/2011 ADRC OC Program Function Information Information & Resource & Resource Referrals Referrals Options Options Community Community Counseling Counseling Education & Education & Advice & Advice & Outreach Outreach Assistance Assistance Assistance Assistance with with Transitions Transitions 5 Information & Resource Referrals Call the County of Orange Office on Aging at 1-800-510-2020 Speak to an Information p & Assistance Referral Specialist Find resources online at www.adrcoc.org The searchable directory includes many resources to help you Visit any of the 3 ADRC partner locations Please refer to your handout for a list of locations close to you 6 3

3/21/2011 Services for Children with Special Needs 7 Learning Objectives • Know the services offered by key agencies • Determine most appropriate resource Determine most appropriate resource • Understand how to prepare and assist families applying for services • Make appropriate referrals • Know transition supports for children as they reach adulthood 8 4

3/21/2011 Background Gertrude Carter, M.D. CalOptima, Chief Medical Officer 9 CalOptima’s Health Care Delivery System Peter Scheid, M.D. CalOptima, Medical Operations Medical Director 10 5

3/21/2011 CalOptima’s Mission To provide members with access to quality health care services delivered in a cost-effective and compassionate manner 11 What does CalOptima cover? • Medical supplies • Physician services • Prescription drugs • Hospital services • Prosthetics and orthotics • Lab tests and X-rays • Transportation • Prenatal care • Hospice • Immunizations • Long-Term Care • Durable medical equipment • Early and Periodic Screening, • Physical, speech and Diagnosis and Treatment occupational therapy (EPSDT) for Children 12 6

3/21/2011 What is “carved out” of CalOptima? • CalOptima contracts with the California Department of Health Care Services for Medi-Cal health benefits • Medi-Cal benefits “carved out” of CalOptima’s contract:  Mental health services  Psychotropic medications  California Children’s Services  Personal care services 13 What is “carved out” of CalOptima? • CalOptima contracts with Managed Risk Medical Insurance Board (MRMIB) for Healthy Families benefits • Healthy Families benefits “carved out” of CalOptima’s contract with MRMIB:  Dental & vision access through plan selected at enrollment  Mental health services for serious emotional disturbance (Covered by Children & Youth Services)  California Children’s Services 14 7

3/21/2011 How is eligibility determined? • Medi-Cal  Orange County Social Services Agency  Children  Pregnant Women  CalWorks/TANF  Persons with Disabilities  Persons aged 65 and over  Social Security Administration  Persons receiving Supplemental Security Income (SSI) or  State Supplemental Payment (SSP) • Healthy Families Program  MRMIB 15 Newly Assigned Members • What does CalOptima know?  Name  Gender  Gender  Address  Phone number  Aid code (reason for Medi-Cal eligibility) • What don’t we know?  Diagnoses  Diagnoses  Medical needs  Barriers to care 16 8

3/21/2011 CalOptima’s Delivery System • 2/3 of Medi-Cal and all Healthy Families members receive care through delegated health networks (see list in hand-out) • 1/3 of Medi-Cal members receive services through CalOptima Direct or CalOptima Care Network (CalOptima works directly with providers)  Populations in CalOptima Direct Administrative  Transitioning members, Medi-Medi, Share of Cost  Populations receiving care through CCN  Long-Term Care Aid Codes  Foster Care (~4,000)  Members with Hemophilia  Other condition-specific populations 17 CalOptima Delivery System  Identification of Children with Special Needs  Health Risk Assessments  Disease Management/Health Education Health Plan  Grievances and Appeals  Customer Service Community Liaison  Customer Service, Community Liaison  Provider Forums  Identification of Children with Special Needs  Case Management for moderate and high Health Network risk members  Utilization Management  Initial Appeals  Direct patient care, identification of clinical needs  Case management for low risk members  Primary care coordination Provider  Initiation of referral process  Interaction with HN and Plan to obtain services 18 9

3/21/2011 CalOptima Services • Early Identification of children with special needs  Health Risk Assessments  Patient Surveys  Utilization Data  Utilization Data  Case Management referrals • Case Management screening to determine needs  Development of Individual Care Plan  Trained nurses and support staff help determine needs, identify resources, and coordinate care between all providers  Regional Center Liaison  Pediatric Specialty Case Manager • In development: Pediatric-specific interdisciplinary care teams 19 CalOptima Services • Provider Support  Continuing Medical Education  Consultation (i.e., doctor to doctor)  Resource manual for providers  Behavioral health support • Member and Family Support  Health Education  Disease Management  Community Liaison (customer service)  Community Liaison (customer service)  Regional Center Liaison • Forum with other stakeholders to improve services  RCOC, CCS, School Nurses 20 10

3/21/2011 Support For CalOptima Members • CalOptima Customer Service and Member Liaison Program for seniors, people with disabilities, chronic conditions or who are homeless conditions or who are homeless  (714) 246-8500  (888) 587-8088 • www.caloptima.org • 1120 W. La Veta Avenue Orange, CA 92868 21 California Children’s Services Orange County Hoda Kaddis, M.D. Medical Director 22 11

3/21/2011 CCS Organizational Structure Children’s Medical Three State Regional Local County CCS Ser ices Services Offices Offices Offices Offices Central State Office in Sacramento Monitoring counties, CCS Determination of Eligibility Overall Program Policy approved facilities and and Benefits, Authorization Development providers, and consulting of Services, and Direct Therapy 23 CCS Eligible Medical Conditions • Serious chronic catastrophic disabling disfiguring conditions, such as:  Cancer  HIV infection  HIV infection  Congenital heart defects  Cleft lip and palate  Insulin dependent diabetes  Hemophilia  Hearing loss  Extreme prematurity  Kidney failure  Severe burns  Severe burns  Traumatic brain injuries. • Medical Therapy Program provides OT/PT for:  Spastic CP  Other disabling conditions, such as Muscular dystrophy 24 12

3/21/2011 CCS Eligibility Requirements • 0 - 21 years old • Residents of OC • Eligible medical condition • Financial criteria  Under 40K  Healthy Families  Medi-Cal  Over 40K or other insurance if estimated out-of-pocket expenses are more than 20% of family’s income • Medical Therapy Program does not require financial eligibility 25 CCS Services • Serves 13,000  68% Medi-Cal  20% Healthy Families  12% straight CCS • Covered conditions carved out of managed care  Refer a child with a diagnosed eligible condition to CCS for treatment • PT /OT in the medical therapy units on public school grounds 26 13

3/21/2011 CCS Services • Medical treatment from approved providers and facilities only with prior authorizations  Except emergency treatment p g y • Payment for treatment of eligible conditions only • Services coordination with managed care, PPOs, RCOC, and school districts 27 CCS Enrollment Process • Referral by fax, mail or in person by anyone • Medical documentation  Reports  Labs  X-rays • Demographic and insurance information • Application and services agreement for non Medi-Cal or HF li HF clients t • Eligibility determination within 5 working days • Authorizations for treatment 28 14