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Island Park Idaho – used with permission
Idaho Department of Health & Welfare
Overview
Denise ChuckovichDeputy Director
February 17, 2016
Primary Care Access Program (PCAP)
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Primary Care Access Program Overview• Program purpose
• Population to be served
• Program scope of services
• Provider responsibilities
• PCAP Status and next steps
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PCAP Purpose• To provide access to primary care
and care coordination for those Idahoans who do not have access to insurance coverage
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4Target Population: People in the Gap
Percent of Federal Poverty Level
Parentsw/children
26%
Adults
100% 400%
No Coverage Advanced Premium Tax Credit
Med
icai
d
Est. 78,000 Adults
Eligibility Limit: Income under $350/month for household of 2
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5Gap Population: Where do They Live?
• Live in every county• 1.6% to 7.3% of
county population• Higher in southwest &
eastern Idaho
Percent of Federal Poverty Level
Parentsw/children
26%
Adults
100%
No Coverage
Med
icai
d
Est. 78,000 Adults
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6Gap Population: Current Health Demographics
• Uninsured, low-income adults are excluded in medical systemo Poor uninsured create bad debt, driving up costs for everyoneo Private providers reluctant to serve
• Gap folks access care through: o Hospital emergency departments o Community Health Centerso Rural Health Clinicso Charity careo Indigent healthcare programso Catastrophic healthcare programs
• Gap adults access episodic care, frequently waiting until conditions escalate; resulting in the most expensive and least effective care
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PCAP Participant Eligibility• Adult 19-64 years old• Income below 100% and no other
insurance coverage• US citizen• Must pay sliding fee to provider
based on income
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PCAP Provider Requirements• Licensed primary care provider• Experience serving low income, uninsured
population• Willing to provide sliding scale fee for services • Demonstrated evidence of progress towards PCMH
recognition or commitment to begin process• Access to discounted pharmaceuticals to pass along
lower pricing to PCAP participants• Provide in-office behavioral health care and referral
as appropriate.
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PCAP Scope of Services• Initial health assessment and
development of care plan• Provide access to preventive and
primary care through medical home model with care management
• Access to discount pharmacy and behavioral health services
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10Patient Centered Medical Home Services
The primary care provider is responsible for a patient’s basic preventive, physical and mental health needs
Patient-Centered Medical Home
Participant
Preventive Care: Physicals, screenings, tobacco cessation
Acute care for injuries, illnesses
Connects to othercommunity services
Basic medications, labs, X-rays
Coordinates care forchronic conditions
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PCAP provides access to prescriptions, often at deeply discounted pricing• Community health centers either have an on-site pharmacy or contract with a
local pharmacy to provide medications • The community health centers presently have access to comprehensive out-
patient formulary at very low costs • Examples:
Medical Home Services--Pharmacy
Diabetes medication: Average wholesale price is $484; PCAP participant pays $17.16
Asthma inhaler: AWP is $85.39; PCAP participant pays $17.08
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Office-based Behavioral Health• PCAP providers will care for
individuals with behavioral health issues that can be managed in a primary care setting
Medical Home Services—Behavioral Health
• All participating PCAP providers will be expected to provide behavioral health services on-site or to refer out to other community resources
• Individuals with more serious behavioral health issues may be referred to the local DHW Behavioral Health Office for care
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13Medical Home Services--Ongoing Case Management
• Amount of ongoing care management depends on participant’s health status and care plan• Individuals in good health may not need regular monitoring, but will require periodic
check-in to insure health status has not changed• Participants with one or more chronic conditions may need to:
Report regularly to clinic regarding health indicators such as weight, blood sugar levels, blood pressure readings
Participate in group visits/classes with other individuals with similar conditions, such as health education class for diabetics
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RHC ConsiderationsRHCs located in rural and frontier areas of state will be key to access for PCAP.
Adequate volume of PCAP participants?
Meet provider requirements?
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15PCAP is NOT an Entitlement Program
• Enrollment is subject to available funding: if funding does not support demand/costs, a waiting list will be created and used
• Participants must pay share of costs and be invested in their care plan, or they will be disenrolled
• Eligibility criteria can be adjusted to improve program performance or administrative efficiency
• Annual utilization and clinical quality reports allows legislators and stakeholders to regularly review program results and monitor effectiveness
• 5-year automatic sunset clause if performance outcomes are not achieved or state wants to change program
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16PCAP: Next Steps
• Programming PCAP Rules and Verification in IBES begins after SNAP multi-day issuance launches on July 1, 2016
• Modifying business processes and hiring and training new staff starting on July 1, 2016 to support startup efforts between July and December 2016
• Coordinating PCAP eligibility with current insurance exchange open enrollment, which begins October 2016, for administrative efficiencies and reduced state costs
• Allowing CHCs and other providers to evaluate demand so they can expand staff and administrative capacity/training to provide for projected enrollees
If Approved
start dateJan. 1, 2017
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Questions?
Denise ChuckovichDeputy Director
Idaho Department of Health and Welfare208 334-5000