InsuranceBA_7.16

Report
California’s
Coordinated Care
Initiative
July 2014
Roadmap
• About the Coordinated Care Initiative
• Cal MediConnect
• Medi-Cal Managed Long Term Services and Supports
• Timeline and Enrollment
• Participating in Cal MediConnect
• Additional Resources
2
The Coordinated Care Initiative:
Where
San Mateo
Alameda
Santa Clara
San Bernardino
Los Angeles
Riverside
Orange*
San Diego
*Participation in Orange County pending readiness reviews.
3
Medicare and Medi-Cal Today
Medicare
Medi-Cal
Who: 65+, under 65 with certain
disabilities
Who: low-income Californians
•
• Doctors
Long-term services and supports
• MSSP: Multipurpose Senior
Services Program
• IHSS: In-Home Supportive
Services
• CBAS: Community-Based Adult
Services
• Nursing facilities
• Hospitals
• Prescription drugs
4
•
Durable medical equipment
•
Medicare cost sharing
The Coordinated Care Initiative:
Two Parts
Medi-Cal
Cal MediConnect
Managed Long-Term
Services and Supports (MLTSS)
Who: many full dual eligible
beneficiaries
Who: Medi-Cal only beneficiaries,
full dual eligibles who opt out of
Cal MediConnect, other identified
groups eligible for Medi-Cal
• Optional
• Combines Medicare and
Medi-Cal benefits into one
managed care health plan
• Additional services,
including care coordination
5
•
Mandatory
•
Beneficiaries will now receive
Medi-Cal benefits through a
managed care health plan,
including LTSS and Medicare
wrap-around.
Cal MediConnect
• Who: Medi-Medi
beneficiaries
• Original Medicare and MediCal services
• One number for all your
health care needs
• Vision benefit: one routine eye
exam annually and a $100 co-pay
for eye glasses/contacts every two
years
• Optional
• Transportation benefit: 30 1way trips per year in addition to
the existing transportation benefit
• Care Coordination
6
Cal MediConnect
Care Coordination
• Cal MediConnect plans will give providers information and
resources to support care coordination.
• Health Risk Assessments (HRAs)
• Primary, acute, LTSS, behavioral health and functional needs
• Interdisciplinary Care Teams
• Beneficiary, plan care coordinator, key providers
• Individualized Care Plans
• Care teams will develop and implement ICPs
• Plan Care Coordinators
• Facilitates communication between plans, providers, beneficiary
7
Care Coordination: Example
Patient X recently had a stroke and is back living at
home.
Under Cal MediConnect, a
plan care coordinator will
ensure the patient has:
• Transportation to
appointments
• Coverage for prescriptions
• Meals on Wheels
• Other support for activities
of daily living
Before Cal MediConnect,
the patient would have to
navigate Medicare, MediCal and county agencies
to get needed social
services – often relying on
their doctor’s office staff
for help.
8
If you have Medicare and Medi-Cal
Option 1: Choose Cal MediConnect
You can combine your Medicare A, B & D with your
Medi-Cal benefits into a Cal MediConnect plan
Select one of the
participating
Cal MediConnect
plans in your county
9
Cal MediConnect Plan Options
Los Angeles
Alameda
• Care1st, CareMore, Health Net,
LA Care and Molina Health
• Alameda Alliance and Anthem
Blue Cross
Orange*
Santa Clara
• CalOptima
• Anthem Blue Cross and Santa
Clara Family Health Plan
San Diego
San Bernardino
• Care 1st, Community Health
Group, Health Net and Molina
Health
• Inland Empire Health Plan and
Molina Health
Riverside
San Mateo
• Inland Empire Health Plan and
Molina Health
• Health Plan of San Mateo
*Participation in Orange County pending readiness reviews.
10
People not eligible for
Cal MediConnect
You can’t join Cal MediConnect if you:
• Are younger than 21.
• Receive developmental disability waiver services from a Regional Center.
• Do not meet your Medi-Cal share of cost, if you have one.
• Have End-Stage Renal Disease (ESRD), except in San Mateo County.
• Have other health coverage, such as retirement, veterans or private coverage.
• Live in a veterans home.
• Receive services through one of the following waiver programs; Nursing
Facility/Acute Hospital, HIV/AIDS, Assisted Living, or In Home Operations (you must
disenroll from these programs to enroll in Cal MediConnect, you will not be passively
enrolled).
• Are enrolled in PACE (you must disenroll to be eligible for the Cal MediConnect; will not be
passively enrolled).
• Live in some rural zip codes in Los Angeles, Riverside and San Bernardino Counties.
11
Medi-Cal
Managed Long-Term
Services and Supports
• Who: Medi-Cal
only beneficiaries,
full dual eligibles
who opt out of Cal
MediConnect,
other identified
groups eligible for
Medi-Cal
• Mandatory
• Same Medi-Cal services
beneficiaries currently receive
• Hearing aids
• Bathrooms aids (grab bars, shower
chairs)
• Non-emergency medical transportation
(wheelchair vans and litter vans)
• Incontinence supplies
•
Medi-Cal long-term services and
supports (MLTSS) will now be
coordinated by a managed care plan
• MSSP: Multipurpose Senior Services
Program
• IHSS: In-Home Supportive Services
• CBAS: Community-Based Adult Services
• Nursing facilities
12
If you have Medicare and Medi-Cal
Option 2: Keep your Medicare as it is and join a Medi-Cal
health plan
•
Enroll in only a Medi-Cal Plan
Your Medicare including your
Part D plan, will stay the
same
•
You will continue to use the
same Medicare providers
•
Your Medi-Cal benefits are
now assigned to the Medi-Cal
health plan
Select one of the
participating
Medi-Cal plans in
your county
13
If you have only Medi-Cal
You must choose a Medi-Cal plan for your Medi-Cal benefits
Enroll in a Medi-Cal Plan
Select one of the
participating
Medi-Cal plans in
your county
14
MLTSS Plan Options
Los Angeles
Alameda
• Health Net (Molina), LA Care
(Anthem, Care 1st, Kaiser)
• Alameda Alliance and Anthem
Blue Cross
Orange*
Santa Clara
• CalOptima
• Anthem Blue Cross and Santa
Clara Family Health Plan
San Diego
San Bernardino
• Care
Community Health
Group, Health Net, Molina, and
Kaiser
1st,
• Inland Empire Health Plan
(Kaiser) and Molina (Health Net)
San Mateo
Riverside
• Health Plan of San Mateo
• Inland Empire Health Plan
(Kaiser) and Molina (Health Net)
*Participation in Orange County pending readiness reviews.
15
PACE
Program of All-inclusive
Care for the Elderly
• Who: Medi-Medi
beneficiaries and
Medi-Cal
beneficiaries
• Option available
to those who are
determined
eligible
You may be eligible to
enroll in a PACE program
If you:
• Are 55 or older
• Live in your home or community setting
safely
• Need a high level of care for a disability
or chronic condition
• Live in a ZIP code served by a PACE
health plan
16
PACE Plans
Alameda
Los Angeles
• Center for Elders’
Independence and On Lok
Lifeways
• Altamed Senior
BuenaCare and
Brandman Centers for
Senior Care
Santa Clara
Orange*
• On Lok Lifeways
• CalOptima PACE
San Bernardino
• InnovAge PACE
San Diego
Riverside
• St. Paul’s PACE
• InnovAge PACE
17
When to Expect Notices
•
Beneficiaries will receive notices 90, 60, and
30 days prior to your coverage date.
• For most people their coverage date is the first day
of their birth month.
• Cal MediConnect official information from the state
will only arrive in blue envelopes.
18
General Timeline
• April 2014 Enrollment in San Mateo
• May 2014 Enrollment in San Diego, Riverside, and
San Bernardino begins
• July 2014 Enrollment in Los Angeles begins*
• January 2015 Enrollment in Alameda, Santa Clara,
and Orange begins*
*Enrollment in Orange County and select Los Angeles plans pending readiness reviews.
19
20
Timeline Specifics
Individuals who receive passive enrollment
notices:
• Already in Managed Medi-Cal – enroll/benefit
added in 1 month
• Not in Managed Medi-Cal – enroll by birth month
• In CCI-health plan DSNPs – enroll in one month in
January
21
Timeline Specifics
Individuals who are eligible for Cal MediConnect
but WILL NOT receive passive enrollment notices:
• Enrolled in non-CCI plan DSNP
• Enrolled in Medicare Advantage
• Enrolled in VA, waiver system, etc.
These populations will be asked to selected a
Managed Medi-Cal (MLTSS) plan.
22
Blue Envelope
23
Cal MediConnect Notices
90 Day Notice
60 Day Notice
24
30 Day Notice
MLTSS
90 Day Notice
60 Day Notice
25
30 Day Notice
Choice Form
Section 3: Cal MediConnect Plan
To select a Cal MediConnect plan,
complete section 3 ONLY.
Section 5: Medi-Cal Plan
To “Opt-Out” of Cal MediConnect,
fill out section 5 ONLY. Choose the
Medi-Cal plan you are already in or
select the Medi-Cal plan you want
to join.
Section 7: PACE Plans
To select a PACE plan complete
section 7 AND also complete
section 3 OR 5 as back-up options.
26
Use the Choice Form to
Choose the Plan you Want
• If you have both Medicare and Medi-Cal and you
do nothing:
• You will be assigned to a Cal MediConnect plan that
is the best match for you.
• If you have only Medi-cal and you do nothing:
• You will be assigned to a Medi-Cal plan that is the
best match for you.
• This way you will not lose your Medicare or
Medi-Cal benefits or services.
27
Enrollment:
Health Care Options
Call Health Care Options to:
• Enroll in a Cal MediConnect plan, or
• Enroll in a Medi-Cal plan (and keep your Medicare
as it is today), or
• Enroll in a PACE plan
1-844-580-7272
28
Enrollment
• The use of independent agents/brokers will not be
permitted and all MMP enrollment transactions must be
processed by the State enrollment broker (Health Care
Options).
• If an individual is cross walked into a Cal MediConnect
plan in some cases the broker may still receive
payment from the health plan.
29
www.calduals.org
30
Additional Resources
• Health Insurance Counseling and Advocacy
Program (HICAP)
• Call HICAP for free unbiased counseling
• Email [email protected]
• Twitter @CalDuals
31

similar documents