Medi-Cal Managed Care Divison - Organization Information
MMCD Organization Chart
The Medi-Cal Managed Care Division is composed of 3 Branches and 1 Section:
Plan management branch
The Plan Management Branch (PMB) is responsible for administration of all Medi-Cal managed care contracts, evaluation of contractor performance and compliance, policy interpretation and application.
The Medi-Cal managed care expansion activities are currently housed within PMB. Managed care expansion, which was the major component of Medi-Cal Redesign approved in the Budget Act of 2005, will implement managed care in thirteen additional counties that are currently fee-for-service counties.
PMB is composed of the following three Sections:
Two-Plan Model Section
The Two-Plan Model Section is responsible for the operational oversight of the Medi-Cal managed care health plans in twelve counties. Managed care health plans include multi-county commercial plan contracts and ten Local Initiative health plans. Over two million Medi-Cal beneficiaries receive their health care under the Two-Plan model. Contract management activities focus on ensuring that Medi-Cal beneficiaries have timely access to quality medical care through monitoring and oversight of plan operations to improve health outcomes.
The Two-Plan Model counties include: Alameda, Contra Costa, Fresno, Kern, Los Angeles, Riverside, San Bernardino, San Francisco, San Joaquin, Santa Clara, Stanislaus and Tulare. Each Two-Plan Model county has a Local Initiative plan and a Commercial health plan contract awarded via a competitive bid process. The exceptions are Fresno, which has two commercial plan contracts because the county chose not to develop a Local Initiative, and Stanislaus and Tulare, which designated Blue Cross as their Local Initiative. Health plan monitoring and oversight activities are conducted by two Units that perform similar functions: the Commercial Plan Unit and the Local Initiative Unit.
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Commercial Plan Unit (CPU) and Local Initiative Unit (LIU)
The CPU and LIU review and coordinate approval of health plan deliverables and monitor managed care plan compliance with contract, statutes, regulations and policies. The CPU and LIU initiate contract processing, contract amendments, change orders and requests for system changes to maintain enrollment criteria, benefit changes and rate adjustments.
County Organized Health System (COHS), Geographic Managed Care (GMC) and Other Contracts Section
The County Organized Health System (COHS), Geographic Managed Care (GMC) and Other Contracts Section has contract management and oversight responsibilities for five COHS contracts, 12 GMC contracts, one Primary Care Case Management (PCCM) contract, one Targeted Case Management (TCM) contract and one Pre-Paid Health Plan. Over one million beneficiaries are enrolled in the GMC and COHS counties.
County Organized Health System (COHS) Unit
The County Organized Health System (COHS) Unit manages and provides monitoring and oversight of five COHS contracts operating in eight counties, one Primary Care Case Management (PCCM) contract with the AIDS Health Foundation in Los Angeles, and one Targeted Case Management (TCM) contract with the Family Mosaic Project in San Francisco. COHS contracts include: Partnership Health Plan of California (Napa, Solano and Yolo), Central Coast Alliance for Health (Monterey and Santa Cruz), Santa Barbara Health Initiative, Health Plan of San Mateo, and Cal Optima (Orange). The COHS Unit reviews and coordinates approval of plan submission requirements and deliverables and monitors managed care plan compliance with contract, statutes, regulations and policies.
Geographic Managed Care (GMC) Unit
The Geographic Managed Care (GMC) Unit manages and provides monitoring and oversight of 12 GMC contracts operating in Sacramento and San Diego and one Pre-Paid Health Plan contract with Kaiser in Sonoma and Marin counties. The GMC Unit evaluates health plan applications submitted for participation in the GMC model, manages the Healthy San Diego administrative contract, and provides contract support to the California Medical Assistance Commission (CMAC) for contract negotiations. The GMC Unit also reviews and coordinates approval of plans submission requirements and deliverables and monitors managed care plan compliance with contract, statutes, regulations and policies.
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Expansion Section
The Expansion Section is responsible for development and implementation of managed care models in 13 new counties. The Budget Act of 2005 authorized expansion of managed care into El Dorado, Imperial, Kings, Lake, Madera, Marin, Mendocino, Merced, Placer, San Benito, San Luis Obispo, Sonoma, and Ventura counties. Expansion staff work with county officials and stakeholders to implement and develop the proposed managed care model and or investigate alternative models. Staff evaluate performance standard enhancements, develop contract language, secure necessary federal waivers or state plan amendments, coordinate readiness reviews, initiate system development, coordinate enrollment activities (Health Care Options), and provide briefings and updates to counties, advocacy associations, legislative staff and administration officials. New managed care contracts are anticipated to begin operation in 2008 through 2010.
Plan Monitoring/Program Integrity Branch
The Plan Monitoring/Program Integrity Branch (PM/PIB) ensures that health plan performance complies with contract requirements for financial solvency, medical compliance, facility site reviews, member rights and program integrity, including anti-fraud activities.
PM/PIB is composed of the following three Sections:
The Medical Monitoring Section
Medical Monitoring Unit
The Medical Monitoring Unit (MMU) ensures that Medi-Cal managed care plans have developed and implemented quality of care monitoring programs and systems so that they provide quality health care services and communicate appropriate plan information with their subcontractors and providers. The MMU reviews and evaluates medical and quality improvement policies and procedures, provider network composition, Evidence of Coverage (EOCs), Memorandum of Understanding (MOUs) with public and other health care agencies, Medical Exemption Requests (MERs), and Expedited Disenrollment Requests (EDRs). The MMU also conducts medical audits of Medi-Cal managed care plans in conjunction with the CDHS Audits and Investigations (A & I) Division and the Department of Managed Health Care (DMHC).
The Member Rights/Program Integrity Section
Member Rights/Program Integrity Unit
The Member Rights/Program Integrity Unit (MR/PIU) is responsible for monitoring managed care health plans for contract compliance with member rights requirements and all applicable State and federal statutes and regulations related to member rights. Member Rights staff review areas including, but not limited to, member grievances, prior authorization request notifications, marketing and enrollment programs, and cultural and linguistics services. Additionally, MR/PIU coordinates and addresses fraud and abuse issues within the Medi-Cal managed care program and contracted health plans. Unit staff research complaints related to fraud and abuse by members and providers and forward them to Audits and Investigation (A&I) for further case investigation. The MR/PIU also provides technical assistance and training on fraud prevention to health plans and facilitates sharing of information and best practices.
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Program Data and Fiscal Monitoring Section
Performance Measurement Unit
The Performance Measurement Unit (PMU) administers the External Quality Review Organization (EQRO) contract and monitors the quality and timeliness of health plan encounter data. PMU ensures that Health Employer Data and Information Set (HEDIS) performance measures and the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) results are audited and validated through the EQRO contractor and are made publicly available in summary reports on the MMCD webpage. PMU also approves and monitors health plans’ quality improvement projects. PMU staff also conduct statistical and analytical research related to the quality of care provided to members of Medi-Cal managed care plans.
Policy and Financial Management Branch
Policy and Financial Management Branch (PFMB) is responsible for financial policy, health plan rate development, processing of notices of dispute and litigation, and federal waivers related to managed care health plan contracts. PFMB is also responsible for the development and analysis of program policies, regulations, legislation and procedures relevant to the managed care program. PFMB develops clinical policy to clarify contractual responsibilities for Medi-Cal managed care plans, and to develop statewide Medi-Cal managed care quality improvement programs.
PFMB is composed of the following three Sections and the Office of the Ombudsman:
Financial Management Section
The Financial Management Section is composed of the Capitation Rate Unit (CRU), the Financial Analysis Unit (FAU), the Notice of Disputes Unit (NOD) and the Fiscal Monitoring Unit (FMU).
Capitation Rate Unit
The Capitation Rate Unit (CRU) is responsible for developing health plan capitation rates for the MMCD, the Fiscal Intermediary & Contracts Oversight Division (FICOD), the Medi-Cal Dental Services Branch (MDSB), the Senior Care Action Network (SCAN), and the Program of All-inclusive Care for the Elderly (PACE). CRU also determines, by using actuarial methods, the prospective per capita rates of payment for services provided under Welfare and Institutions Code section 14301 for Medi-Cal beneficiaries enrolled in Managed Care Organizations (MCOs).
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Financial Analysis Unit
The Financial Analysis Unit (FAU) monitors fiscal policy standards affecting the Division’s financial oversight of the Medi-Cal Managed Care Program. FAU works with contract management staff to ensure the correct application and payment of capitation rates. The FAU, in coordination with the DHCS Fiscal Forecasting Division, acts as the liaison regarding financial issues between outside entities including the Department of Finance (DOF), the Legislative Analyst's Office (LAO), and the Centers for Medicare and Medicaid Services (CMS). FAU staff prepare cost effectiveness analyses for the federal waivers of managed care programs, develops managed care capitation payments and other managed care payments, as well as reviews and analyzes statutes, regulations, and contracts affecting payment for managed care services.
Notice of Disputes and Appeals
Staff from the Financial Management Section also assist the Office of Legal Services (OLS) as expert witnesses in court hearings and Notice of Dispute (NOD) settlements between health plans and the Department. Other responsibilities include tracking and managing the NOD process, preparing responses to health plan disputes, and processing and facilitating the Division's participation in appeals and court hearings.
Fiscal Monitoring Unit
The Fiscal Monitoring Unit (FMU) performs health plan financial monitoring to assure appropriate fiscal management of more than $6 billion in annual Medi-Cal managed care payments. The FMU conducts ongoing reviews (desk and field audits) of health plan financial reports and conducts ongoing financial management efforts to determine health plan financial viability. Unit staff also communicates with the Department of Managed Health Care (DMHC) on various financial issues affecting contracted health plans licensed by DMHC.
Policy and Contracts Section
Policy Unit
The Policy Unit reviews and analyzes legislation that could potentially affect the Medi-Cal managed care program. The unit is also responsible for developing legislatively mandated reports and renewing, modifying, amending and maintaining the four federal Medicaid waivers under which the program currently operates. The Policy Unit develops amendments to the State Medicaid Plan, researches and develops program Policy and All Plan Letters, and develops any resulting contract or regulatory language required for the managed care program. Adjunct responsibilities also include the interpretation or clarification of federal or state statutes, regulations, or other policy-making instruments.
Contract Processing Unit
The Contract Processing Unit (CPU) processes all new or amended Medi-Cal managed care contracts, including those covered by the Long-Term Care Division (LTCD). The CPU coordinates and processes contract information and documents for the Division’s Plan Management Branch, LTCD, and the California Medical Assistance Commission (CMAC).
Medical Policy Section
The Medical Policy Section works collaboratively with contracted managed care health plans to establish project priorities that will improve the quality of care provided to beneficiaries. Quality improvement projects include statewide collaboratives that combine the expertise of DHCS, health plan staff and outside experts to address issues that affect all health plans; small group collaboratives in which plans work together to address a health issue of mutual interest; and individual plan quality improvement projects, designed by a single health plan to address an area of specific interest to that plan and its beneficiaries. Section staff provide technical assistance and training to health plan staff and providers about areas of clinical interest related to various projects and meet with the health plan medical directors every other month to ensure that DHCS addresses issues of concern to the plans and their members. Section staff review reports submitted by the health plans that examine their performance along a number of indicators, primarily nationally recognized indicators from the National Committee on Quality Assurance (NCQA).
Office of the Ombudsman
The Office of the Ombudsman (OMB) serves as a resource for Medi-Cal managed care health plan members and helps solve problems from a neutral standpoint to ensure that our members received all medically necessary covered services for which plans are contractually responsible. The Office of the Ombudsman is also responsible for coordinating and processing state hearing requests related to Medi-Cal managed care issues. The Office of the Ombudsman can be contacted via a toll-free line at 1-888-452-8609 or by email at MMCDOmbudsmanOffice@dhcs.ca.gov.
Administrative Support Unit
The Administrative Support Unit (ASU) provides Division and Branch level support in the areas of telecommunications, non-managed care plan contracts, budget information, public record act requests, purchasing, space management , personnel services, general administration, and health and safety. The ASU is also the lead in outside audits of MMCD systems and coordinates related responses for MMCD. In addition, the ASU is responsible for overseeing the MMCD CalATERS mailbox and provides assistance to MMCD employees processing expense claims through CalATERS.
Systems Support Unit
The System Support Unit (SSU) acts as liaison between the Information Technology Services Division (ITSD) and Electronic Data Systems (EDS) through the Fiscal Intermediary & Contracts Oversight Division (FICOD). The SSU updates the statewide database for changes in the managed care program such as the addition or deletion of contracted health plans and aid codes; updates the Fee-For-Service claims payment system to incorporate the changes in managed care contracts in order to prevent duplicate payments; arranges for provider bulletins and letters to be sent to the provider community on behalf of the division; updates the provider manuals as changes occur in the managed care program; and is the initial contact for trouble shooting plan or provider system problems. Additionally, SSU is responsible for maintaining the MMCD website and for the development of information technology related written products.
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