If you have both Medicare and Medi-Cal (called dual eligible), you may have the choice to participate in a new pilot program called Cal MediConnect. This program is being tried out in Los Angeles and seven other counties in California.
You likely will be receiving information about this program – including an enrollment form – starting in April 2014. These materials will come in a blue envelope in the mail.
If you qualify for both Medi-Cal and Medicare (Parts A and B and are eligible for Part D), and you live in one of eight counties participating in Cal MediConnect, you are eligible to enroll in the pilot program. Cal MediConnect is available in Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, Alameda and Santa Clara.
Beneficiaries NOT eligible for MediConnect include those who:
- Are under the age of 21
- Receive development disabled waiver from a regional center
- Do not meet Medi-Cal share of cost (if a beneficiary has Medi-Cal share of cost, they must meet it each month by being in a Medi-Cal funded nursing facility or by receiving In-Home support services in order to qualify for passive enrollment
- Have end-stage renal disease (exceptions for San Mateo and Orange counties)
- Have other coverage such as retirement, veterans or private coverage
- Receive services from one of the following waiver programs: nursing facility/acute hospital, HIV/AIDS, assisted living, or in-home operations (If a beneficiary wants to join MediConnect and is part of one of these programs, the beneficiary must dis-enroll from these programs. Beneficiaries who are part of these waiver programs will NOT be passively enrolled.)
- Enrolled in PACE (Beneficiaries who want to join MediConnect must dis-enroll from PACE. They will NOT be passively enrolled.)
- Live in some rural ZIP codes of Los Angeles, Riverside and San Bernardino counties (rural Los Angeles County ZIP code is 90704)
If you received healthcare coverage through Medicare, but are not eligible for Medi-Cal, the current changes do not affect you.
All Medi-Cal beneficiaries, however, regardless of Medicare eligibility, most likely need to enroll in a Medi-Cal managed health benefit plan in order to continue to access their Medi-Cal benefits. This includes Long-Term Services and Support (LTSS), In-Home Supportive Services (IHSS), Multipurpose Senior Services Program (MSSP), Community-Based Adult Services (CBAS) and nursing facility care.
No, you do not have to enroll in the Cal MediConnect pilot program. However, dual eligibles who do not wish to enroll in Cal MediConnect must opt out of the program. Otherwise, you will be automatically enrolled. This means the California Department of Health Services will choose your plan for you and you may need to go to a different doctor and/or hospital, which means that you may lose coverage to your Providence hospital its affiliated physicians. Dual eligibles are people who have both Medicare and Medi-Cal. If you enroll in Cal MediConnect and decide that you want to change, you can opt out of the program at any point.
Also, if you want to keep your current Medicare plan and not participate in Cal MediConnect, you will still need to enroll in a Medi-Cal managed care plan to use your Medi-Cal benefits. For more information, call 844-CS-MEDIS (844-276-3347). Available 24 hours a day.
You will still be responsible for the same Medicare and Medi-Cal premiums, copays and deductibles you had prior to enrolling in Cal MediConnect. There is no change in cost to you as the beneficiary.
Cal MediConnect is designed to coordinate all your care through a single health plan with one insurance card. The plan includes both Medicare and Medi-Cal benefits, including medical services, long-term care, mental health and social supports.
All services under original Medicare and Medi-Cal will be covered by under Cal MediConnect. In addition, there will be a supplemental vision and transportation benefit that includes yearly eye exam, $100 copay for glasses and contacts every two years, and 30 one-way transports to medical appointments or other health-related trips. The plan also will provide additional care coordination support for those who need it.
There are no additional costs to join MediConnect but beneficiaries should check their Cal MediConnect plan about costs associated with Medicare Part D and to make sure their medications are covered.
It is important to note that choices for physicians and hospitals will be limited in Cal MediConnect plans. You will need to make sure that your preferred doctor and hospital are part of whichever option you choose. For more information, call 844-CS-MEDIS (844-276-3347). Available 24 hours a day.
Yes, your coverage does not change.
Yes, you may disenroll from Cal MediConnect and go back to regular Medicare or a Medicare Advantage plan in any month.
To do this, call Health Care Options at 844-580-7272 (TTY: 800-430-7077), or contact your plan provider and tell them you would like to leave the program.
You will still need to be enrolled in a managed health plan for your Medi-Cal benefits. Leaving Cal MediConnect will only affect how you get your Medicare benefits.
The Cal MediConnect plan you choose is required to work with you to get you the care you need.
If your current doctor or other healthcare service is not in-network, you eventually will be required to change to an approved provider. In many cases, however, you may have some time before you must change physicians (12 months for Medi-Cal doctors and six months for Medicare doctors), as long as your provider agrees to accept your new health plan’s rates as payment. If you are in a Medi-Cal nursing home, you will be able to stay unless the facility is excluded from your plan’s network for quality concerns.
Referrals for specialty care should be coordinated through your Primary Care Provider.
If you need to select a new plan, you will receive three different notices, sent 90, 60 and 30 days ahead of your enrollment date. Both Cal MediConnect beneficiaries and those in Medi-Cal fee-for-service who need to choose a managed care plan for their Long-Term Services and Supports (LTSS) will be receiving notices ahead of enrollment dates.
- 90 days ahead: This first notice will alert you to the coming change.
- 60 days ahead: This second notice will include a packet with information about plan benefits and provider networks to help you select a plan. This will include a plan that is the best match for you based on how many of your current providers are included in a plan’s provider network. Please ensure that this new plan includes your Providence affiliated physician by calling your physician. Click here to learn about plans accepted by your Providence hospital.
- 30 days ahead: This third notice will provide you with information about your specific plan. This will be the plan you have chosen based on the 60-day notice. If you are dual eligible and do nothing, you may be automatically enrolled in Cal MediConnect, and the program will pick a healthcare plan for you. If this occurs, you may lose coverage for care at your Providence Hospital and with your doctor. Those beneficiaries who are NOT eligible for Cal MediConnect and who are already enrolled in a Medi-Cal managed care plan will receive one notice prior to the change in their benefit package. This change is the MLTSS program, which adds long-term services and supports to beneficiaries’ existing plan. To select your Cal MediConnect plan, or opt out of the program and keep regular Medicare, call Health Care Options at 1-844-580-7272 or TTY: 1-800-430-7077.
Health Care Options
This branch of the state’s Medi-Cal Managed Care Division provides information to Medi-Cal beneficiaries. If you do not want to mail in your health plan choice form, you can enroll in your preferred plan by calling the number below.
- 844-580-7272; TTY users, 800-430-7077
Health Care Options also has locations where you can talk privately with an enrollment specialist in person. www.healthcareoptions.dhcs.ca.gov/HCOCSP/Presentation_Sites/
Cal MediConnect Ombudsman Program
Offered by the state’s Cal MediConnect program, this office can assist enrollees in navigating issues and filing appeals.
Health Insurance Counseling and Advocacy Program (HICAP)
Volunteer counselors can provide information over the phone and conduct free educational presentations.
- 800-434-0222 (In Los Angeles County, the direct number is 213-383-4519; TTY users, 711)
Website dedicated to pooling information about California’s Coordinated Care Initiative
- 800-MEDICARE (800-633-4227)