Cal Medi-Connect is a 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. Medi-Connect began to enroll approximately 456,000 duals – about half of the 1.1 million Californians who qualify for both Medicare and Medi‐Cal benefits — into Medi‐Cal managed care plans this summer. Advocates unsuccessfully sought injunctions to halt implementation of the project in both state and federal court (see below for details on legal challenges).
As of October 3, 2014, the state had sent enrollment notices to almost half of the 456,000 individuals eligible. To date, 36% have opted to be excluded, according to the state. The notices will continue to be sent out over a 12-month period, distributed during beneficiaries’ birth months.
CalDuals Physician Toolkit
CalDuals has updated its Physician Toolkit, which provides physicians information on both Cal Medi-Connect and the Coordinated Care Initiative. It contains several resources, including an overview and information on the following:
- How to submit crossover claims to Medi-Cal plans
- Contracting with Cal MediConnect plans
- How crossover claims are processed for Medi-Cal managed care patients
- Continuity of care
- Sample patient letters (for contracted and non-contracted physicians)
Provider Considerations for Patients Who Opt Out
If a patient opts out of Medicare Advantage and remains with fee-for-service Medicare, the Medi-Cal managed care plan cannot require authorizations for physician services as the secondary payor (see Coordinated Care Initiative Overview for more information). The California Medical Association has noted that no change has been made to the rules governing the billing of the 20 percent Medicare copay for dual eligible patients. It continues to be unlawful to bill dual eligible patients. In limited circumstances, Medi-Cal may cover Medicare coinsurance and copays. Such “crossover” claims for Medicare coinsurance and copays should be sent to the patient’s Medi-Cal plan (see Payment for Medicare Physician Services Under the CCI for more information.)
Beneficiaries may contact the Cal Medi-Connect Ombudsman Program with questions or concerns. Ombudsman services are available Monday through Friday from 9:00 a.m. to 5:00 p.m., by calling (855) 501-3077 (TTY 1-855-847-7914).
Please also visit the California Medical Association website for updates on the Coordinated Care Initiative.
Legal Challenges to Cal Medi-Connect
State Court Case
On August 1, 2014, Sacramento Superior Court Judge Shellyanne Chang ruled that the Los Angeles County Medical Association and other groups that filed a lawsuit in July did not prove that Cal MediConnect would harm patients. Based on her findings, she denied the groups’ request for a preliminary injunction.
The lawsuit called the state program ill-conceived and confusing, as it aimed to enroll dual eligibles into Medi-Cal managed care plans. The population includes the elderly, poor and persons with permanent disabilities. Without their knowledge, consent, or understanding, patients will be passively assigned away from their current doctor to one of five medical groups that likely do not understand their conditions, medical histories, physical limitations and social needs.
“The members of the Los Angeles County Medical Association are disappointed by the court’s ruling to move forward with the Cal MediConnect demonstration, which is ill conceived, ill designed, and will jeopardize the health of many of the state’s most vulnerable population, the poor the elderly and the disabled,” said Dr. William Averill, a Torrance-based cardiologist and executive board member of the Los Angeles County Medical Association, quoted in a story by the Los Angeles Daily News.
United States District Court Case
In an ongoing effort to delay Cal Medi-Connect, the Medicaid Defense Fund filed a lawsuit in U.S. District Court in Los Angeles on August 29, 2014, seeking an injunction to halt Cal Medi-Connect. The Medicaid Defense Fund requested an expedited hearing prior to Cal Medi-Connect sending another set of notices to dual eligibles that they will be shifted into managed care plans if they do not respond. On October 3, advocates dropped their effort to seek a preliminary injunction in federal court in part citing procedural difficulties.
Coordinated Care Initiative Overview Webinar
September 24, 2014 — CRA, in coordination with DHCS, provided a webinar on Cal Medi-Connect and Managed Medi-Cal, covering basics on eligibility and enrollment, care coordination, continuity of care, how to continue to see your patients and more. The recorded webinar will be posted online shortly.