“Dual Eligible Beneficiaries” are seniors and people with disabilities who are dually eligible for both of the public and health insurance programs. Both the state Medi-Cal program and the federal Medicare program are partnering to launch a 3-year demonstration to promote coordinated health care delivery to these dual eligible beneficiaries. The program will be called Cal MediConnect.
The purpose of the Cal MediConnect program is to improve care coordination for dual eligible beneficiaries and drive high quality care that helps people stay healthy and in their homes for as long as possible. The program will be implemented starting January 2014. The Cal MediConnect program is part of California’s larger Coordinated Care Initiative (CCI). Major parts to the CCI are:
- 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 (LTSS): All Medi-Cal beneficiaries, including dual eligible beneficiaries, required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around benefits.
The goal of the government is to integrate all services and financing for dual eligible beneficiaries. This will promote care coordination and result in improved beneficiary health and lower costs. 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. Timeline for the Cal MediConnect program:
- October 2013–Notifications mailed to eligible participants
- January 1, 2014–Enrollment begins
- January–March 31, 2014–Voluntary enrollment
- April 1, 2014–December 31, 2014–“Passive Enrollment”* begins
*“Passive Enrollment”: 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.
Individuals can “opt out” of Cal MediConnect and keep their Medicare benefits. Beneficiaries must still get their Medi-Cal benefits through a health plan. Under Cal MediConnect, Medi-Cal benefits will also include long-term services and supports. 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. Currently, there are only two primary health plans under Cal MediConnect–LA Care and HealthNet. Only LA Care has sub-plans which include CareMore, Care 1st, and Kaiser. HealthNet does not have any sub-plans. These plans will be responsible in providing their enrollees all Medicare and Medi-Cal benefits and services, including medical care, long-term care, behavioral health care and social supports. Newly enrolled beneficiaries would be able to maintain relationships with their out-of-network Medicare providers for up to 6 months upon enrollment and out-of-network Medi-Cal providers for up to 12 months. Benefits included in the Cal MediConnect are:
- Primary care
- Specialty physician care
- Prescription drugs
- Hospital services
- Nursing home care
- Durable medical equipment
- Rehabilitation services
- Mental health and substance abuse services
- Dental
- Vision
- Non-emergency medical transportation.
- Home health
- Long-term services and supports (LTSS):
- Short-term and long-term nursing facility care
- In-Home Supportive Services (IHSS)
- Multipurpose Senior Services Program (MSSP)
- Community Based Adult Services (CBAS)
People receiving other home- and community-based waiver services will not be eligible to join the demonstration. These waiver programs are: Nursing Facility/Acute Hospital, HIV/AIDS, Assisted Living, and In- Home Operations. Dual Eligible Fact Sheet http://www.calduals.org/background/fast_facts/