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, expansion into new counties, and the Medi-Cal Managed Care Office of the Ombudsman.
Plan Management Branch is composed of the following sections and office:
Two-Plan and GMC Section
COHS and SPD/Waiver Section
Office of the Ombudsman
Two-Plan and GMC Section
The Two-Plan and Geographic Managed Care (GMC) Section is responsible for the operational oversight of the Medi-Cal managed care health plans in sixteen counties. The managed care health plans include commercial and Local Initiative health plans that are managed by the Commercial Plan and Local Initiative Units. Over 3.4 million Medi-Cal beneficiaries receive their health care under the Two-Plan and GMC models. 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, Kings, Los Angeles, Madera, Riverside, San Bernardino, San Francisco, San Joaquin, Santa Clara, Stanislaus and Tulare. Most Two-Plan Model counties have a Local Initiative plan and a commercial health plan. The commercial plan contract is awarded via a competitive bid process. The exceptions are Stanislaus and Tulare, which designated Anthem Blue Cross as their Local Initiative.
GMC counties include Sacramento and San Diego. There are multiple commercial health plans in both GMC counties. The Commercial Plan Unit also manages the Healthy San Diego administrative contract.
Back to Top
COHS and SPD/Waiver section
The County Organized Health System (COHS) and SPD/Waiver Section has contract management and oversight responsibilities for six COHS contracts, one Primary Care Case Management (PCCM) contract, one Targeted Case Management (TCM) Behavioral Health contract and one Pre-Paid Health Plan. Nearly one million beneficiaries are enrolled in COHS counties.
County Organized Health System (COHS) Unit
The County Organized Health System (COHS) Unit manages and provides monitoring and oversight of six COHS contracts operating in fourteen counties, one Primary Care Case Management (PCCM) contract with the AIDS Health Foundation in Los Angeles, and one Targeted Case Management (TCM) Behavioral Health contract with the Family Mosaic Project in San Francisco. COHS contracts include: Partnership HealthPlan of California (Marin, Mendocino, Napa, Solano, Sonoma, and Yolo), Central California Alliance for Health (Merced, Monterey, and Santa Cruz), Santa Barbara San Luis Obispo Regional Health Authority (Santa Barbara and San Luis Obispo), Health Plan of San Mateo, CalOptima (Orange) and Gold Coast (Ventura). 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.
Senior and Persons with Disabilities (SPD)/Waiver Unit
The Seniors and Persons with Disabilities (SPD)/Waiver Unit is responsible for development and implementation of procedures to begin and monitor mandatory enrollment for SPD beneficiaries across all Two-Plan and Geographic Managed Care health plans. The SPD/Waiver Unit is comprehensively involved in processes related to: member enrollment, plan readiness, network adequacy assessments, access/facility site review tools, the 1115 Medicaid Waiver, contract language, outreach and education, beneficiary informing materials, risk assessment, and default enrollment protocols. Implementation of mandatory SPD enrollment is slated for June 1, 2011.
Back to Top
Office of the Ombudsman
The Medi-Cal Managed Care Office of the Ombudsman helps solve problems from a neutral standpoint to ensure that our members receive all medically necessary covered services for which plans are contractually responsible.
The Ombudsman will not automatically take sides in a complaint. We consider all sides in an impartial and objective way. It is our job to help develop fair solutions to health care access problems.
Back to Top