COUNTY OF SAN MATEO

Inter-Departmental Correspondence

Health System

 

DATE:

March 21, 2011

BOARD MEETING DATE:

April 26, 2011

SPECIAL NOTICE/HEARING:

None

VOTE REQUIRED:

Majority

 

TO:

Honorable Board of Supervisors

FROM:

Jean S. Fraser, Chief, Health System

SUBJECT:

Fifth Amendment to the Agreement with the Health Plan of San Mateo for Administration of the Consolidated Access and Care for Everyone Program

 

RECOMMENDATION:

Adopt a Resolution authorizing the President of the Board to execute the Fifth Amendment to the Agreement with the Health Plan of San Mateo for administration of the Consolidated Access and Care for Everyone Program, increasing the number of participants for the third party administrative services and changing the not-to-exceed amount by $84,852 to a maximum of $8,454,852, with no change in the term of January 1, 2009 to December 31, 2011, or maximum contract obligation.

 

BACKGROUND:

On November 6, 2007, your Board approved an Agreement with the Health Plan of San Mateo (HPSM) for administration of the Consolidated Access and Care for Everyone (ACE) Program, a pilot project funded by the California Department of Health Care Services that has allowed expanded adult coverage. On March 25, 2008, your Board approved the first-year implementation plan for the Health System Redesign Initiative, which included a focus on streamlined administration of public healthcare coverage programs. On May 20, 2008, your Board accepted the Blue Ribbon Task Force on Adult Health Care Coverage Expansion Final Planning Phase Recommendations. These recommendations called for the HPSM to serve as the single third-party administrator (TPA) to provide unified administration of the adult coverage programs in San Mateo County and stronger alignment with the HPSM’s Medi-Cal and Medicare programs. This alignment allowed for greater access to care, improved utilization management, and more effective partnerships with participants in the provider network.

On December 9, 2008, your Board executed an Agreement with the HPSM to incorporate the Wellness, Education, and Linkage Low Cost (WELL) Program into the existing ACE TPA service functions. The Agreement also called for the HPSM to serve as the conduit for funding directed to the provision of care to the medically indigent. The HPSM manages provider services, contracting/network management, claims processing/data management, outpatient pharmacy benefit, utilization/medical management, collection of participant fees, customer service, grievances/appeals, quality assessment/ improvement, participant information materials and reporting.

From April 2009 through August 2010, the Agreement was amended four times to allow payments to Ravenswood and the Half Moon Bay pharmacies, adjust the rate for cardiac services at Seton Hospital, allow the Chief of the Health System to make subsequent changes not exceeding $25,000, and minor administrative changes in data exchange procedures as well as the payment schedule due to the increase in the number of participants.

 

DISCUSSION:

Enrollment in the County ACE program has increased 69% since January 2009. The HPSM charges fees based on a per participant count group in five tiers. The current contract allows for 19,375 participants. This amendment will increase that amount to 30,000.

 

The Amendment and Resolution have been reviewed and approved by County Counsel.

 

The contractor has assured compliance with the County's Contractor Employee Jury Service Ordinance, as well as all other contract provisions that are required by County ordinance and administrative memoranda, including but not limited to insurance, hold harmless, non-discrimination, and equal benefits.

 

Approval of the Amendment contributes to the Shared Vision 2025 commitment of a Healthy Community by providing unified administration of adult coverage programs which will allow for greater access to care, improve utilization management and more effective partnerships with participants in the provider network. It is anticipated that with continued flattened economy, the number of participants will increase in the program.

 

Performance Measure(s):

Measure

FY 2009-10
Actual

FY 2010-11
Projected

Number of participants

23,454

25,698

 

FISCAL IMPACT:

Under the new payment schedule, the Health System’s total fiscal obligation for TPA services shall not exceed $8,454,852, an increase of $84,852 over the current schedule. Costs anticipated for the indigent medical services continue slightly under, budget allowing the maximum contract obligation of $179,370,000 to remain the same. Expenses have been included in the San Mateo Medical Center and Contributions FY 2010-11 Adopted Budgets and will be included in future budget requests with no increase in Net County Cost. There is no change in the contract term.