California’s Duals Demonstration – Cal MediConnect
The state Medi-Cal program and the federal Medicare program are partnering to launch a three-year project to promote coordinated health care delivery to seniors and people with disabilities who are dually eligible for both of the public health insurance programs, “dual eligible beneficiaries.”
The program will be called Cal MediConnect.
It will be implemented no sooner than April 2014 in eight counties: Alameda, San Mateo, Santa Clara, Los Angeles, Orange, San Diego, Riverside and San Bernardino.
The Cal MediConnect program aims to improve care coordination for dual eligible beneficiaries and drive high quality care that helps people stay health and in their homes for as long as possible. Additionally, shifting services out of institutional settings and into the home and community will help create a person-centered health care system that is also sustainable.
The Cal MediConnect program is part of California’s larger Coordinated Care Initiative (CCI). Building on many years of stakeholder discussions, the CCI was enacted in July 2012 through SB 1008 (Chapter 33, Statutes of 2012) and SB 1036 (Chapter 45, Statutes of 2012).
Major Parts of the Coordinated Care Initiative
- Cal MediConnect Program: A voluntary three-year demonstration for dual eligible beneficiaries to receive coordinated medical, behavioral health, long-term institutional, and home- and community-based services through a single organized delivery system. No more than 456,000 beneficiaries would be eligible for the duals demonstration in the eight counties.
- Managed Medi-Cal Long-Term Supports and Services (MLTSS): All Medi-Cal beneficiaries, including dual eligible beneficiaries, are required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around benefits.
Click here to see fact sheets on the Coordinated Care Initiative.
Who are dual eligible beneficiaries?
Dual eligible beneficiaries are people who qualify for both public health insurance programs, Medicare and Medi-Cal. In California, as many as seven in ten dual eligible beneficiaries are age 65 and older, and most are women. Approximately one in three are younger people with disabilities. California has about 1.1 million of these beneficiaries. Of these, about 456,000 are estimted to be eligible for enrollment into the Cal MediConnect program, including a 200,000 enrollment cap in Los Angeles. (Learn more)
Click on each county below to learn more about the specifics across the state:
When will enrollment into the Cal MediConnect program being?
Enrollment in Cal MediConnect will begin no sooner than April 2014. Notification of these changes will be mailed to eligible participants starting in January 2014.
Enrollment will be phased in over 12 months in all counties, except Los Angeles and San Mateo. The Los Angeles enrollment strategy is currently in development and in San Mateo enrollment will occur the first month of the program.
Understanding Enrollment for Different Populations
- For people with both Medicare and Medi-Cal eligible for Cal MediConnect: The state will use a passive enrollment process. This means that the state will enroll eligible individuals into a health plan that combines their Medicare and Medi-Cal benefits unless the individual actively chooses not to join and notifies the state of this choice. The state will send eligible individuals multiple notices describing their choices, including the option to “opt out” of joining a Cal MediConnect health plan.
“Opting out”: This is when an eligible beneficiary chooses not to join a demonstration health plan and keep his or her Medicare benefits separate. If a person chooses a Medi-Cal plan only, s/he indicates that s/he wishes to “opt out” of the Cal MediConnect managed care demonstration. Beneficiaries who enroll in a Cal MediConnect health plan may opt out or change health plans at any time.
Note: Opting out applies only to Medicare benefits. Beneficiaries must still get their Medi-Cal benefits through a health plan, as described below.
- For nearly all people with Medi-Cal: The state will require mandatory enrollment into a Medi-Cal health plan. This means that nearly all people with Medi-Cal in the eight CCI counties MUST get all their Medi-Cal benefits, including long-term services and supports, through a Medi-Cal health plan. Most people with only Medi-Cal already are enrolled in a Medi-Cal health plan; now they will also get their long-term supports and services through their health plan.
- For people with both Medicare and Medi-Cal who do not enroll in a Cal MediConnect Health Plan: The state will require enrollment in a Medi-Cal plan for all Medi-Cal long-term services and supports and any Medicare deductibles or costs. For dual eligible beneficiaries, enrolling in a Medi-Cal health plan does not change their Medicare benefits. They can still go to their Medicare doctors, hospitals, and providers.
How would services be integrated by Cal MediConnect health plans?
Cal MediConnect health plans will be responsible for providing their enrollees all Medicare and Medi-Cal benefits and services, including medical care, long-term care, behavioral health care and social supports. Beneficiaries, their family members and other caregivers will be able to participate in care coordination teams that help ensure delivery of the right services at the right time and place.
Strong consumer protections grounded in personal choice and continuity of care will be core to the program’s success. State and federal officials will monitor the health plans closely to ensure provision of all beneficiary protections. Additionally, the In-Home Supportive Services program would become a managed care benefit, but it would remain an entitlement program and current consumers’ rights would not change.
Why is the government proposing these changes?
Today, dual eligible beneficiaries must access services through a complex system of disconnected programs funded by different government offices. This fragmentation often leads to beneficiary confusion, delayed care, inappropriate utilization and unnecessary costs. Integrating all services and financing for dual eligible beneficiaries will promote care coordination and result in improved beneficiary health and lower costs.
Click here for more answers to Frequently Asked Questions.