DHCS suspends planned passive enrollment for duals project The Department of Health Care Services (DHCS) announced last week that it would not move forward with its planned annual passive enrollment of dual eligible beneficiaries under the Coordinated Care Initiative (CCI) after it received feedback from the California Medical Association (CMA) and 40 other stakeholders asking the agency to pursue enrollment strategies that support voluntary "opt-in" enrollment. Instead, DHCS said it will implement a voluntary "opt-in" enrollment effort beginning in July 2016. The new streamlined enrollment strategy will include mandatory Managed Medi-Cal Long-Term Supports and Services (MLTSS) plan enrollment. DHCS said it would monitor participation in the program; should voluntary enrollment not prove to be a viable option for program sustainability, passive enrollment remains an option in the future. In April, DHCS released a series of proposals that would have changed the CCI enrollment process to 1) passively enroll beneficiaries into Cal MediConnect; and to 2) streamline enrollment by allowing plans to eliminate or dramatically reduce the role of the enrollment broker. CMA, in partnership with Justice in Aging and other patient advocacy groups, signed a joint letter strongly opposing the proposals. “Experience shows that passive enrollment strategies result in high opt-out rates, confusion, disruption in care, distrust of managed care and high costs to plans,” the letter to DHCS said. “(P)assively enrolling over 100,000 beneficiaries in a two-month period is staggering. The plans, HICAPs, Ombudsman, enrollment broker, and the broader community lack the capacity to meet the needs of the affected beneficiaries, especially on the expedited timeline DHCS has proposed, under which the first set of notices would be mailed to beneficiaries.” The Coordinated Care Initiative was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program began with a three-year demonstration project that expected to see a large portion of the state's dual eligible beneficiaries transition to managed care plans. Although the state is not going forward with passive enrollment in 2016, DHCS has stated they are still considering a passive enrollment strategy for 2017. Click here to read CMA's letter to DHCS on this issue. For more about the duals program, visit www.cmanet.org/duals. Contact: Lishaun Francis, (916) 551-2554 or lfrancis@cmanet.org. June 8, 2016 Managed Care, Medi-Cal, Medicare Medi-Cal, Medicare, Cal-MediConnect, Department of Health Care Services, Dual Eligible 0 0 Comment Read More »
CMA opposes proposed changes to duals demonstration The Department of Health Care Services (DHCS) recently released a series of proposals that would change the Coordinated Care Initiative (CCI) enrollment process to 1) passively enroll beneficiaries into Cal MediConnect; and to 2) streamline enrollment by allowing plans to eliminate or dramatically reduce the role of the enrollment broker. The California Medical Association (CMA), in partnership with Justice in Aging and other patient advocacy groups, signed a joint letter strongly opposing the proposals. The Coordinated Care Initiative was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program began with a three-year demonstration project that expected to see a large portion of the state's dual eligible beneficiaries transition to managed care plans. Experience shows that passive enrollment strategies result in high opt-out rates, confusion, disruption in care, distrust of managed care and high costs to plans. "These strategies simply do not work," the letter said. "The proposed enrollment changes ignore lessons learned from implementation thus far, and require substantial resources from DHCS, the plans, the enrollment broker and the stakeholder community to implement – resources that should be leveraged on improving the quality of the program and the beneficiary experience and thus promote retention." Throughout the development of the Coordinated Care Initiative, DHCS and the Centers for Medicare and Medicaid Services (CMS) repeatedly promised to protect beneficiaries through the complicated transition into managed care. Yet, DHCS and CMS moved forward with program implementation, ignoring stakeholder recommendations to slow down and conduct additional systems testing. As a result, beneficiaries experienced significant disruption and confusion, and anticipated enrollment goals were not met. Today, two years into implementation, health plans are just starting to deliver the coordination of benefits promised under this new delivery model. The enrollment proposals ignore DHCS’s own evaluation data and threaten to revert CCI back to the enrollment chaos of early implementation. Click here to read the letter. For more about the duals program, visit www.cmanet.org/duals. April 28, 2016 General, Medi-Cal, Medicare Dual Eligible, Medi-Cal, Medicare, DHCS, Regulatory Advocacy 0 0 Comment Read More »
CMA publishes duals project FAQ The 2012 California state budget authorized a three-year demonstration project that transitions dual eligibles into managed care and allows them to receive medical, behavioral, long-term supports and services and home-and-community-based services coordinated through a single health plan. The Cal MediConnect project was approved in 8 counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. No more than 456,000 individuals will be allowed to enroll into Cal MediConnect. Los Angeles’ enrollment will be capped at 200,000. To help physicians and their patients better understand the program, the California Medical Association (CMA) has published "Cal MediConnect Physician FAQ: What you need to know about keeping your patients and billing for the dual eligible population." The FAQ is available free to members in CMA's online resource library. For more details on Cal MediConnect, visit www.calduals.org and www.cmanet.org/duals. Contact: Lishaun Francis, (916) 551-2554 or lfrancis@cmanet.org. October 21, 2014 Medi-Cal, Medicare Dual Eligible, Medi-Cal, Medicare, Cal MediConnect 0 0 Comment Read More »
DHCS releases duals project toolkit The California Department of Health Care Services (DHCS) has published a physician toolkit to help providers and their patients understand the Cal MediConnect duals demonstration project. The toolkit has been developed in conjunction with Harbage Consulting and various stakeholder groups, including the California Medical Association. The toolkit contains several documents, including an overview and several fact sheets that include 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) The toolkit also confirms that 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 the Coordinated Care Initiative Overview fact sheet for more information). It should be 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 fact sheet for more information. Physicians should also be aware that the new Cal MediConnect "Choice Form" that is now online is only a visual sample, indicating patients must use their unique forms sent to them in their "Plan Choice" booklets. Lastly, if you or your patients have questions that the plan cannot respond to, you can always contact the Cal MediConnect Ombudsman at (855) 501-3077 (TTY 1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m. For more details on Cal MediConnect, visit www.calduals.org and www.cmanet.org/duals. October 6, 2014 Medi-Cal, Medicare Dual Eligible, Medi-Cal, Medicare, Cal MediConnect 0 0 Comment Read More »
DHCS announces new continuity of care rules for duals demonstration project The California Department of Health Care Services (DHCS) recently announced new continuity of care rules for the Cal MediConnect duals demonstration project. The project – an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities – transitions a large portion of the state's dual eligible beneficiaries to managed care plans. Although the program already had continuity of care provisions, the new rules make it easier for a patient to continue receiving needed care from out-of-network physicians without interruption. The new continuity of care rules allow beneficiaries who meet certain criteria to keep their current providers for up to six months for Medicare services and up to 12 months for Medi-Cal services. Patients must demonstrate they’ve seen the out-of-network physician at least once in the previous 12 months for primary care and twice in the previous 12 months for specialists. Providers can request continuity of care The new rules will now allow providers to request continuity of care for their patients under the duals demonstration project. Previously, only the patient could initiate such a request. This new rule will help beneficiaries who have difficulty navigating the health care system so they can maintain their provider for up to 12 months. Continuity of care can be requested via telephone Under the new rules, continuity of care requests can be made via telephone and plans will be prohibited from requiring beneficiaries to submit a request through a paper form. Plans must process request within 3 days Under the new rules continuity of care requests must be processed within three days if there is a risk of harm to the beneficiary. Urgent requests will be processed within 15 days and all other requests are to be processed within 30 days. Retroactive continuity of care Under these new rules, providers or the beneficiary can now request continuity of care after delivering the service – ensuring payment for treatment. To qualify, the request must be received within 20 business days of the first service following the beneficiaries’ enrollment in Cal MediConnect. Once a beneficiary is approved for continuity of care, providers must work with the health plans to ensure compliance with the plan’s utilization and management policies. These changes in continuity of care do not apply to providers of DME, transportation or ancillary services. DHCS is expected to release a Dual Plan Letter within the next few weeks with direction on the new continuity of care rules for the Cal MediConnect population with an effective date. CMA is pleased with the efforts DHCS has made to strengthen the physician-patient relationship and will continue to work with the department in ensuring adequate access to care. September 19, 2014 Medi-Cal, Medicare DHCS, Medi-Cal, Medicare, Cal MedConnect, Dual Eligible 0 0 Comment Read More »
DHCS revises Cal MediConnect 'Choice Forms' After advocacy from the California Medical Association (CMA) in conjunction with patient advocacy groups, the California Department of Health Care Services (DHCS) has revised its “Choice Forms” that allow dual eligibles to opt-out of the Cal MediConnect duals demonstration project and remain in traditional Medicare fee for service. The project was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that transitions a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara. The previous Choice Forms did not make it clear how a patient could opt-in or out of the program and DHCS was criticized for its lack of transparency in the documents. CMA was very vocal in requesting DHCS change the forms to clearly state the patient’s options. The state hopes the new forms provide clarity and make it easier for patients to make the choice between opting into the Cal MediConnect program or opting out of it. The Spanish language forms were also revised. The updated forms are found here and should be included in new Plan Choice books for newly enrolled members. The plan Choice Form is located in the middle of the Plan Choice Book. DHCS will also soon be finalizing a physician toolkit to help physicians and their patients understand the project. The toolkit has been developed in conjunction with Harbage Consulting and various stakeholder groups. The various pieces of the toolkit will be released individually as they are finalized. Watch DHCS’s weekly Coordinated Care Initiative updates for more information. September 11, 2014 Medicare Department of Health Care Services, DHCS, Dual Eligible, Medicare, Cal MediConnect 0 0 Comment Read More »
Cal MediConnect lawsuit unsuccessful Last week, the Sacramento Superior Court denied a request to delay implementation of the Cal MediConnect project. In a last minute challenge to the program, the Los Angeles County Medical Association (LACMA) joined a coalition of plaintiffs, including three Los Angeles independent living centers, to file a lawsuit in Sacramento Superior Court to stop the implementation of the project. The Cal MediConnect project was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that will see a large portion of the state's Medicare/Medi-Cal dual eligible beneficiaries transition to managed care plans. The project will impact approximately 456,000 dual eligible beneficiaries in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara. The lawsuit alleged that Cal MediConnect is not legally authorized because DHCS failed to obtain timely federal approval of the demonstration project as required under the state law establishing the project. Second, the lawsuit alleged that there are deep flaws with the implementation of the project thus far, including problems with the notices to beneficiaries and the enrollment form. Specifically, the lawsuit alleged the notices were not written at a 6th grade reading level as required by law and in addition, the enrollment form is too confusing to meaningfully provide an opt out choice for beneficiaries. The California Medical Association (CMA) was not a named party in the lawsuit. However, CMA believes the lawsuit raises legitimate issues about the rollout and implementation of Cal MediConnect, specifically concerning adequate notice and information to affected beneficiaries and providers. In an unrelated move, the Department of Health Care Services (DHCS) has delayed the implementation of the Cal MediConnect project for Alameda and Orange counties until July 2015. CMA will continue to work with DHCS and other stakeholder groups to identify suggestions for improvement in the Cal MediConnect implementation and rollout. To see the current timeline for implementation of Cal MediConnect program, click here. August 8, 2014 Medi-Cal, Medicare Dual Eligible, Medi-Cal, Medicare, Cal MediConnect 0 0 Comment Read More »
Another delay for the Cal MediConnect project for dual eligibles The California Department of Health Care Services (DHCS) recently announced yet another delay for the Cal MediConnect project for dual eligibles. Implementation in Orange County has been delayed indefinitely, following a Centers for Medicare and Medicaid Services (CMS) audit of CalOptima—which is the county's only Medi-Cal managed care plan. The audit uncovered a number of serious issues that must be resolved before the duals transition can move forward in Orange County. Previously, Orange County was scheduled to begin passive enrollment on April 1, 2014. According to DHCS, implementation of Cal MediConnect in Orange County has been delayed indefinitely while CalOptima takes corrective action as directed by CMS. Because patients in Orange County have already received the 90-day notice, CalOptima will be sending a follow up letter to notify them that their coverage is not changing. These letters are expected to be mailed by end of next week. Patients who are currently enrolled with CalOptima will continue to receive medical benefits and coverage. DHCS last week announced that passive enrollment has been delayed by one month in Riverside, San Bernardino and San Diego counties, and is now set to begin in May. These delays are in addition to previous notice of delays in Santa Clara, Alameda and Los Angeles counties. DHCS also announced it would be adding additional plans in Los Angeles County (CareMore, Care 1st and Molina). The Cal MediConnect project was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that would see a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara. DHCS will be notifying affected patients 90, 60 and 30 days prior to their passive enrollment date. San Bernardino and Riverside Counties: Inland Empire Health Plan and Molina Dual Options, voluntary enrollment period begins no sooner than April 1, 2014; passive enrollment begins no sooner than May 1, 2014. For more information on the duals demonstration project, visit www.cmanet.org/duals and www.calduals.org. February 12, 2014 Medi-Cal, Medicare Medi-Cal, Medicare, Dual Eligible, Insurance/Reimbursement 0 0 Comment Read More »
Duals demonstration project delayed in three counties The California Department of Health Care Services (DHCS) has delayed passive enrollment for three of the eight counties affected by the state's "pilot project" to redesign care for Medicare/Medi-Cal dual eligibles. The project in these three counties—Alameda, Santa Clara and Los Angeles—will begin instead with a voluntary period, during which patients can choose early enrollment with a Medi-Cal managed care plan, or wait until the automatic passive enrollment period, which will begin no earlier than July 1, 2014. The project—known as Cal MediConnect—was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that would see a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara. There is no change to implementation date for the remaining five counties: Orange, Riverside, San Bernardino, San Diego and San Mateo. These five counties will begin passively enrolling patients in a managed care plan beginning April 1, 2014. Once the passive period begins, individuals in all counties except San Mateo will be automatically enrolled over a 12 month period based on birth month. (San Mateo will have a hard start date of January 1, 2014, rather than a 12 month rollout.) Patients have the option to select a specific plan of their choosing or to opt out of the project by notifying the state of this choice. Alameda and Santa Clara will begin their three month voluntary enrollment April 1, 2014, with passive enrollment beginning no earlier than July 1, 2014. Los Angeles will begin its three monthly voluntary enrollment April 1, 2014, with passive enrollment start dates staggered depending on the plan. Health Net will begin passive enrollment no sooner than July 1, 2014, and LA Care will begin passive enrollment no sooner than December 1, 2014. For more information, visit www.cmanet.org/duals and www.calduals.org. Contact: CMA’s reimbursement helpline, (888) 401-5911 or kmarck@cmanet.org. December 16, 2013 Managed Care Dual Eligible, Insurance/Reimbursement, Medicare, Medi-Cal 0 0 Comment Read More »
State delays duals pilot project until April 1 The California Department of Health Care Services (DHCS) announced today that it would delay by three months implementation of the state's "pilot project" to redesign care for Medicare/Medi-Cal dual eligibles. The program, called CalMediConnect, is now expected to begin no earlier than April 2014. The project was authorized by the Assembly in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that would see a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara. Patients will be enrolled in a managed care plan unless they actively opt out. The California Medical Association (CMA) had urged DHCS to withdraw the overly-ambitious project proposal and to take more time to develop a scaled-down project that gives seniors and the professionals that take care of them information and feedback mechanisms to assure continuity of care and improved care coordination. Unfortunately, the Centers for Medicare and Medicaid Services approved the project, clearing the state to begin implementation. CMA will work with DHCS and other stakeholders to minimize the impact of the transition on physicians and their patients. CMA has also established this resource center to help physicians and their patients understand what is being implemented. There you will find: Basic information about what is being implemented Eligibility, enrollment and opt-out information Continuity of care provisions Financing and payment information Patient letters For more information, visit www.cmanet.org/duals. August 15, 2013 Managed Care, Medi-Cal, Medicare DHCS, Medi-Cal, Medicare, Dual Eligible, Insurance/Reimbursement 0 0 Comment Read More »
