Island Park Idaho – used with permission

Idaho Department of Health & Welfare

Overview

Denise ChuckovichDeputy Director

February 17, 2016

Primary Care Access Program (PCAP)

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

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

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

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

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

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

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

Questions?

Denise ChuckovichDeputy Director

Idaho Department of Health and Welfare208 334-5000

chuckovd@dhw.idaho.gov