Beginning October 2013, Californians who are eligible for both Medicare and Medicaid (Medi-Medi) will have to sign up with one single health plan. This is as a result of a signed Duals Demonstration Memorandum of Understanding (MOU) on March 27, 2013 between California’s Department of Health Care Services (DHCS) and the federal Centers for Medicare and Medicaid Services (CMS). This project will test a new model for providing Medi-Medi enrollees with a new integrated care. The new delivery system is called the Cal MediConnect program in California and will be phased in over time.
The need to expand care coordination to dual eligibles is so great that, under the federal Affordable Care Act, the government created a new office–the Medicare-Medicaid Coordination Office (MMCO). Dual eligible individuals are low-income seniors and people with disabilities who are Medicare-Medicaid enrollees. The MMCO has been working with several states, including California, to design innovative demonstration projects that aim to significantly improve the health and quality of life for dual eligibles while containing costs through enhanced care coordination.
Consequently, one of the main goals of the new program is for the beneficiaries to receive a more coordinated and accountable care. Currently, dual eligibles must carry multiple insurance cards and know different program rules because they have to navigate two and often three or more separate systems to receive care. The new program will consolidate all of the beneficiary’s insurance coverage into one plan. Although the open enrollment period starts in October 2013, the new program will phase in at different times for different counties in the state. For example, Los Angeles County’s enrollment will begin in October 2013 but will happen over 15 months. The new program will phase in over time and will only allow 456,000 of the 1.2 million dual eligible beneficiaries in California to participate in the program. The 1.2 million dual eligible beneficiaries are distributed in every county in California with 10 of the 58 counties accounting for about 75% of dually eligible beneficiaries. Los Angeles County is home to nearly one in three of these dual eligible beneficiaries. The five counties with the most beneficiaries are Los Angeles (370,000), San Diego (76,000), Orange (71,500), San Bernardino (53,000), and Santa Clara (50,000) Of the 370,000 beneficiaries in Los Angeles, the MOU has placed a cap of 200,000 Angelino beneficiaries who may enroll in Cal MediConnect. The earlier proposal had no such cap. In addition, those beneficiaries who enroll in the new Cal MediConnect can opt out at any time. Originally, California proposed an initial 6-month stable enrollment period, during which eligible beneficiaries would have remained in the same health plan. Finally, one of the major contested items on the new MOU was that the Home and Community-based Services (HCBS). These services would remain intact. The original proposal called for closing these services. HCBS provides opportunities for Medicaid beneficiaries to receive services in their own home or community. These programs serve a variety of targeted population groups, such as people with mental illnesses, intellectual disabilities, and/or physical disabilities. The wheels of change have begun to spin and there is not turning back. However, there are still a significant number of steps in implementing the Cal MediConnect program. First, the health plans have to be ready and operational for the new program. New contracts between the health plans, CMS and DHCS have to be executed. In addition, the contracts should specify the capitation rates. Not only the operating systems should be developed, the systems should also be constantly monitored and evaluated. Only time will tell. Related information: