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.
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.
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.