Provider FAQ

What are the Coordinated Care Initiative (CCI) and Cal MediConnect?

California’s Coordinated Care Initiative (CCI) was passed by the state legislature in 2012 to improve how the state delivers health care to low-income seniors and people with disabilities. Too often these vulnerable populations suffer from fragmented services resulting from multiple funding sources that are cut during the legislative budget process every year, as well as uncoordinated delivery of medical, long-term care, home and community based, and behavioral health services. A coordinated health care system will provide better care, improve health outcomes and help contain costs.

There are two parts to CCI: Managed Long-Term Services and Supports (MLTSS), which will change from a Medi-Cal fee-for-service benefit to a Medi-Cal health plan benefit; and Cal MediConnect which provides the option for older, low-income residents who qualify for both Medicare and Medi-Cal (dual eligible patients) to receive all of their benefits from one single, coordinated health plan with one ID card, one set of benefits and one number to call for support.

Why should physicians participate in Cal MediConnect?

Benefits for physicians include:

Simplified Administration
• Cal MediConnect may offer greater financial stability and simplify billing and system processes.
• Receive regular capitation payments from a single payer, with one phone number for questions or assistance.

Complete, Coordinated Care
• Have help coordinating your patients’ health care services between you and their other health care providers; and with the social services they need.
• All L.A. Care Cal MediConnect physicians will receive a Health Risk Assessment from the plan about your patients and access to health navigators who work with your patient to coordinate care.

Access to New Patients & Support Services
• As a member of the Cal MediConnect provider network, you will have access to a new group of patients, a new stream of income, and additional support services.
• New relationships with providers can increase referrals and build awareness of your practice.

Jumpstart on Coordinated Care Delivery Model
• Health reform is here to stay. Federal and state governments are moving toward the coordinated care model of health care service delivery to improve quality and contain costs.
• Be better positioned for the future by practicing in this model while continuing to treat your Medicare and Medi-Cal patients.

How does an interested physician participate in Cal MediConnect?

If you wish to work with L.A. Care, please contact our Director of Contracting at (213) 694-1250 and we will be happy to connect you with an Independent Physician Association (IPA) or other medical group with which we work (see list of contracted IPAs included in this packet).

There are five Cal MediConnect plans in L.A. County. Why should I choose to work with L.A. Care?

L.A. Care is the only publicly operated plan in L.A. County. Since 1997, L.A. Care has been helping people get the health care and support they need to help them stay well, active and living on their own with appropriate support when needed. Unlike for-profit plans, 95% of our profits go back into providing health care for our members. Part of our commitment to service is providing support for our doctors. That is why we have made a significant investment in technology to assist in preparing providers for new systems of coordinated care, including providing access to electronic health records and e-consult services.

Can I participate in several health plans at once?

Yes, you are able to participate in several health plans if you are contracted with an IPA or medical group that is contracted with more than one Cal MediConnect plan.

How are participating physicians paid?

The health plans participating in Cal MediConnect use a capitated model of payment. Physicians and other providers will receive a per member per month (PMPM) fee for each patient who is participating in the program. Capitation PMPM rates are determined and vary by medical group and IPA.

Will I still be able to see my patient after he/she enrolls in Cal MediConnect?

If you are contracted with the health plan that your patient has chosen [through an Independent Physician Association (IPA) or a Participating Physician Group (PPG)], you will be able to continue seeing your patient. If not, the following continuity-of-care process will apply: Patients may continue to see their non-contracted physicians for 6 months for their Medicare services or 12 months for their Medi-Cal services after enrolling in a Cal MediConnect plan, as long as the following Continuity of Care guidelines are met:
• The enrollee or their representative requests continuity of care from the Cal MediConnect plan.
• There is a demonstrated preexisting relationship between the patient and the physician prior to enrollment in Cal MediConnect.
• The physician is willing to accept the Cal MediConnect plan rate or the applicable Medicare rate, whichever is higher, and agree to receive payment from the plan.
• There are no quality-of-care issues or a failure to meet federal or state requirements that would exclude the physician from the plan’s network.

Any services provided during that 6- or 12-month period will be paid at the Medicare or Medi-Cal rate, as appropriate.

What will happen after the Continuity of Care period ends?

After the 6- or 12-month Continuity of Care period ends, physicians will have the option to join the provider network. If a physician chooses not to join, your Medi-Cal and Cal MediConnect patients will need to select a physician who is participating in the network.

What happens if my dual eligible patient opts out of Cal MediConnect?

A dual eligible patient who does not enroll in Cal MediConnect will continue to receive their Medicare services as they do currently, through either a Medicare Advantage plan or traditional Medicare fee-for-service, but most Medi-Cal benefits will be now administered by a Medi-Cal health plan. Please note that dual eligible patients who do not enroll in Cal MediConnect are still required to enroll in a Medi-Cal health plan in order to receive their important Managed Long-Term Services and Supports (MLTSS), including Community-Based Adult Services (CBAS).

If my dual eligible patient joins a Medi-Cal health plan, will I still be paid by Medicare for my services?

If a dual eligible Medi-Cal patient declines to enroll in a Cal MediConnect plan, physicians should bill for Medicare services exactly as you have done in the past. Even if the patient is enrolled in a Medi-Cal health plan (which is still required to receive Medi-Cal benefits) you should still bill for Medicare services exactly as you always have. There is no change in what Medicare fee-for-service will pay for billed charges – generally, 80% of the Medicare fee schedule.

How do I bill for the 20% co-pay not covered by Medicare for my dual eligible patients in Medi-Cal plans?

Physicians should first bill Medicare and then bill the Medi-Cal health plan with an Explanation of Benefits from Medicare. The Medi-Cal health plan will pay the same amount that the physician would have been paid by fee-for-service Medi-Cal.

Who are the “dual eligibles”?

“Dual eligibles” are individuals who qualify for both Medicare and Medi-Cal – typically, low-income seniors and people with disabilities. These patients are also sometimes referred to as “Medi-Medis.” Only dual eligible patients may enroll in Cal MediConnect.

Will my dual eligible patients who qualify be automatically enrolled?

There are three possible paths a patient may take: An individual can actively choose a health plan, be passively enrolled in a health plan if they take no action, or opt out of the Medicare portion of the program. (Note: They cannot opt out of the MLTSS part of the CCI).

If your dual eligible patients do not actively choose to enroll in a specific Cal MediConnect plan, those patients will be placed into a plan, or “passively” enrolled. Your dual eligible patients have the ability to change health plans or opt out of the Medicare portion of Cal MediConnect at any time. They cannot opt out of the MLTSS benefit for their Medi-Cal.

What is the process for my dual eligible patients to enroll?

Dual eligible patients who qualify receive 90-day, 60-day and 30-day informational notices in distinctive blue envelopes from the State’s Department of Health Care Services. If patients approach you with questions and you feel that actively choosing a Cal MediConnect health plan would be right for them, they can enroll at any time by choosing a plan on the choice form that arrives in the blue envelope. Patients can also call the plans directly. Questions about L.A. Care’s Cal MediConnect plan can be directed to (888) 522-1298.

Why should my dual eligible patients participate in Cal MediConnect?

Cal MediConnect will dramatically improve the way health care services are delivered to the state’s most vulnerable patients. By transitioning to a single health plan, eligible patients will receive more benefits at no extra cost, as well as have a single point of contact for all their health care needs.

In addition to all the benefits and services they have now through Medicare and Medi-Cal, patients will receive complete, coordinated care. This is the greatest advantage to this program. This population of patients often has multiple chronic conditions to manage, as well as the aging process, which—when they need a lot of care and services—can be frustrating and confusing. Through Cal MediConnect, the plans and/or Independent Physician Associations (IPAs) will provide care teams focused on meeting each individual’s needs for medical care, long-term care, behavioral health care and social services. This team will serve as the patient’s navigators through the health care system, coordinating care with physicians, pharmacists, specialists and other providers. The result: better health outcomes, more support for patients, and a system that is much more responsive to the patient’s needs.

What benefits and services are covered under Cal MediConnect?

All the benefits and services that are now covered separately under Medicare and Medi-Cal will be included, only now available in one single, coordinated health plan:

• Medical Care
• Doctor & Specialist Visits
• Lab Work
• X-Rays
• Hospital Stays
• Medical Equipment & Supplies
• Prescription Medications
• Mental/Behavioral Health
• Long-Term Care
• Skilled Nursing Facilities
• Long-Term Services & Supports
• In-Home Supportive Services
• Community-Based Adult Services
• Multipurpose Senior Services Program
• Non-Emergency Transportation
• Home & Community-Based Waiver Programs

Additional new benefits: Vision, Dental, Non-emergency Transportation.

If a dual eligible patient opts out of Cal MediConnect but joins a Medi-Cal plan, does the patient have to change physician?

No. Patients with Medicare and Medi-Cal who join a health plan only for their Medi-Cal benefits can still see their Medicare physicians. They do not have to change physicians, specialists, pharmacies or hospitals. The only change is that they will now receive their Medi-Cal benefits (Managed Long-Term Services and Supports, including Community-Based Adult Services) through their Medi-Cal health plan.

 

H8258_15129_2015CMC
CMS Approved
Updated 5/05/2015

 

You may need Adobe Reader to view some of the content of this page. Download Acrobat Reader