Providers

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About the Coordinated Care Initiative

Frontline health care providers know better than most how coordinated care can help their patients – particularly patients with multiple chronic conditions or those who need additional supports to stay living in their home and community.

The federal Medicare program and the state Medi-Cal program have partnered to start a new project to improve care for California’s seniors and people with disabilities who are dually eligible for both of the public health insurance programs, “dual eligible beneficiaries.” This project, the Coordinated Care Initiative (CCI), will take place in seven counties: Los Angeles, Orange,* Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. The CCI has two parts:

  • Cal MediConnect: All of a beneficiary’s medical, behavioral health,** long-term institutional, and home- and community-based services will be combined into a single health plan. This will allow providers to better coordinate care and make it simpler for patients to get the right care at the right time in the right place.
  • Medi-Cal Managed Long-Term Supports and Services (MLTSS): Medi-Cal beneficiaries, including dual eligible beneficiaries who have opted out of Cal MediConnect or who are not eligible for Cal MediConnect, are required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including Long-Term Supports and Services (LTSS) and Medicare wrap-around benefits.

What do providers need to know about the CCI?

More Information & Educational Materials

 

Provider Fact Sheets

Pharmacist Fact SheetsHow Medicare Part D transitions under the CCI

 

 

Frequently Asked Questions: Providers

What information can I give my patients?

It is important that beneficiaries have all the information they need about these changes so they have a good understanding of their options and can make informed choices based on their needs.

The CalDuals Beneficiary page has FAQs and fact sheets designed to help beneficiaries understand the changes and their options.

Your beneficiaries will receive notices prior to their eligibility date. These blue envelopes will come from the Department of Health Care Services – Health Care Options. You may want to advise them to be on the lookout for these letters.

Additional resources:

  • The Health Insurance Counseling and Advocacy Program (HICAP): 1-800-434-0222
  • Health Care Options: 1-844-580-7272 (TTY 1-800-430-7077)

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How will I get paid?

In most cases, you will need to contract with the Cal MediConnect and/or Medi-Cal managed care plans participating in the CCI to get paid for treating patients enrolled in those plans.

  • Under Cal MediConnect, providers will see streamlined administration as they will be able to submit claims to one plan, rather than navigating both the Medicare and Medi-Cal billing processes.
  • Under MLTSS, providers will still need to bill Medicare for Medicare services (whether Medicare Advantage or fee-for-service) and bill Medi-Cal for the Medi-Cal potion of services. Medicare will remain the primary payer and the Medi-Cal managed care plan is the secondary payer.

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How do I contract with a Cal MediConnect or Medi-Cal health plan?

Health plans must have providers for all covered benefits and adequate access to all services – and are checked for this on an ongoing basis.

You must join the health plans’ networks to receive payment. This means undergoing provider credentialing process and signing contracts. For physician services, many health plans work through medical groups.

To find contact information for provider relations for the plans in your county:

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How will care coordination work under the CCI?

Cal MediConnect plans will give providers information and resources to support care coordination.

  • Health Risk Assessments (HRAs): Plans will conduct HRAs to identify higher risk beneficiaries who could benefit from care coordination.
  • Interdisciplinary Care Teams: Teams composed of the beneficiary, the plan care coordinators and key providers will help manage and coordinate care for the higher risk beneficiaries.
  • Individualized Care Plans: Care plans will facilitate timely access to care and services needed by beneficiaries.
  • Plan Care Coordinators: Coordinators will help facilitate communication among a beneficiary’s providers, including physicians, long-term supports and services providers and behavioral health providers. They will also help connect beneficiaries to social services to help them live as independently as possible.

To learn more about care coordination:

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How does CCI protect continuity of care for beneficiaries?

Cal MediConnect and Medi-Cal health plans are required to make sure beneficiary care continues and is not disrupted. The health plan will work with you and your patients to make sure they get all the care they need.

Continuity of care protections work a little differently for various types of providers under the CCI. Beneficiaries have the right to continue to receive needed services, but eventually, they must get all covered services from providers who work with the plan.

  • Physicians: If your beneficiary enrolls in a Cal MediConnect or Medi-Cal managed care health plan and you are not part of the network, your beneficiary has a right to see you for up to six months for Medicare services and 12 months for Medi-Cal services – if you and the plan reach agreeable terms. You must:
    • Have seen the patient at least once in the 12 months before their enrollment in the plan for primary care, and twice for specialists
    • Be willing to work with the plan;
    • Accept payment from the plan; and
    • Not be excluded from the plan’s network for quality or other concerns.
  • Nursing Facilities: Beneficiaries have the right to stay in their current nursing home under Cal MediConnect, unless it is excluded from the plan’s network for quality or other concerns.
  • Long-term Supports & Services (LTSS): Beneficiaries won’t have to change In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS) or Multipurpose Senior Services Program (MSSP) providers.
  • Other Providers: Continuity of care protections do not apply to suppliers of medical equipment, medical supplies, and transportation. They also do not apply to home health or physical therapy providers.

For more information about continuity of care, read this fact sheet.

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For additional information, read our Fact Sheets related to the CCI.
*Orange County participation pending readiness reviews.

**Some behavioral health benefits will continue to be provided through the counties, not by the Cal MediConnect plans.