The ______ regulates all the Health Plans serving Medi-Cal at the Federal Level.
Center of Medicare and Medicaid Services (CMS)
Name the three systems a beneficiary may receive medical services under Medi-Cal
Medi-Cal Fee For Service, Medi-Cal SOC, Medi-Cal Managed Care
Who regulates the health plans servicing Medi-Cal at the State level.
DHCS- Dept of Health Care Services
Which model in the Medi-Care Managed Care system is offered in Los Angles County?
a. County organized health systems
b Geographic manged care
c. Two-plan model
d. Full scope Medi-Cal
C. Two-Plan Model
When did LA Care go live in the Medi-Cal Managed program?
April 1997
Name LA Care Health Plan Partners.
Anthem Blue Cross, Care 1st, Kaiser, LA Care Health Plan
Who does L.A care Heath Plan serve?
The vulnerable, low income population of LA County
MCLA is a/ an ____ Providing health care services to its members through contracted medical group, hospital, pharmacies and ancillary facilities.
D. HMO /PLAN
Members are assigned to a ____ who manages and coordinates all of their health care needs.
PCP
What is the difference between Clinic and IPA?
~A Clinic has PCP, specialist, ancillary services all in the same building and the doctors are employee of the clinic.
~ An IPA the doctors own their own practices and is contracted with the medical association
What does S/R mean? Explain what it is.
Shared Risk- is when the health plan delegates to the Medical group to be responsible for all the professional services and fee while the plan is responsible for all the facility services.
What two aid code categories qualify for the Med-Cal Managed Care program?
Mandatory and Voluntary
What is PPG? Explain what it is
Participating Physicians Group- They are all the medical groups contracted under LA Care directly or indirectly
If the member asks you "what is the difference between LA Care and Health Net" What would you say?
They both have the same services. Only the doctors, hospital, and pharmacy be different. Health net has 2 plan partners: Molina , Health net and LA Care has 4 plan partners: BCSC, CFST, KAIS, MCLA
Who are our Medi-Cal Members? Name the groups who make up our membership?
1.Pregnant women
2.Parents with minor children
3.0-21 yrs
4.65 and older
5.blind, aged and disabled
6.Foster Care
7.Cal Works and SSI
8.250% of FPL
9.US citizens, Documented immagrants
10. Lives in LA county
Explain the process for member to see the specialist?
the PCP must submit a referral to the medical group for authorization to see the specialist who is contracted with the members medical group.
When a Medi-Cal member is enrolled into the Managed Care program they are assigned to:
B. Health plan, medical group, PCP
Name the 5 Primary doctors specialties with code and age range:
