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Cal MediConnect

Martha Smith Chief Program Officer, Dual Eligible Demonstration Health Net, Inc. Paul Van Duine Senior Director of Provider Network Operations L.A. Care Health Plan CAPG Southern California Contracts Committee Meeting Annual joint meeting with HASC October 3, 2013 1

Agenda Background and General Update LA Care Network Strategy Coordinating Behavioral Health Health Net Network Strategy


California is implementing a Duals Demonstration under the Coordinated Care Initiative

The passing of the Coordinated Care Initiative (CCI) is a catalyst for three key changes in California healthcare in the 8 selected counties: California CCI Legislation Mandatory enrollment into a Medi-Cal health plan Mandatory transition of Medi-Cal Long Term Services and Supports (LTSS) to Medi-Cal health plans Voluntary transition of Dual Eligibles into a Demonstration plan (passive, with opt-out) 3

As a result of CCI, what changes for Medi-Cal Benes?

• Most Medi-Cal beneficiaries will have to join a Medi-Cal health plan for benefits like: o o o o Long Term Services and Supports (LTSS) Non-emergency transportation (medically necessary) Incontinence supplies Some medical equipment that Medicare doesn’t cover.

• Dually Eligible beneficiaries can join the Duals Demonstration and get ALL of their healthcare from one health plan (Medicare and Medi-Cal benefits) • Dually Eligible beneficiaries can opt out of joining a health plan for the Medicare portion of their services. They will have to remain in a health plan for their Medi-Cal services


California Demonstration Sites

Eight counties have been selected

based on current State authority*:


Los Angeles

(DE pop. 374 K, eligible: 271K) o  Health Net  LA Care

San Diego

(DE pop. 75 K eligible: 51K)   Health Net Molina   Care 1st Community Health Group o o o o o o


(DE pop. 73 K eligible: 57K):  CalOptima

San Bernardino

  (DE Pop. 54 K eligible: 36K) Inland Empire Health Plan Molina Healthcare


(DE Pop. 50 K eligible: 34K)   Molina Healthcare

Santa Clara

(DE Pop. 50 K eligible: 35K)  Inland Empire Health Plan Anthem Blue Cross  Santa Clara Family Health Plan


(DE Pop. 42 K eligible: 31K)  Anthem Blue Cross  Alameda Alliance for Health

San Mateo

(DE pop. 15 K eligible: 11K)  Health Plan of San Mateo


What will the Program Look Like? Benefit Plan Configuration


• Parts A, B, and D benefits covered


• All Medi-Cal services currently required in managed care services • Long-Term Supports and Services o o Skilled Nursing Home and Community-Based programs

Supplemental benefits:

• Vision, Transportation • (optional dental)


• With mental health and substance use programs • Other “non-benefit” community based programs


What will the Program Look Like?

Who and How?

Who Will Be Included in Cal MediConnect?

• Beneficiaries eligible for both full benefit Medicare and Medi-Cal in the CCI counties

Populations excluded from the Demo

• Partial-Benefit Dual Eligibles • • • • • • Beneficiaries with other health coverage (not including Medicare Advantage or partial coverage plans) Beneficiaries under age 21 Existing ESRDs (enrollment will be consistent with MA today) Beneficiaries with developmental disabilities receiving services through Regional Centers or a State Developmental Center Enrollees of selected waiver programs Beneficiaries living in zip codes not covered by managed care


What will the Program Look Like?


• • •

The Demonstration will begin no sooner than April 1, 2014 Enrollment

o Enrollment for the eight counties in the CCI will have different approaches  Los Angeles  enrollment will phase in over 12 months with the first three months being a period of only active choice enrollment – Active/elective enrollment April – June 2014 – Passive enrollment by birth month beginning July 2014 – March 2015 – 200,000 enrollment cap  San Diego  enrollment will phase in over 12 months by birth month beginning o o o   April 2014 San Mateo and Orange  commence all at once on April 2014 Passive enrollment with a voluntary opt out for the Medicare benefit only  Beneficiaries can opt out of Cal MediConnect If beneficiaries don’t choose to opt out or select a health plan, they will be automatically enrolled by the State into either L.A. Care or Health Net Current D-SNP and MA enrollees are passively enrolled in January 2014 Beneficiaries can still opt out later even if they get automatically enrolled Financing: – Capitated payment models with 3-way contracts between CMS, CA Department of Health Care Services (DHCS), and health plans


Coordinated Care Initiative Requirements

The legislation establishing the CCI contains many projections for beneficiaries covering:

• Meaningful Information of Beneficiary Rights and Choices : o Notices sent at least 90, 60, and 30 days prior to enrollment (coordinated with CMS) • • Continuity of Care o People can continue to see their Medi-Cal providers for 12 months and Medicare doctors for 6 months Self-Directed Care: • • o People will have the choice to self-direct their care, including being able to hire, fire, and manage their IHSS workers Appeals & Grievances: o DHCS is working with CMS on a coordinated appeals process Strong Oversight & Monitoring: o Evaluation Coordinated with DHCS and CMS