San Francisco Medical Society Blog

10,000 Health Care Providers to Rally to Stop Medi-Cal Cuts at State Capitol

Mon, 13 May 2013 16:21:30 GMT

SFMS and CMA have joined an unprecedented coalition of physicians, dentists, health care workers and hospitals working to stop the 10% Medi-Cal reimbursement rate cut.

The We Care for California coalition was borne of an effort to build a strong coalition of diverse organizations fighting to ensure that California’s health care system doesn’t continue to get short changed. So often in the past, health care advocates have become divided in their efforts, so focused on individual organizational interests, that the collective strength is weakened. We Care for California intends to stand undivided in using the coalition’s collective influence in defense of health care.

The coalition’s first major effort is to ensure that two CMA-sponsored bills—SB 640 (Lara) and AB 900 (Alejo)—are passed by the Legislature and signed by Governor Brown. Both bills, sponsored by CMA, would stop the 10 percent Medi-Cal rate cut.

Join “We Care for California” in Sacramento on Tuesday, June 4 from 11 am to 4 pm

to call on State Legislators and the Governor to stop the $1 billion reduction in provider rates in the Medi-Cal program. SFMS/CMA physicians will stand with nurses, dentists, and other health care providers as well as patient and consumer groups to advocate for the support of SB 640 and AB 900.

This will be the largest health care gathering ever at the state Capitol, and will send a powerful message that we expect our elected leaders to stand up for quality care in California.

The goal is to bring 10,000 health care providers together from across the state participate.

Buses will be available to transport anyone who wants to participate from hospitals around the state to the Capitol building in Sacramento at no charge to the participant. If you are interested in attending the event, please register at www.wecareforca.org to reserve a seat on the bus nearest you.

Click here for detailed event and RSVP information.

SFMS/CMA-Sponsored SB 640 Bill to Stop Implementation of Medi-Cal Cuts Introduced Today

Thu, 04 Apr 2013 15:13:07 GMT

Senator Ricardo Lara (D – Long Beach) introduced Senate Bill 640 today, which will stop the implementation of a 10% rate cut to Medi-Cal. The cut was part of the health services trailer bill (AB 97) to the 2011-12 state budget. SB 640 is co-sponsored by the SFMS and CMA.

“California has one of the lowest reimbursement rates for Medicaid in the nation,” said CMA President Paul Phinney, MD. “At a time when millions of new patients will be entering the program under health reform, the state should not be looking to rate cuts as a budget solution.”

SB 640 would block the 10% Medi-Cal provider rate cut and would stop the state from ‘clawing back’ rate cuts from providers dating back to 2011.

SFMS and CMA applaud Senator Lara for his commitment to ensure accessible health care for all. Cutting resources while adding patients to the Medi-Cal managed care system will make it hard for patients to find doctors and will delay much needed federal health reform in California. The cuts in trailer bill AB 97 were proposed when California was facing an enormous budget deficit. Those times have changed and there is no need to punish California’s poor and vulnerable patients any longer.

"This measure protects our most vulnerable communities from the devastating impacts of the cuts to Medi-Cal," stated Senator Lara. "I am proud to partner with CMA and the broad coalition of advocates to ensure that all of our communities have access to health care."

Following approval of the AB 97, CMA along with the California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Suppliers, Aids Healthcare Foundation and American Medical Response, filed suit against both the California Department of Health Care Services and the U.S. Department of Health and Human Services seeking to stop implementation of the cuts. That case is currently being considered by the 9^th Circuit Court of Appeals.

Click here for more information about the CMA lawsuit to stop the Medi-Cal cuts.

CMS Approves Medicare/Medi-Cal Duals Project

Thu, 28 Mar 2013 17:28:13 GMT

The Department of Health Care Services (DHCS) announced that the federal Centers for Medicare and Medicaid Services (CMS) has given approval to the project to require Medicare/Medi-Cal dual eligibles to enroll in a managed care plan. The project, which was previously known as the “Coordinated Care Initiative,” will now be called CalMediConnect.

Size and Scope of the Project

The project will begin no sooner than October 1, 2013 and will impact approximately 450,000 duals in eight counties—Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara. As a result of intensive SFMS/CMA advocacy, enrollment in Los Angeles County will be capped at 200,000 people.

Duals should receive their first notices about the transition in July 2013, with enrollments set to begin in October. How quickly enrollment happens will vary by county, from three months in San Mateo to 15 months in Los Angeles. In all other counties, the time frame will be 12 months.

Although patients will be passively enrolled, they will be able to opt out for their Medicare benefits at any time. There will be no lock-in period.

Continuity of Care Provisions

Under the terms of the MOU, duals who do enroll in managed care for their Medi-Cal and Medicare benefits will be able to continue seeing an existing Medicare provider for up to six months, even if that physician is not contracted with the health plan. Payment for the services will be at Medicare rates.

Also, in urgent or emergent situations, plans will be required to pay out-of-network providers at Medicare rates. This is a provision that SFMS/CMA fought for in the bill to protect physicians, especially those in emergency rooms.

Network Adequacy

SFMS/CMA is pleased that the plan includes extensive network adequacy and financial solvency requirements for the participating plans. This, again, was something we have fought for in the legislative process.

Next Steps

Now that DHCS and CMS have finalized their MOU, they will be jointly negotiating with health plans on a three-way contract. As noted above, duals should be receiving notifications about the change in July.

Feds Allows States to Cut Medicaid Pay, Files Brief in CMA Court Battle

Fri, 08 Mar 2013 12:59:51 GMT

The U.S. Department of Justice filed a brief last Friday before the Ninth Circuit Court of Appeals arguing states can cut Medicaid (Medi-Cal in California) providers’ reimbursement as long as it does not harm access to care.

Earlier this year, SFMS/CMA have requested an en banc review from the Ninth Circuit as part of an effort to stop the State of California from implementing a 10% cut to Medi-Cal provider reimbursement rates.

In December 2012, a three judge panel of the Ninth Circuit ruled that the state could move forward with the rate cuts, passed by the Legislature in the spring of 2011, despite an earlier district court ruling that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care. CMA and the other plaintiffs in the case are requesting a rehearing from the full Ninth Circuit Court of Appeals.

The justice department's brief urged the court to uphold the cuts and insisted that the Centers for Medicare and Medicaid Services (CMS) is not required to disapprove the plan amendments because they were motivated by “budgetary reasons.”

"It is entirely appropriate for a state to review its Medicaid plan to determine whether it can continue to satisfy its statutory obligations at lower payment rates," the justice department wrote in the brief.

CMA and the other plaintiffs in the case—California Dental Association, California Pharmacists Association , National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation and American Medical Response—argue that reducing payments in the Medi-Cal system will force providers out of the program at a time when millions of new patients will be diverted into the Medi-Cal system.

If the state moves forward with these cuts, access to care will be devastated, not only for the existing Medi-Cal patients, but also the 900,000 kids moving from the Healthy Families program into Medi-Cal in 2013 and the millions of patients that will be newly eligible for Medi-Cal under the Affordable Care Act in 2014.

CMA Files Request for En Banc Review to Stop Medi-Cal Cuts

Mon, 28 Jan 2013 13:53:11 GMT

This morning, the California Medical Association (CMA) filed a request for an en banc review by the Ninth Circuit Court of Appeals to stop the State of California from implementing a 10% cut to Medi-Cal provider reimbursement rates. Last month , a three judge panel of the Ninth Circuit ruled that the state could move forward with the rate cuts, passed by the Legislature in the spring of 2011, despite an earlier district court ruling that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care. CMA and the other plaintiffs in the case are now requesting a rehearing from the full Ninth Circuit Court of Appeals.

Following the reversal, Governor Jerry Brown issued his 2013-2014 budget proposal, which includes a 10% Medi-Cal reimbursement cut, retroactive to January 1, 2013.

CMA and the other plaintiffs in CMA et al. v. Douglas et al. – California Hospital Association, California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation and American Medical Response – argue that reducing payments in the Medi-Cal system will force providers out of the program at a time when millions of new patients will be diverted into the Medi-Cal system.

“Cutting payment to Medi-Cal providers by 10 percent will have a huge impact on patient access to care,” said Paul R. Phinney, MD, CMA president. “The state is in much better fiscal shape now than when these cuts were initially proposed in 2011 and with millions of new Medi-Cal patients entering the program under the Affordable Care Act, we simply cannot continue to cut resources and expect successful implementation of health reform in California.”

The lawsuit to prevent the cuts was originally filed by CMA in November 2011.

Brown Highlights Budget, Health Care in State of the State Address

Fri, 25 Jan 2013 11:06:42 GMT

Governor Jerry Brown promoted his fiscal year 2013-2014 budget proposal and discussed several state health care initiatives in In his State of the State address yesterday.

Budget Comments

Earlier this month, Brown released his budget plan. He said that if implemented, the proposal would leave the state with a budget surplus of $851 million. The plan projects $98.5 billion in revenue and transfers, and it estimates $97.7 billion in spending.

Brown's plan includes an expansion of Medi-Cal to individuals with incomes up to 138% of the federal poverty level. The expansion—included in the Affordable Care Act—is expected to add up to 1.5 million newly eligible adults to the program.

The budget plan also includes a 4.9% funding increase for In-Home Supportive Services—with an assumption that the state will implement a 20% reduction in IHSS service hours in November—and a $142 million funding increase for Cal-WORKs, the state's welfare-to-work program

In addition, the budget proposal allocates $1.6 billion for a court-appointed federal overseer to manage continued improvements in the state's prison health care system.

Health Care Comments

Discussing the Medi-Cal expansion, Brown called the initiative "incredibly complex" and said it will "test our ingenuity" and "will not be achieved overnight." He said, "Given the costs involved, great prudence should guide every step of the way."

Brown also said that the state must develop "the right relationship with the counties" to successfully implement the expansion.

Brown also called for a special session of the Legislature beginning next week that will focus on implementing ACA provisions.

Source: California Healthline, January 25, 2013.

Transition from Healthy Families to Medi-Cal Has Begun

Mon, 14 Jan 2013 12:39:06 GMT

The Department of Health Care Services (DHCS) received federal approval to begin transitioning approximately 860,000 low income children from the Healthy Families program into Medi-Cal Managed Care. Phase 1A of the transition (see schedule below) began on January 1, 2013.

The transition, proposed by Governor Brown and passed by the Legislature last summer as part of a larger plan to close the budget deficit, is expected to save about $64 million this year. SFMS/CMA has opposed the plan since it was first proposed and believes the move will likely have a negative impact on those who rely on the Healthy Families program for health care coverage.

SFMS/CMA continues to attend stakeholder meetings and will work closely with DHCS during the transition.

The Healthy Families program transition is scheduled for a four-phase roll out. The first two phases will affect children who are covered by health plans that participate in both the Healthy Families and Medi-Cal managed care programs in their counties of residence. These children will continue to be covered by their current plans. Children in all four phases will receive advance notice of their transition to the Medi-Cal managed care program. Children in phase 1 will receive a 60-day notice and children in phases 2-4 will receive a 90-day notice in advance of the effective date that will include more details about the transition, covered benefits under Medi-Cal and their health plan options, as well as information on who to contact for assistance.

Phase 1

More than 403,000 children will be transitioned in the first phase. This phase is divided into three parts. Part A began on January 1, 2013, and affects Alameda, Orange, Riverside, San Bernardino, San Diego, San Francisco, San Mateo and Santa Clara counties. Part B will impact Contra Costa, Fresno, Kern, Kings, Los Angeles, Madera, Monterey, Napa, Sacramento, San Diego (Health Net), San Luis Obispo, Santa Barbara, Santa Cruz, Solano, Sonoma, Tulare and Yolo counties and will begin on or after March 1, 2013. Part C will begin on or after April 1, 2013, and affects Kern, Los Angeles, Tulare, Sacramento, San Diego, San Joaquin and Stanislaus counties.

Phase 2

Approximately 269,000 children will be transitioned in Phase 2, which is scheduled to begin on or after April 1, 2013.

Phase 3

This phase will impact approximately 126,000 children who are covered by health plans that do not participate in Medi-Cal managed care or subcontract with a Medi-Cal managed care plan. These children will be enrolled in a Medi-Cal managed care health plan in their county of residence. Enrollment will include consideration of the child’s primary care providers. Phase 3 is scheduled to begin on or after August 1, 2013.

Phase 4

This phase will impact approximately 42,000 children residing in counties that currently do not participate in Medi-Cal managed care. These children will be moved into the Medi-Cal fee-for-service system. If the state is successful in expanding Medi-Cal managed care statewide, these children will at that time move into managed care plans. Phase 4 is scheduled to begin on or after September 1, 2013.

As with the beginning of a new year, we remind you to request new copies of enrollees’ membership cards, especially in the case of those patients who have moved from the Healthy Families program to Medi-Cal managed care. In Phase 1, patients are going to be already enrolled in the same plan they had before unless they have asked to change to another participating Medi-Cal managed care plan, thus another reason for verifying enrollment information

CMA and DHCS are cohosting a webinar on the Healthy Families Program transition on February 5, 2013, at 12:15pm. DHCS will present an overview of the transition and a summary of the implementation phases in 2013. The webinar is free and open to all health care providers.

Click here for webinar details and registration.

SFMS/CMA Responds to Ninth Circuit Ruling Vacating Preliminary Injunction for Reimbursement Rate Cuts

Fri, 14 Dec 2012 11:28:14 GMT

On Thursday, a three judge panel of the California Ninth Circuit Court of Appeals issued its opinion in CMA et al. v. Douglas et al. The Ninth Circuit panel reversed the district court’s decision and ruled that California can reduce Medi-Cal payments for health care providers by 10%.

As you will recall, the SFMS/CMA—along with the California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation, and American Medical Response—filed a lawsuit against the California Department of Health Care Services (DHCS) and the U.S. Department of Health and Human Services (HHS). The lawsuit was filed in response to HHS's approval of the state's 2011 10% reimbursement rate cut for Medi-Cal providers. On February 1, 2012, U.S. District Court Judge Christina Snyder granted our request for a preliminary injunction to invalidate and stop the implementation of the approved 10% Medi-Cal rate reduction. Today’s decision vacates the preliminary injunction.

The rate cuts will significantly impact access to care for Medi-Cal patients.

CMA President Paul Phinney, MD said, “Our hope is that state officials and Governor Brown can look at the situation and decide not to move forward with these cuts. It was a tough budget decision that was made when the state was in a much more dire fiscal situation than it is now. Moving forward with these cuts will impact the 900,000 kids moving from the successful Healthy Families Program into Medi-Cal, the millions of patients that will be newly eligible for Medi-Cal under federal health reform and the existing patient base as well. We need to ensure that health insurance isn’t just an empty promise for these patients.”

SFMS/CMA will be meeting with our partners and stakeholders to evaluate options moving forward, including requesting an En banc rehearing from the full Ninth Circuit Court of Appeals.

California’s Dual Eligibles Initiative Under National Spotlight

Thu, 06 Dec 2012 12:33:45 GMT

Patient advocates across the nation are closely watching California’s transition of beneficiaries eligible for both Medicare and Medi-Cal from traditional fee-for-service plans to managed care plans.

The California initiative is in its second year. State officials seek to transfer so-called dual eligibles to managed care plans to improve their health care services and reduce costs.

The state has estimated that the initiative will save $663 million next year and that it will yield additional savings in subsequent years. Federal officials have begun implementing a similar national effort under a provision in the Affordable Care Act.

Howard Kahn—CEO of L.A. Care, the largest public health plan in the U.S. with one million members in Los Angeles County—said the California initiative allows health plans to organize all of the care that dual eligibles receive and curb unnecessary treatments. However, some patient advocates who have followed the California initiative wonder if the federal demonstration project will put patients at too great a risk.

A report released by the California HealthCare Foundation in August 2012 determined several problems with the transition, such as:

A short timeline that allotted the state only seven months between federal approval and when enrollment began;
Privacy rules that prevent some health plans from receiving complete patient records;
Transfer guidance that confuses certain patients about whether their preferred physicians participate in various managed care plans; and,
An appeals process that patients seeking exemption from the program find onerous.

According to Kaiser Health News, California's initiative has caused some patients to leave trusted physicians and others to start receiving generic drugs that they say are ineffective.

In addition, health experts have expressed concern that insurers participating in the initiative have little experience overseeing the long-term home care needs of certain dual eligible patients.

Source: California Healthline, December 6, 2012.

Medi-Cal Requiring Physician Re-enrollment

Fri, 09 Nov 2012 11:51:53 GMT

The California Department of Health Care Services (DHCS) will soon be notifying physicians that they must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). The ACA requires every state Medicaid program (Medi-Cal in California) to revalidate provider enrollment information at least every five years beginning January 2, 2013.

DHCS is currently working to identify an initial list of all physicians and other providers who will be required to revalidate. Notices of revalidation will be mailed beginning the second week of January 2013. Notices will be sent to business location on file with DHCS. Each notice will include information on which application(s) must be completed. Anyone receiving a notice must complete and return the requested form(s) and required attachments within 35 working days of the date of the notice. Failure to do so may result in payment delays.

Physicians, who have revalidated, updated, or submitted new applications to the Medicare program within the last 12 months (January 1 through December 31, 2012) will not be required to revalidate at this time. However, your Medicare enrollment information must match the information on file with the Medi-Cal program. If the information does not match, you will receive notice from DHCS requiring you to revalidate.

SFMS/CMA will be hosting two live webinar training courses with representatives from DHCS to walk attendees through the Medi-Cal enrollment process for both individual providers and groups. Also to be discussed will be program requirements and how to avoid common mistakes that can lead to delays, denials and exclusion from the Medi-Cal program. These extended-length webinars are free to members, and will be held November 15, 2012, and January 16, 2013, from 12:15 to 1:45 pm.

Click here for more information or to register for the complimentary webinar(s).

SFMS Supports Bills to Reinstate Medi-Cal Managed Care Organization Tax and Healthy Families

Mon, 27 Aug 2012 14:00:15 GMT

SFMS/CMA support SB 301 (DeSaulnier) and AB 826 (Swanson), which would reinstate the Medi-Cal Managed Care Organization (MCO) Tax and the Healthy Families Program. Both bills have support from Republicans and Democrats in both houses.

In June, Governor Brown signed the proposal to transition all of the children currently enrolled in Healthy Families to Medi-Cal. If approved by the Centers for Medicare & Medicaid, the move would have an enormously negative impact on the 900,000 children that rely on Healthy Families for heath care coverage.

“The proposal signed in June puts the health of millions of California’s children at risk, as Medi-Cal already faces serious challenges in providing access to care for its enrollees,” said CMA President James T. Hay, MD. “SB 301 and AB 826 will ensure that California’s children have access to the care they need and deserve.”

When the MCO Tax was created in 2009, it was to address persistent funding shortfalls that plagued the Healthy Families Program. Since the creation of the tax, Healthy Families has been stable and successful in providing care for the nearly 900,000 children it serves.

Click here to download a sample letter supporting legislation to restore Healthy Families (SB 301 and AB 826) to send to your local legislators.

Ask the SFMS: Can I Balance Bill My Medi-Medi Patient?

Fri, 13 Jul 2012 16:16:47 GMT

Can I bill my Medi-Medi (patients who have Medicare as their primary insurance and Medi-Cal as secondary) patient for the 20 percent copay after Medicare pays?

Generally speaking, the answer is no. A physician who bills the Medicare program for services provided to a patient also eligible for benefits under the Medicaid program must do so on an assignment basis. Additionally, Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997, prohibits Medicare providers from "balance billing" Medicare beneficiaries who have secondary coverage under a state Medicaid plan.

If a physician knowingly and willfully violates the law, he or she faces the possibility of exclusion for five years from all programs that receive federal funding. This means physicians could lose their ability see patients covered under Medicare, Tricare, Medi-Cal, Medicare Advantage (managed care) programs and Federal Workers’ Compensation. In addition to exclusion, the federal government may impose civil monetary penalties.

Physicians who are not currently enrolled in the Medi-Cal program may enroll as Medi-Medi-only providers. More information about Medi-Cal provider enrollment and applications can be found at www.medi-cal.ca.gov.

For more information on billing Medi-Cal and Medi-Cal managed care patients, sign in to the member-only resource section and download the “Side Agreements with Medi-Cal Patients.pdf.”

Ask the SFMS

SFMS will be launching "Ask the SFMS" series on sfms.org and in the San Francisco Medicine journal in the coming months.

We have gathered experts in the field of practice management, payor reimbursement, coding/billing, contract review, legal/malpractice, financial planning/management, health policy, and more to answer questions our members may have.

Click here to submit a question to Ask the SFMS.

Low Reimbursement Rates May Hinder Medi-Cal Expansion

Thu, 12 Jul 2012 12:58:55 GMT

As California prepares to expand Medi-Cal coverage under the federal health reform law, physicians across the state are expressing concern that the program's reimbursement rates are inadequate.

Background on the Medi-Cal Expansion

The state currently has 7.7 million Medi-Cal beneficiaries, but enrollment in the program could increase by 30% in the next few years.

California expects to enroll 1.5 million or more adults in Medi-Cal once federal health reform law provisions take effect in 2014. Meanwhile, about 900,000 California children will be transferred to the program following the elimination of the Healthy Families program.

About Medi-Cal Reimbursements

California has one of the lowest Medicaid reimbursement rates in the U.S., ranking 47^th out of the 50 states. Meanwhile, state lawmakers last year approved an additional 10% Medi-Cal reimbursement cut for health care providers, but the cut is on hold while a lawsuit filed by physicians to block the cut is pending.

When Dr. Jerold Kaplan made a home visit last year to a man with a foot wound, he billed Medi-Cal what he thought was a modest $90.

His payment: $8.96.

The Berkeley wound surgeon received a bit more for his home visit to a quadriplegic last year: $13.44.

Medi-Cal told him it cut both payments in half because of late paperwork. But even at the full rate, he would have received no more than $27 for a house call, barely enough to cover gas.

As a result of the low reimbursement rates, many California health care providers have stopped accepting Medi-Cal beneficiaries or have limited the number of Medi-Cal patients they see.

Details of the Concerns

Health care stakeholders have raised concerns that physicians, clinics, and hospitals that accept Medi-Cal beneficiaries will become overwhelmed when the program is expanded.

William Lewis, a Los Gatos ear, nose, and throat doctor and former president of the Santa Clara County Medical Association, said that even if beneficiaries find a physician who accepts Medi-Cal, “they have to wait much longer for an appointment and as a result, they are going to the emergency room for routine care and that clogs up the ER.” He added, “That is clearly going to get worse if you’re adding people without adding doctors.”

State Response

Norman Williams, a spokesperson for the Department of Health Care Services, said California has nearly 80,000 physicians enrolled as Medi-Cal providers—a number that has held steady for the past five years.

He noted that Medi-Cal reimbursements will increase in 2013 and 2014 to Medicare levels. Williams said the pay boost should help encourage doctors to treat Medi-Cal beneficiaries.

Source: California Healthline, July 12, 2011.

Elimination of Healthy Families Severely Impact Children’s Access to Care

Fri, 22 Jun 2012 12:47:17 GMT

Governor Brown’s announcement that a budget agreement to eliminate the Healthy Families Program has been reached, could have an enormously negative impact on 880,000 children that rely on the Healthy Families Program for health care coverage. Disrupting the care of these children could result in mass confusion for families and disruption in care for children. The agreement would move all of the children and teenagers from the Healthy Families Program to Medi-Cal. Healthy Families has been a successful program providing health, dental and vision coverage to lower income children.

“The move to eliminate the Healthy Families Program would be devastating for children and teenagers throughout California that depend on the program for medical care,” said CMA President James T. Hay, MD. “What the governor has proposed will undoubtedly ensure that those kids now have a harder time getting access to care.”

SFMS/CMA has joined together with over 40 organizations in opposition of the proposal because of the ramifications it would have on California’s most vulnerable children.

SFMS/CMA, along with other provider and children’s groups has proposed a compromise effort to restructure Healthy Families by moving only the ‘bright line’ children—those whose parents earn between 101 and 138% of the Federal Poverty Level (FPL) into Medi-Cal. The state is required to transition these children due to federal health reform.

The proposal to start with the ‘bright line’ children is supported by analyses recently released by both the Legislative Analyst’s Office (LAO) and the Urban Institute.

Coalition of Health Care Organizations Issues Joint Letter Opposing Governor's Dual Eligible Proposal

Wed, 13 Jun 2012 16:44:17 GMT

In an open letter to members of the California State Legislature, nearly twenty organizations representing a wide variety of health care stakeholders urged their representatives to oppose Governor Brown’s dual eligible proposal. The proposal would move patients eligible for both Medicare and Medi-Cal into a Medi-Cal Managed Care program, ultimately disrupting care and harming patients.

Members of the California State Legislature,

In 2010, the Legislature gave the Department of Health Care Services (DHCS) authority to undertake pilot projects to redesign care and treatment for vulnerable seniors enrolled in both Medicare and Medi-Cal, the “dual eligibles.” The pilot projects were supposed to take place in up to four counties, and seniors would be given the opportunity to opt out if they wanted to stay with their doctors.

Before these pilot projects have even started, Governor Brown has proposed to rapidly expand them, to eight counties initially and statewide over the next two years. The plan for this transition is contained in a trailer bill to the State Budget, and a related proposal that has been submitted to the federal government. It has been titled the “Coordinated Care Initiative.”

We, the undersigned organizations, are asking the legislature to deny the Governor’s request to expand the dual eligible projects, and to request that DHCS work with the legislature and stakeholders on true pilot projects to test different ways of delivering the best care to vulnerable seniors.

1) This is no longer a “pilot project” or a “demonstration project.”

Just the four counties authorized in existing law – Los Angeles, Orange, San Diego, and San Mateo – account for almost half of the state’s dual eligible population. With an additional four counties –Alameda, San Bernardino, Santa Clara, and Riverside – the projects will include almost 70% of the state’s dual eligible population.

This can no longer be called a “pilot project” or a “demonstration project.” It simply includes too much of the target population. If the state generates lessons learned through the project, there will be no opportunity to apply changes.

2) DHCS is proposing to passively enroll seniors into the dual eligibles into the project, and it is not clear how they’re going to do it.

Under this program, seniors will have the right to opt out and stay in traditional Medicare. But to exercise that right, seniors will have to be aware of what is happening and what paperwork they will need to complete. This information should be available as soon as possible, and available in multiple formats and languages.

As of the writing of this letter, DHCS has not even developed a draft of the form that seniors will use to select a plan or opt out. Preventing seniors from exercising any choice will result in this medically vulnerable population losing access to longstanding relationships with their providers.

3) The duals proposal must be seen in the context of other DHCS programs and proposals.

Right now, the state is completing the transition of 400,000 seniors and persons with disabilities (SPDs) into Medi-Cal managed care. They are now proposing to shift 1.2 million dual eligibles, more than 800,000 children on Healthy Families, and hundreds of thousands of patients in rural counties.

In total, Medi-Cal is proposing to shift more than 3 million beneficiaries between now and 2015. We do not believe that DHCS can shift all of these beneficiaries in this incredibly tight timeline without causing massive disruptions in care.

Conclusion

With all of the above in mind, the undersigned organizations ask the Legislature to reject the Coordinated Care Initiative trailer bill when it is presented as part of the State Budget. We further ask that legislators urge the Department of Health Care Services to withdraw their overly-ambitious 4-county proposal to the federal government and take more time to develop a scaled-down project that gives seniors and the professionals that take care of them information and feedback mechanisms to assure continuity of care and true improved care coordination.

We look forward to working with you.

Signed,

California Medical Association
AARP
American Congress of Obstetricians & Gynecologists, District IX
Association of Northern California Oncologists
California Academy of Eye Physicians and Surgeons
California Academy of Family Physicians
California Academy of Physician Assistants
California Association for Health Services at Home
California Medical Transportation Association
California Podiatric Medical Association
California Psychiatric Association
California Radiological Society
California Society of Anesthesiologists
California Society for Dermatology and Dermatologic Surgery
California Society for Physical Medicine and Rehabilitation
IHSS Consumers Union
Medical Oncology Association of Southern California
Pharmaceutical Research and Manufacturers of America
Polio Survivors Association

Help SFMS/CMA stop the dual eligibles expansion. Contact your legislator today! Click here for talking points and sample letters.

Urge Your Legislators to Stop Forcing Medicare/Medi-Cal Dual Eligibles Into Managed Care Plans

Thu, 07 Jun 2012 14:27:20 GMT

Due to advocacy on the part of the SFMS, CMA, and other stakeholders, the plan to shift Medicare/Medi-Cal “dual eligibles” into a managed care plan has been delayed.

Under a pilot project approved by the Legislature in 2010, dual eligibles—those who meet eligibility requirements for both the Medicare and Medi-Cal programs—in Los Angeles, Orange, San Diego, and San Mateo counties will be passively enrolled into a managed care plan. This means that if dual eligibles wish to remain in fee-for-service Medicare, they will have to actively choose to do so.

The plan was previously scheduled to begin on October 1, 2012, but due in large part to SFMS/CMA advocacy efforts it will now begin in early 2013, according to a plan submitted to the Centers for Medicare & Medicaid Services (CMS) by the state last week. The effective date of the enrollment will be no earlier than March 1, 2013, and not later than June 1.

SFMS/CMA had expressed serious concern that, with the very tight timeline originally proposed by the state, there would not be adequate time for patients and physicians to learn about the proposed changes. Physicians will now have the rest of 2012 to educate their patients about enrolling in a plan or exercising their right to opt out of the program.

The plan submitted to CMS also exempts end-stage renal disease (ESRD) patients completely from the program. This too, was based on concerns raised by CMA and others about the potential disruptions to dialysis treatment that could be caused by the transition to managed care.

While CMA continues to oppose the dual eligibles pilot project, these two steps are improvements that will make the plan more workable for physicians if any part of it moves forward.

Now that the duals plan has been submitted to CMS, SFMS/CMA will be submitting comments to the federal government asking them to limit the size and scope of the projects, and to ensure that key physician and patient protections are included.

In his 2012 budget, Governor Jerry Brown proposed expanding the four county pilot project statewide. SFMS/CMA need your help to stop this expansion.

Use CMA’s new Legislator Connect Hotline at (877) 362-8455 to be connected to your legislator. You will be asked to enter your zip code and select your Assembly Member and Senator.

Click here for talking points and a sample letter to submit to your legislators asking them to oppose forcing dual eligibles into managed care.

Click here for sample letters to the editor to submit to local media outlets.

Click here for up-to-the-minute information about the dual eligible project.

SFMS/CMA Oppose Expansion of Dual Eligible Managed Care Pilot Program

Mon, 04 Jun 2012 11:49:49 GMT

Governor Jerry Brown continues to push to move all “dual eligibles”—patients covered through both Medi-Cal and Medicare—into managed care. In his revised budget plan, the Governor proposes expanding the four-county pilot project to include eight counties.

SFMS and CMA believe the pilot project as currently defined will lead to disruptions in care for the state’s neediest and sickest patients. The project, authorized by the Legislature in 2010 (SB 208), is set to begin in early 2013.

The initial four counties selected by the California Department of Health Care Services—Los Angeles, Orange, San Diego and San Mateo counties—contain almost half of all of the dual eligibles in California. SFMS and CMA believe this can no longer be called a pilot project, and are urging the Legislature to reject the Governor’s proposal to expand the project.

To mitigate disruptions in care, CMA has requested, among other things:

Meaningful patient and physician protections that cannot be negotiated away
Provider reimbursement at or above Medicare levels
Ability for patients to opt out of the program and to change plans if they were auto-assigned
That participating plans be required to use the most current billing, diagnostic coding and editing procedures

The Governor’s proposed budget also continues the plan to transition all Healthy Families children into Medi-Cal managed care. SFMS/CMA are working with the legislature and the administration on alternatives that will protect physicians and patients.

Thanks to our legal and legislative advocacy efforts, the Governor’s revised budget proposal doesn’t include Medi-Cal payment cuts, despite numerous recent attempts to slash the state’s already low provider rates. Most recently, a federal court judge in February issued a final order enjoining the state of California from implementing a 10% cut to Medi-Cal reimbursement rates. Between this upcoming budget year and the last, CMA’s legal advocacy has prevented more than $420 million in provider rate cuts.

For more details on the governor's revised budget as it relates to health care, see CMA’s Budget Summary.

Below: The division of responsibilities between Medicare and Medi-Cal.

Medi-Cal Primary Care Rates to Increase to Medicare Levels in 2013

Mon, 21 May 2012 12:38:11 GMT

Medi-Cal primary care physicians will receive a two-year, $11 billion pay increase, under a proposal released last week by U.S. Department of Health and Human Services. The proposal, which implements a provision of the Affordable Care Act (ACA), would on average result in a 50 to 60 percent increase in Medi-Cal rates for primary care physicians, including family medicine, pediatrics and internists, plus related subspecialties. The ACA calls for Medicaid payments to primary care physicians to be raised to Medicare levels for 2013 and 2014.

The increase, effective in 2013 and 2014, bring Medicaid payments to primary care physicians in line with those for Medicare. Although Medicaid is jointly funded by states and the federal government, the increase would be paid for entirely by the feds.

“The payment increase proposed today will be an important tool for states to ensure their primary care networks are prepared for increased enrollment as the health care law is implemented,” said Marilyn Tavenner, Acting Administrator for the Centers for Medicare & Medicaid Services (CMS), in a statement issued last Wednesday. “Today’s action will help encourage primary care physicians to continue and expand their efforts to provide checkups, preventive screenings, vaccines and other care to Medicaid beneficiaries.”

SFMS/CMA have been working closely with CMS to ensure that the definition of primary care used is as broad as possible. We believe this two-year pay increase is a step in the right direction; however, it is critical that we find a long-term solution that will ensure that the influx of new Medi-Cal patients will be able to find a doctor.

SFMS/CMA believe the two-year pay bump will prevent many primary care physicians from leaving the program, but it may not be enough to attract new physicians. Some primary care physicians will not want to enroll in the program and establish patient relationships, only to have to pull out in two years and leave their patients, she says.

Currently, California’s rates rank 47th in the nation and are on average 50 percent below Medicare rates. Because of these low rates, two-thirds of California’s physicians cannot afford to participate in the program and more than 50 percent of Medi-Cal patients report they can’t find a doctor.

Urgent Survey Response Requested: State Releases Plan to Move Medicare/Medi-Cal Patients into Managed Care Plans

Wed, 25 Apr 2012 16:41:28 GMT

On June 1, 2011, California began its transition of seniors and persons with disabilities (SPD) from Medi-Cal fee-for-service program into managed care plans, and will continue over the next several years until complete. Almost immediately, SFMS/CMA began receiving a wide range of complaints and reports of serious problems involving disruption of patient care.

Over 50 percent of Medi-Cal patients involved in the initial phases of the transition had been automatically assigned to health plans due to failure to respond to notices during the enrollment period. Was this truly the patient’s fault? Or was this the result of poor planning, lack of communication or other language barriers? Nonetheless, CMA has received numerous reports of patients losing access to physicians who cared for them for many years, and have also received an increasing number of complaints of plans and IPAs/medical groups refusing to contract with physicians who have been long time Medi-Cal providers.

While CMA has continued to work with the Department of Health Care Services (DHCS) to address those issues, the state now is seeking approval from the Centers for Medicare & Medicaid Services (CMS) to shift “dual eligibles” (persons with Medicare and Medi-Cal coverage) into Medicare and Medi-Cal managed care plans in four counties including Los Angeles, Orange, San Diego and San Mateo on January 1, 2013. If the state plan is approved by CMS, patients will begin receiving enrollment notices on October 1 through November 31 of this year. Furthermore, the state is once again seeking authority to automatically enroll individuals who do not actively enroll or opt-out within the required time frame.

The state’s plan is currently in a thirty (30) day public comment period. CMA is collecting data on the extent of problems and other issue physicians and their patients have experienced thus far. Examples of delayed and/or denied medical treatment, disruption in continuity of care, and other issues that negatively impacted the financial viability of your practice can be extremely powerful.

Your participation in this survey is crucial. The information you provide will be reflected in CMA’s response to the state’s proposal and will help us better advocate for solutions.