Session 5 | August 29, 2024
10:00 a.m. – 12:00 p.m., Pacific Time
An LHPC members-only virtual learning series

Overview

CalAIM — DHCS’ multi-year, transformational reform of the Medi-Cal program — requires all Medi-Cal managed care plans to operate an Exclusively Aligned Enrollment (EAE) Dual-Eligible Special Needs Plan (D-SNP) by January 2026 with the goals of improving outcomes and streamlining care for the more than 1.7 million Californians who are dually eligible for Medi-Cal and Medicare. Given the complexity and timeline of standing up and operating Medicare D-SNPs, and because they are subject to different federal and state rules and regulations, local plans must begin planning and preparing now to ensure strategic and operational readiness for go-live.

Join us for this multi-part virtual learning series where you will learn from local plan leaders who have already implemented an EAE D-SNP, get updates on federal and state requirements, and hear insights from subject matter experts on what it takes to successfully stand up and operate a Medicare D-SNP. Developed with support from the California Health Care Foundation and The SCAN Foundation, the learning series will increase your knowledge and understanding of D-SNP compliance requirements, Medicare financing and risk adjustment, provider network considerations, Part D/pharmacy, marketing and communications and more.

The learning series will run through December 2025; stayed tuned for updates on upcoming sessions.

Session 5 Agenda

Past Session Agendas

Session 1: Medicare Compliance
March 21, 2024 | 1:00 – 3:00 p.m.
Athena Chapman, President, Chapman Consulting LLC
Julie Mason, President, Integritas Medicare

• Medicare Advantage (MA) compliance requirements — seven required elements
• Centers for Medicare and Medicaid Services (CMS) perspectives on and expectations for MA compliance
• Roles of the plan compliance department and other operational areas
• Fraud, waste and abuse (FWA) — what CMS requires
• Differences between Medicaid and Medicare compliance requirements/expectations
• California-specific requirements and additional oversight

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Session 2: Medicare Financing
April 25, 2024 | 10:00 a.m. – 12:00 p.m.
Chris Esguerra, MD, Chief Medical Officer, Health Plan of San Mateo
Yvonne Tso, PharmD, MBA, Sr. Vice President, Integritas Medicare

• Understanding capitation payment methodology
• Ensuring payments sufficiently cover medical expenses
• Plan premiums and how rebates must be used (Part C and D)
• Coding intensity increases and impacts
• How quality bonus payments are realized
• Annual revenue reconciliation for Part D
• Annual Advance Notice

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Session 3: Provider Network & Reimbursement Considerations
May 30, 2024 | 1:00 – 3:00 p.m.
Mike Opich, Sr. Vice President & Network Development Consultant, Integritas Medicare
Kirk Fermin, Director, Provider Network, Inland Empire Health Plan
Dan Gomez, Vice President, Provider Experience, Inland Empire Health Plan
Rafael Gomez, Principal, El Cambio Consulting
Coline Ingalla Manager, Provider Network, Inland Empire Health Plan
Tracee Roque, Director, Provider Contracting, Inland Empire Health Plan
Danny Vargas, Director, Provider Contracting, Inland Empire Health Plan
*Additional speakers to be announced

• D-SNP network adequacy requirements — provider types and specialties, time and distance standards, county classifications
• Contract types and language requirements
• Centers for Medicare & Medicaid Services evaluation timeline and process for network development
• Network development strategy and provider reimbursement considerations
• Strategies for building a D-SNP network based on an existing Medi-Cal plan network

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Session 4: Medicare Part D/Pharmacy
June 25, 2024 | 1:00 – 3:00 p.m.
Yvonne Tso, PharmD, MBA, Sr. Vice President, Integritas Medicare
Ria Paul MD, Chief Medical Officer, Santa Clara Family Health Plan
Anna Yang, Director, Pharmacy, Santa Clara Family Health Plan

• Medicare Part D — what’s required of health plans
• How Part D works within the managed care construct
  • Covered benefits/services and what’s carved out
  • Beneficiaries enrolled in managed care plans vs Original Medicare (fee-for-service)
  • Delivery of Part D benefits
  • Transition requirements
  • Part D and STAR measures
• Formulary administration and pharmacy benefit manager (PBM) oversight
• Important changes impacting Medicare Part D — Inflation Reduction Act 2022, other regulatory priorities

Learning Series Faculty

Athena Chapman
President
Chapman Consulting LLC

Chris Esguerra, MBA, FAPA, CHCQM
Chief Medical Officer
Health Plan of San Mateo

Kirk Fermin
Director, Provider Network
Inland Empire Health Plan

Dan Gomez
Vice President, Provider Experience
Inland Empire Health Plan

Rafael Gomez
Principal
El Cambio Consulting

Coline Ingalla
Manager, Provider Network
Inland Empire Health Plan

Julie Mason
Founder and President
Integritas Medicare

Mike Opich
Sr. Vice President & Network Development Consultant
Integritas Medicare

Ria Paul, MD
Chief Medical Officer
Santa Clara Family Health Plan

Tracee Roque
Director, Provider Contracting
Inland Empire Health Plan

Yvonne Tso, PharmD, MBA,
Sr. Vice President
Integritas Medicare

Danny Vargas
Director, Provider Contracting
Inland Empire Health Plan

Anna Yang
Director, Pharmacy
Santa Clara Family Health Plan

*Additional speakers to be announced

Registration

This is an LHPC members-only learning series.

This learning series is developed with support from the California Health Care Foundation and The SCAN Foundation. Participation in the series is complimentary; however, registration is required.

The series will accommodate up to 300 participants per session. Registration will close after the deadline or once the seat limit has been reached.

Registration closes August 22 at 5:00 p.m.

Participating in the Webinar: You will only need a computer with an updated web browser (Google Chrome, Microsoft Edge, Mozilla Firefox or Safari are recommended). Participants may opt to listen to the webinar via telephone or device.